Impact of mediastinal lymph node dissection on octogenarians with non-small cell lung cancer

Objective: Impacts of mediastinal lymph node dissection on a patient’s course after pulmonary resection is unclear in octogenarians with non-small cell lung cancer. Methods: Retrospectively identified subjects included 39 octogenarians and 1 nonagenarian, with grades according to the Charlson Comorbidity Index ranging from only 0 to 2. We performed mediastinal lymph node dissection in 19 patients (D group), and just lymph node sampling biopsy in the other 21 (S group). We compared clinicopathologic features and outcome after surgery between both groups. Results: Deterioration of performance status at the time of discharge, evident in 17 patients overall, was significantly more frequent in the D group. Postoperative complications occurred in 27 patients overall and there was no significant difference between the two groups. Survival rates in younger patients at 1, 3, and 5 years were 86, 59, and 49%, respectively; in octogenarians these were 83, 58, and 42% (no significant difference). Nor did survival differ significantly by surgical management of mediastinal lymph nodes; 1-, 3-, and 5-year survival rates were 94, 63, and 40%, respectively in the D group and 78, 66, and 43%, respectively in the S group. Conclusion: Octogenarians with non-small cell lung cancer should be treated by urgent pulmonary resection whenever possible. Since mediastinal lymph node dissection has little effect on long-term survival or the carried risk of worsening performance status at discharge, pulmonary resection without complete mediastinal lymph node dissection should be considered.     

A new end graft holder for coronary artery bypass grafting.

This article describes the construction and use of a new end graft holder during coronary artery bypass grafting (CABG). The instrument consists of a pinching device attached to a flexible arm and a fixation clamp. This device provides secure stabilization and enables excellent positioning of the graft without producing graft injury.     

Time and cost involved in the care of newly registered patients with diabetes mellitus and other lifestyle diseases at diabetes clinics in Japan (JDDM 4).

AIMS: To study the time and cost involved in the care of newly registered outpatients with Type 2 diabetes mellitus (DM), compared with patients with hypertension and/or hyperlipidaemia (HTL). METHODS: A total of 313 patients with DM and 58 patients with HTL without diabetes were registered on their first visits to 11 diabetes clinics across Japan. The time and cost involved in their care was recorded over the following 5 months. RESULTS: In the first 3 months, there was an extensive time commitment to both groups. The time spent by physicians was 1.5 times longer for DM than for HTL. The total care time spent by all the care providers for DM was twice that for HTL. The cost of DM care was twice that for HTL, with the cost of medicines excluded. However, half of the cost for DM was for laboratory tests. When these were excluded, and the remaining cost divided by the time spent, the amount for DM was half of that for HTL. Over the 5 months, mean glycated haemoglobin (HbA(1c)) in DM patients improved from 8.0% to 6.5%, and 72% of DM patients achieved the glycaemic target of HbA(1c) < or = 6.5%. CONCLUSIONS: DM care in a diabetes clinic requires a great deal more time and resources than HTL to achieve the best outcome. An educational system for self care, presently lacking in the primary care setting in Japan, would improve glycaemic control for DM patients in the community.     

Efficacy of cardiac MRI in the evaluation of ischemic heart disease.

With the development of fast scan techniques and technical advances in software, cardiac MRI can now be used for morphological and functional evaluation of the heart with good reliability and high spatial and temporal resolution. Cardiac MRI is employed at many institutions, mainly for assessing ischemic heart disease. Cardiac MRI can be used to identify coronary artery stenosis, evaluate myocardial viability, assess left ventricular wall motion and function, measure coronary blood flow and flow reserve, and obtain other useful information for the diagnosis of ischemic heart disease in a single examination, serving as a true comprehensive cardiac study. With regard to the evaluation of coronary artery stenosis, new techniques, such as whole-heart coronary MRA, permit visualization of the coronary arteries to their peripheral branches without contrast agent. Good results have been reported for whole-heart MRA as compared with X-ray coronary angiography (CAG). Attempts to evaluate plaque characteristics by visualizing the walls of the coronary arteries have also been reported recently. Technical improvements have been made in myocardial perfusion MRI to detect myocardial ischemia and in delayed contrast-enhanced MRI to assess myocardial viability, and some researchers have recently reported that the diagnostic capabilities of these techniques match or surpass those of cardiac nuclear medicine studies. We outline the features of the latest MR imaging techniques for the diagnosis of ischemic heart disease, discuss their practical applications, and compare them with other imaging modalities.     

Skullbase-penetrating injuries caused by umbrella tips: case reports

Two cases of skullbase-penetrating injuries caused by umbrella tips are reported. Case 1: 24-year-old male. Admitted with disturbance of consciousness, left hemiparesis, nasal bleeding, and laceration of left lower eyelid because of having been stabbed by an umbrella tip. Pupils and fundi revealed no definite findings. Plain skull X-ray showed turbid ethmoid sinus and fracture of planum sphenoidale. Cranial CT showed right putaminal hematoma with intraventricular hemorrhage and pneumocephalus. Increased ICP necessitated surgery two days after the injury. Dural laceration of planum sphnoidale, laceration of left optic nerve, right rectal gyrus contusion and rebleeding from the right lenticulostriate branch were observed. Dural plasty and removal of hematoma with external decompression were carried out. He had a good postoperative course, but left visual loss and left hemiparesis remained. Case 2: 29-year-old male. Admitted with excoriation of his right nostril because of having been stabbed by an umbrella tip, severe headache, and nasal discharge. Oculomotor palsy was observed as well as CSF rhinorrhea and meningeal irritability. Plain skull X-ray showed niveau in sphenoidal sinus, pneumocephalus, and fracture of sella turcica. His complaint disappeared after conservative therapy. We reviewed the literature and found only 4 similar cases. The skullbase, because of its anatomical character, is likely to be penetrated in orbital and periorbital injury caused by umbrella tips. Cases which include disturbance of consciousness have a poor prognosis. We hope the fact that umbrella tips can easily become life-threatening objects will come to the attention of the general public so that similar cases may be avoided.     

Thoracic duct cyst in supraclavicular region.

A 28-year-old female attended an outpatient clinic in October, 1989, because of a tumor in the left supraclavicular fossa, detected in a health examination. Following exploratory puncture of the tumor which yielded milky-white fluid, suggesting a cyst in the thoracic duct, she was admitted to our department. The cyst was unilocular measuring about 6 cm in diameter, and the fluid content was chyle-rich in lipids. Lymphography demonstrated a lymphatic structure adjacent to the lesion and scattered lymph vessels on the cyst surface. On November 16 the cyst was resected. A restiform structure was observed between the cyst and the thoracic duct, but the presence or absence of communication was unclear. The histological diagnosis was thoracic duct cyst. Thoracic duct cyst occurring in the cervical region is very rare. Our case may provide useful information as to its pathogenesis and the mode of retention of cyst fluid.