Ruptured aneurysm at an anastomotic artery extending from the vertebral artery to the posterior inferior cerebellar artery: a case report

A 51-year-old hypertensive man presented with subarachnoid haemorrhage. He had a past history of cerebellar infarction due to occlusion of the right posterior inferior cerebellar artery (PICA) 4 years earlier. Digital subtraction angiography showed a saccular aneurysm above an arterial loop extending from the vertebral artery to the distal part of the PICA, reminiscent of peripheral PICA branches. We performed aneurysmal neck clipping with excellent outcome. Aneurysms at anastomotic arteries are extremely rare and can result from increased haemodynamic stress. We report the first case of a ruptured aneurysm at an anastomotic artery in the posterior circulation territory.     

Endovascular aortic repair for spontaneous rupture of a non-aneurysmal infrarenal aorta

We report the case of a patient who underwent an endovascular aortic repair for spontaneous rupture of a non-aneurysmal infrarenal aorta. A 67-year-old male with a diagnosis of infrarenal aortic rupture was referred to our hospital. Preoperative computed tomography showed focal ulcers adjacent to the site of rupture, with no evidence of aneurysm formation, suggesting that this aortic rupture was likely to be associated with perforation of penetrating atheromatous ulceration. Open surgical repair might have carried a high-risk because of the patient's history of laparotomy and respiratory impairment, so endovascular aortic repair was planned. We deployed a Powerlink proximal infrarenal cuff 25-25-75L at the rupture site through the femoral artery, with the additional placement of two extra large Palmaz stents at the proximal and distal sites of the Powerlink stent-graft. Completion angiography showed total exclusion with no endoleaks. The patient was successfully extubated on the third postoperative day and recovered well until he contracted aspiration pneumonia two weeks after surgery. Unfortunately, he eventually died of a non-aortic cause three months after the operation. Endovascular aortic repair may be an alternative to conventional surgical repair for high-risk patients with spontaneous infrarenal aortic rupture.     

Successful treatment of acute promyelocytic leukemia in a patient on hemodialysis

Acute promyelocytic leukemia (APL) has the best prognosis among acute leukemias, but there is little data about APL in patients on hemodialysis. A 64-year-old hemodialysis patient was successfully treated for APL by induction therapy with all-trans retinoic acid (ATRA), three courses of consolidation therapy with Ara-C, mitomycin?C (MIT), daunorubicin (DNR), and idarubicin (IDR), and maintenance therapy with ATRA. Complete remission has been maintained for 42?months in this patient. With dose modification, ATRA and chemotherapy may be safely given to patients on hemodialysis.     

A large-sized bubbling appearance of the glomerular basement membrane in a patient with pulmonary limited AL amyloidosis and a past history of lupus nephritis

We report an unusual pathological finding, a large-sized bubbling appearance of the glomerular basement membrane (GBM), in a patient with pulmonary limited AL amyloidosis and a past history of lupus nephritis. The first renal biopsy specimen from 10 years ago, when systemic lupus erythematosus was diagnosed, demonstrated mild mesangial proliferation and subepithelial deposits (WHO classification: III + V). Light microscopy of the current biopsy using periodic acid methenamine silver (PAMS) stain demonstrated a large-sized bubbling appearance of the GBM; however, very weak immunoglobulin and complement deposition was observed in immunofluorescence studies. Routine electron microscopy demonstrated partial subendothelial expansion with electron-lucent materials, but no electron-dense deposits or amyloid fibrils. Electron microscopy with PAMS stain revealed electron-lucent endothelial scalloping, including some cellular components and microspheres in the GBM; however, it is not clear if these materials are derived from endothelial cells. One possibility is that these unique findings represent a recovery phase of lupus membranous nephritis; another is that these findings correspond to a new disease entity.     

High-grade invasive urothelial carcinoma with focal plasmacytoid differentiation successfully treated by transurethral resection followed by chemoradiotherapy

We report a case of high-grade invasive urothelial carcinoma with plasmacytoid differentiation of the urinary bladder. A 75-year-old woman was referred to our hospital because of macroscopic hematuria. Cystoscopy detected a solid pedunculated bladder tumor, and a transurethral resection of the bladder tumor (TUR-Bt) and the image findings showed pT1N0M0 bladder cancer. The histopathological examination revealed the coexistence of a large component of high-grade invasive urothelial carcinoma and a small component of plasmacytoid carcinoma. Following the TUR-Bt, external beam radiotherapy and chemotherapy with gemcitabine and nedaplatin were carried out. The bladder tumor has not recurred for 2 years after the TUR-Bt.     

