B-Lynch suture for the treatment of uterine atony

INTRODUCTION

Over 125,000 women die of postpartum haemorrhage (PPH) each year, with the commonest cause being uterine atony (75-90 percent). Failing conservative management, hysterectomy is usually the final resort. In 1997, Christopher B-Lynch devised an innovative technique to treat uterine atony, and it has been widely used around the world since its original report. However, there are hardly any reports of this technique being utilised in East Asian countries, including Singapore. Our study reviews the cases in which the B-Lynch suture was used to treat uterine atony, and the clinical outcomes of these cases.

METHODS

A retrospective study of data of all women who delivered between May 2004 and June 2007 was collected from the department's database, to identify patients who had undergone the B-Lynch procedure. Primary PPH is defined as a blood loss of more than 500 ml at or within 24 hours of delivery.

RESULTS

There were a total of 5,470 deliveries during this period, with primary PPH occurring in 100 cases. The B-Lynch procedure was performed in seven women, avoiding the need for a hysterectomy in five cases.

CONCLUSION

Our series of cases treated with the B-Lynch procedure showed that it is an effective method of containing PPH. It has the advantage of being applied easily and rapidly, and should be taught to all trainees and registrars in obstetrics. It should be attempted when conservative management of PPH fails and before any radical surgery is considered.

[Off-pump coronary artery bypass and right ventricular branch translocation for coronary aneurysm; report of a case]

The successful surgical treatment for a coronary artery aneurysm was reported. A 38-year-old female presented with angina pectoris due to right coronary artery stenosis. Angiography revealed a right coronary artery aneurysm and 90% stenosis at a site just proximal to the aneurysm, accompanied by the relatively large right ventricular (RV) branch originating from a mid portion of the aneurysm. Off-pump coronary artery bypass grafting (CABG) to the right coronary artery (RCA) #3, translocation of RV branch to RCA #3, and ligation of RCA proximal and distal to the aneurysm were successfully performed. Post-operative course had been uneventful with satisfactory angiographic results. Coronary translocation with CABG could be a treatment option for coronary artery aneurysms.

Flow interruption of the distal radial artery: treatment for finger ischemia in a matured radiocephalic AVF

PURPOSE

To establish an effective approach for diagnosis and treatment of hand ischemia in matured radiocephalic arteriovenous fistulae (AVF).

METHODS

One hundred and fifty end-stage renal disease patients (4% of our practice) presented to our outpatient vascular access facility complaining of a range of symptoms including coldness, numbness and pain in the fingers indicative of ischemia due to steal syndrome. In 15 patients the symptoms of steal syndrome were limited to the fingers, sparing the hand. Physical examination was indicative of steal syndrome caused by shunting of blood from the ulnar artery via the palmar arch, away from the fingers and into the fistula. To confirm the diagnosis, angiography was performed which demonstrated retrograde flow in the distal radial artery (DRA), a hypertrophied palmar arch, and a patent hypertrophied ulnar artery. Ischemia was treated with DRA flow interruption. Transcatheter coil embolization of the DRA (10 patients) was preferred because it proved to be a quick, safe and effective technique. Whenever embolization was not possible ligation of the DRA was performed in accordance with accepted surgical literature (five patients).

RESULTS

DRA flow interruption was effectively accomplished by either ligation or coil embolization in all cases. All patients had symptomatic improvement. Complete symptom resolution was experienced by 100% (10/10) of patients who received DRA embolization and by 3/5 patients who required ligation. The average follow-up period was 9 months. There were no complications during the procedure or during the follow-up period.

CONCLUSION

Diagnosis using physical examination, angiography and treatment with embolization or ligation of the DRA can be performed with great success in an outpatient setting.

[Ascending aortic dissection associated with pulmonary contusion caused by blunt trauma]

A 77-year-old female tumbled and struck her front chest wall twice. After the event, hemosputum was observed and she complained of slight chest discomfort. As chest pain continued to worsen a week after the event, she was transferred to our hospital. The computed tomography (CT) revealed an ascending aortic dissection and bilateral pulmonary contusion. In the intensive care unit (ICU), antihypertensive therapy was given immediately and delayed surgical repair was planned because of pulmonary contusion. Twenty days after the event, proximal hemiarch replacement was performed. Postoperative course was uneventful without any complication. She was discharged on the 23rd day after the operation.

[Open stent-grafting for the distal arch aneurysm using a new delivery sheath]

Surgical graft replacement of the distal aortic arch aneurysm has been known to have rather poor outcome. Open stent-grafting has been employed in many institutions, but several complications have been reported. Especially, embolism of the distal artery by debris of aneurysmal wall is a serious complication. Therefore we have developed and applied a new delivery sheath. The sheath is constructed with a ready-made delivery sheath and a part of a ready-made tracheostomy tube. That is called "balloon sheath". Five patients underwent distal arch stent-grafting using the device, all of whom had excellent result. The merits of the sheath are smooth delivery of stent-graft and less invasiveness for aortic wall. The new device is considered to be able to prevent aortic wall injury and peripheral embolic complication during insertion of stent-graft.

[Clinical evaluation of hydrocolloidal dressing in 147 patients undergoing cardiovascular surgery]

Recent evidence has suggested that a moist environment plays an important role in wound healing. Karayahesive, one type of hydrocolloidal dressing, contains natural karaya gum as a hydrophilic gel. We applied hydrocolloidal dressing to operative wounds in 147 patients who underwent cardiovascular surgery from April 2001 through August 2002 to evaluate its clinical usefulness. The dressing was kept on the wounds for 7 days after operation, but was immediately switched to conventional dressing with gauze if there was any problem. A total of 144 patients (98%) had no wound chest infections. Good wound healing was obtained with only 1 dressing, removed 7 days after operation, in 128 patients (87%). In 19 patients (13%), the hydrocolloidal dressing was switched to conventional dressing. In 13 of these patients the hydrocolloidal dressing dissolved naturally or exudation occurred; clinically, there were no local problems; however, 3 patients had infection, 2 had fat necrosis, and 1 had burn injury caused by electrocautery. No patients had skin problems caused by this dressing. We conclude that hydrocolloidal dressing can be used safely and effectively in patients undergoing cardiovascular surgery and reduce the workload of healthcare workers.

[Ruptured syphilitic ascending aortic aneurysm; report of a case]

Syphilitic cardiovascular disease has become a rarity today. It most commonly affects the ascending aorta and aortic arch. A case is reported of a 50-year-old female with a ruptured syphilitic ascending aortic aneurysm who underwent an emergency operation. The patient was emergently admitted with complaint of severe dyspnea, circulatory shock due to cardiac tamponade was observed in the emergency room. Bentall's procedure was performed. Intraoperative findings showed multi-cystic dilatation of an aortic root. Penetration was existed on right side posterior wall of an aortic root. Postoperative pathological examination of the aneurysmal wall revealed the characteristic finding of syphilitic aortitis. The postoperative course was uneventful and the patient has been doing well at period of 3 years after operation.

[Primary cardiac malignant lymphoma diagnosed intraoperatively during aortic valve repair; report of a case]

A 58-year-old male who complained of chest oppression on effort was diagnosed as aortic regurgitation by echocardiography. The cardiac catheterization was showed moderate aortic regurgitation. He was referred to our hospital for aortic valve replacement. We considered preoperatively that the aortic regurgitation is due to infective endocarditis or aortitis syndrome. We have not noticed cardiac tumor at all until aortic valve replacement. Postoperative pathological diagnosis of the tumor was malignant lymphoma. The tumor had a characteristic architecture of a cardiac MICE (mesothelial/monocytic incidental cardiac excrescence). After the operation, additional chemotherapy using doxorubicin and cysplatin was performed. The patient has been doing well for 5 years after operation.

[Combined operation for left ventricular aneurysm and ventricular septal perforation with normal coronary arteries; report of a case]

We experienced a rare case of left ventricular aneurysm (LVA) and ventricular septal perforation (VSP) with normal coronary arteries, and had a good outcome by undergoing Dor procedure and direct closure of VSP individually. A 68-year-old female was printed out cardiac systolic murmur. Echocardiogram revealed LVA and VSP, but coronary arteriogram showed no significant stenosis. The apex was incised longitudinally, lateral and parallel to the interventricular groove. VSP was directly closed by 2 pieces of 3-0 polypropylene suture with felt strip. Purse-string stitch with 3-0 polyester suture around the transitional zone between fibrotic tissue and viable tissue was secured to firm fibrous tissue. The residual orifice was closed with an elliptical composite patch of equine pericardial patch and polyester velour with 3-0 polypropylene suture. We considered based on the operative finding that myocardial infarction (MI) led to LVA and VSP. Coronary thrombosis rather than coronary spasm may have provoked MI because spasm provocative test was negative.