Value of Multidetector-row Computed Tomography in Diagnosis of Portal Vein Invasion by Perihilar Cholangiocarcinoma

BACKGROUND: Although knowledge of cancer invasion of the portal bifurcation is vitally important in planning an operation for perihilar cholangiocarcinoma, the diagnostic capability of multidetector-row computed tomography (MDCT) for this purpose has not been assessed. We evaluated how well MDCT could identify cancer invasion of the portal bifurcation by perihilar cholangiocarcinoma. METHODS: Between April 2003 and June 2005, perihilar cholangiocarcinoma was resected in 87 patients, 83 of whom underwent MDCT within 1 month before the surgery. Three-dimensional volume-rendered (3DVR) and multiplanar reformation (MPR) images were examined for evidence of portal vein invasion. Agreement with intraoperative and pathologic findings was assessed. Portal bifurcation findings by 3DVR and MPR were classified into no portal vein stenosis, unilateral stenosis, or more extensive stenosis, and also into tumor contact with the bifurcation in no, one of two, or two projections. RESULTS: For macroscopic portal vein invasion, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were 81.5, 91.1, 81.5, 91.1, and 88.0% in 3D portography and 96.3, 92.6, 86.7, 98.1, and 94.0% in MPR, respectively. Findings by both 3DVR and MPR were significantly correlated with depth of cancer invasion (p < 0.001). CONCLUSION: MDCT is useful in assessing cancer invasion of the portal vein bifurcation by perihilar cholangiocarcinoma.     

p53 antibodies in the serum of patients with prostate cancer

We assessed the potential clinical utility of levels of p53-specific antibodies as a novel serum biomarker of prostate cancer that could be used in conjunction with level of PSA. Material and methods Serum levels of p53-specific antibodies in patients with relapsed, newly diagnosed prostate cancer and in patients with benign prostate hyperplasia were quantified by an enzyme-linked immunoabsorbent assay. Result There was no significant difference (P = 0.96) between the serum levels of p53-specific antibodies in patients with newly diagnosed prostate cancer and with benign prostatic hyperplasia. In the newly diagnosed prostate cancer group, stage T1c (n = 8) showed the lowest p53-specific antibody level. However, the difference between T1c group and benign prostatic hyperplasia group was not significant (P = 0.686). The relapsed cancer group tended to have low levels of the antibodies, and, there was no significant difference between the relapsed prostate cancer group and the benign prostatic hyperplasia group (P = 0.14). The serum levels of p53-specific antibodies in patients with metastatic and with localized prostate cancer showed no significant difference (P = 0.68). Conclusion The use of titers of p53-specific antibodies to make differential diagnosis between prostate cancer and benign prostatic hyperplasia might have no role, and the antibodies should not be used as a marker of prostate cancer by itself. Because our study is based on small number of patients, further studies are necessary before its absolute validity can be determined.     

Liver Transplantation for Cystic Fibrosis in Adults

Purpose To expand our knowledge on liver transplantation for cirrhosis associated with cystic fibrosis in adults. Methods Five patients who underwent a liver transplantation due to cystic fibrosis were reviewed. The outcome of the patients in terms of age, immunosuppression regimen, patient and graft survival, and pre- and post-transplant complications were investigated. Results Five adult liver transplant patients had cystic fibrosis (0.2%). These included 4 men and 1 woman with a mean age of 31 ± 10, ranging from 22 to 52 years old at the time of transplantation. All patients had lung problems. Four patients had exocrine and two had endocrine pancreatic insufficiency. Two are currently alive with a follow-up of 5.8 years and 4 months after transplantation, respectively. There were three deaths from pulmonary embolism at 4.5 years, myocardial infarction with cyclosporine nephrotoxicity at 10.7 years, and lymphoproliferative disorder at 5 months after transplantation. No deaths occurred from lung infection. Only one patient had postoperative pulmonary infectious complications, which were successfully treated with antibiotics and did not result in mortality. Conclusion Adult liver transplantation for end-stage liver disease associated with cystic fibrosis offers encouraging results with a rapid general improvement after surgery and it is now considered to be a safe and acceptable treatment for this disease population.     

Prospective analysis of clinical evaluation and self-assessment by patients after decompression surgery for degenerative lumbar canal stenosis.