[Bilateral coronary ostial stenoses with aortic regurgitation in a patient with syphilitic aortitis]

Syphilitic aortitis is now rare in developed countries and is sometimes overlooked. A 61-year-old man with bilateral coronary ostial stenoses (#5:90%, #1:99%) and Sellers III/IV aortic regugitatioin (AR) induced by syphilitic aortitis presented with chest pain. Preoperative rapid plasma reagin titer and Treponema pallidum hemagglutination test were strongly positive, 256 fold and 191.25 C.O.I., respectively. Aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) with bilateral internal thoracic arteries (ITA) was performed successfully. The angiographic features as follows: 1) coronary artery stenosis is generally limited to the ostia, 2) the grade of stenosis is almost always more than 90%, 3) AR is frequently associated with coronary ostial stenosis. CABG should be performed with ITA, not saphenous vein grafts, to avoid occlusion of the ostium of the saphenous vein graft by syphilitic aortitis. Retrograde cardioplegia should be performed if ostial stenosis is severe.

[Surgical repair of left ventricular free wall rupture using layered fibrin glue sheet and fibrin glue; report of a case]

A 57-year-old man with acute myocardial infarction (#13:90%, #6-#8:75%) was admitted to our hospital after the administration of tissue plasminogen activator. Three hours' after emergent percutaneous transluminal coronary angioplasty, he developed left ventricular free wall rupture in the left circumflex artery area. After bleeding was completely controlled by aortic cross clamping, a three-layered of fibrin glue sheet (TachoComb) with fibrin glue was extensively applied to the ruptured site including the infarcted area. He was discharged on the 25th postoperative day and underwent coronary artery bypass grafting to the left anterior descending artery three weeks later. This experience suggests that the layered TachoComb and fibrin glue are effective for left ventricular free wall rupture.

Multiplex sequence-tagged site PCR for efficient screening of microdeletions in Y chromosome in infertile males with azoospermia or severe oligozoospermia

The multiplex STS-PCR method was used to detect microdeletions in the long arm of the Y chromosome (Yq) of cytogenetically normal men. One hundred infertile men with azoospermia or oligozoospermia were screened with the multiplex PCR method using 58 STSs, which are specific to Yq for detecting microdeletions on this chromosome. Correlations between the microdeletions on Yq and phenotypes of spermatogenetic disturbance were also examined. Ten patients (10%) had microdeletions on Yq. Seven of the 60 azoospermic patients (11.7%), and 3 of the 40 oligozoospermic patients (7.5%) had microdeletions on Yq. None of the patients showed microdeletions in the AZFa region, but 2 had deletions in the AZFb region, another 2 in the AZFc region, including DAZ, and 1 had deletions in both the AZFb and in the AZFc, including RBM and DAZ. Single microdeletions were found in 4 patients, all of them in the AZFc around DAZ, and 1 patient had 2 microdeletions in the AZFb. The improved multiplex STS-PCR method efficiently detected microdeletions in 10% of azoospermic or severe oligozoospermic men who were cytogenetically normal. All of these microdeletions were presented in the AZFb and/or AZFc regions. This suggests that these regions contain candidate genes for spermatogenesis.

[Effect of autologous platelet-rich plasma (PRP) in cardiac surgery]

Autologous platelet-rich plasma (PRP) was harvested before cardiopulmonary bypass (CPB). After heparin neutralization, it was returned to patients. The purpose of this study was to examine platelet function and the amount of blood loss and blood transfusion after transfusion of PRP. Twenty-eight patients undergoing elective coronary artery bypass grafting and other procedures were divided into three groups: group A; patients undergoing CAGB between May and October 1997 (n = 10), group B; patients undergoing other between May and October 1997 (n = 8), group C; patients undergoing CAGB before May 1997 (n = 10). Blood cell count, platelet aggregation in response to ADP, and platelet adhesion were measured before CPB, just after CPB, after infusion of protamine and PRP, 24 hrs after CPB and 48 hrs after CPB. Blood loss and blood transfusion in group. A and group C were examined after CPB. There was no significant difference in platelet count between group A and group B. There was significant difference in platelet aggregation in group A. There was no significant difference in blood loss after CPB between group A and group C, but there was a significant difference in blood transfusion between group A and group C. These results suggest that PRP was useful to preserve platelet function and to decrease blood loss after CPB in cardiac surgery.