BACKGROUND CONTEXT: Objective measures including neurological findings, radiographic evaluation, and the Japanese Orthopaedic Association (JOA) score are commonly used for the evaluation of surgical outcomes. Because many surgeries are performed primarily to improve quality of life, a patient's subjective evaluations are also important for accurately assessing surgical outcomes. Currently available instruments for assessing quality of life include the Short-Form 36 (F-36), the Oswestry disability index (ODI), and the visual analog scale (VAS) clinical pain scale. PURPOSE: The aims of this study were to measure surgical outcomes by using both objective measures and subjective measures including patient self-assessments and psychological changes; to assess the adequacy of the JOA alone for measuring outcome; and to determine which measures, the SF-36v2, ODI, VAS, or JOA correlate with the VAS pain scale score in lumbar canal stenosis. STUDY DESIGN: We performed a prospective study to measure surgical outcomes for lumbar canal stenosis using traditional objective measures such as neurological findings and subjective measures such as performance of ADLs, patient self-assessments, and psychological changes. PATIENT SAMPLE: Forty-two surgical patients with a mean age of 66.8+/-10.9 years at the time of surgery were included in the study. All cases were followed for more than 2 years. Surgical indications included no response to conservative treatment and neurological deterioration. Neurological symptoms were classified as nerve root type, cauda equine type, or combined type. We performed surgical decompression at the location of the dural or root indentation by myelography. The concomitant diagnosis causing the spinal stenosis was degenerative spondylolisthesis in 20 cases undergoing posterolateral fusion with pedicle screws. OUTCOME MEASURES: Surgical outcomes were assessed by comparing preoperative and 24-month postoperative JOA scores for low back pain, SF-36v2, ODI-v2, and VAS scores. Statistical analysis was performed by using the analysis of variance. A p value<0.05 was considered statistically significant. METHODS: Objective clinical measures, patient self-assessments, and psychological changes were measured before and at 24 months postoperatively. We also examined which measurements correlated with the VAS scale for pain evaluation, thereby relating patient satisfaction to surgery outcome. RESULTS: All JOA, SF-36v2, ODI-v2, and VAS scores significantly improved postoperatively. The physical component summary (PCS) of the SF-36 v2 showed significant improvement, although all scores remained less than the Japanese norm-based scores (NBSs). The mental component summary (MCS) exhibited such a significant improvement that all postoperative subscales were higher than the Japanese NBS. JOA scores significantly correlated only with postoperative lower-extremity VAS score. All PCS and two MCS scores significantly correlated with the VAS score for low back pain. Parts of the PCS and MCS significantly correlated with the lower-extremity VAS. The ODI significantly correlated with both the preoperative and postoperative VAS scores for low back pain as well as with the postoperative lower-extremity VAS score. CONCLUSIONS: The JOA, SF-36, ODI, and VAS questionnaires are all useful instruments for measuring surgical outcomes. The VAS score is a better assessment of physical rather than mental health. The ODI is more reflective of patients' subjective symptoms. Finally, the SF-36 is particularly informative because it includes questions addressing both psychological and physical status. Therefore, when combined, the SF-36v2, VAS, and ODI scores are a valuable complement to the JOA scores in evaluating outcomes of surgery for lumbar canal stenosis.     

Effect of synchronized intermittent mandatory ventilation on respiratory workload in infants after cardiac surgery

BACKGROUND: Synchronized intermittent mandatory ventilation (SIMV) is commonly used in infants and adults. However, few investigations have examined how SIMV reduces respiratory workload in infants. The authors evaluated how infants' changing respiratory patterns when reducing SIMV rate increased respiratory load. The authors also investigated whether SIMV reduces infant respiratory workload in proportion to the rate of mandatory breaths and which rate of SIMV provides respiratory workloads similar to those after tracheal extubation. METHODS: When 11 post-cardiac surgery infants aged 2-11 months were to be weaned with SIMV, the authors randomly applied five levels of mandatory breathing: 0, 5, 10, 15, and 20 breaths/min. All patients underwent ventilation with SIMV mode: pressure control ventilation, 16 cm H2O; inspiratory time, 0.8 s; triggering sensitivity, 0.6 l/min; and positive endexpiratory pressure, 3 cm H2O. After establishing steady-state conditions at each SIMV rate, arterial blood gases were analyzed, and esophageal pressure, airway pressure, and airflow were measured. Inspiratory work of breathing, pressure-time products, and the negative deflection of esophageal pressure were calculated separately for assisted breaths, for spontaneous breaths, and for total breaths per minute. Measurements were repeated after extubation. RESULTS: As the SIMV rate decreased, although minute ventilation and arterial carbon dioxide tension were maintained at constant values, spontaneous breathing rate and tidal volume increased. Work of breathing, pressure-time products, and negative deflection of esophageal pressure increased as the SIMV rate decreased. Work of breathing and pressure-time products after extubation were intermediate between those at a SIMV rate of 5 breaths/min and those at 0 breaths/min. CONCLUSION: When the load to breathing was increased progressively by decreasing the SIMV rate in post-cardiac surgery infants, tidal volume and spontaneous respiratory rate both increased. In addition, work of breathing and pressure-time products were increased depending on the SIMV rate.