Adrenal steroids in human prostatic cancer cell lines

Adrenal androgens function as an androgen source within prostate and androgen target tissue. This study compares the ability of three human prostatic cancer cell lines to metabolize the adrenal androgens, dehydroepiandrosterone (DHEA), and androstenedione under living culture conditions. Androgen-independent cell lines PC-3 and DU145 and androgen-dependent cell line LNCaP were investigated. The effect of glucuronide and sulfate conjugates was also investigated. There was a strong tendency in PC-3 or DU145 to convert androstenedione to DHEA or DHEA-S reservoir. On the other hand, LNCaP was capable of converting DHEA into androstenedione and subsequently into dihydrotestosterone (DHT). Moreover, androgens were converted into a glucuronide conjugate in LNCaP, but not in PC-3 or DU145. As a result, the metabolism of the adrenal precursor shifted to androgen formation in LNCaP. This could be confirmed by means of reverse transcription-PCR of uridine diphosphoglucuronosyl-transferase (UGT) 2B15. Kinetic properties of UGT activity in LNCaP revealed DHT to be a better substrate than testosterone. In conclusion, the findings show that the adrenal precursor pool has the potential to contribute to the regulation of prostatic cells. Moreover, the presence of UGT activities in LNCaP may have a regulatory effect on the active androgen level in the intracellular environment.

Mutations that affect dimer formation and helicase activity of the hepatitis C virus helicase

Interaction between viral proteins is necessary for viral replication and viral particle assembly. We used the yeast two-hybrid assay to identify interactions among all the mature proteins of the hepatitis C virus. The interaction between NS3 and NS3 was one of the strongest viral protein-protein interactions detected. The minimal region required for this interaction was mapped to a specific subdomain of 174 amino acids in the N terminus of the helicase region. Random mutations in the minimal region were generated by PCR, and mutants that failed to interact with a wild-type minimal fragment were isolated using the yeast two-hybrid assay as a screen. Three of these mutations resulted in a reduction or a loss of interaction between helicases. Analytical gel filtration showed that in the presence of an oligonucleotide, wild-type helicases form dimers whereas the mutants remain mostly monomeric. All three mutants were partially or almost inactive when assayed for helicase activity in vitro. Mixing a mutant helicase (Y267S) with wild-type helicase did not dramatically affect helicase activity. These data indicate that dimerization of the helicase is important for helicase activity. The mutations that reduce self-association of the helicase may define the key residues involved in NS3-NS3 dimerization.

[Clinicopathological study of the testicular microlithiasis]

PURPOSE

Testicular microlithiasis (TM) is a relatively rare condition characterized by calcific concref1p4 within the seminiferous tubules. Little has been reported on the incidence or the clinical implication of TM among Japanese. To address the problem, we evaluated pathologic specimens from biopsies and orchiectomies, of testes with various conditions.

MATERIALS AND METHODS

Pathologic specimens of the testes of 200 cases, 56 from orchiectomy and 144 from testicular biopsy, were investigated.

RESULTS

The pathological diagnosis of TM was confirmed in seven (3.5%) cases, four of which were associated with germ cell tumors and the other three were obtained from testicular biopsies performed for examination of infertile men. Of the 41 patients with germ cell tumors, four (9.8%) were found to have TM, and another three (2.5%) were identified among 122 patients with infertility. The prevalence of TM is significantly higher in specimen with germ cell tumors than those without germ cell tumors (p < 0.05).

CONCLUSIONS

Although TM is rarely encountered, this condition is relatively often accompanied by testicular malignancy. Further investigation would be fundamental to ascertain the relationship between TM and testicular malignancy.

Determination of sulfite in Oriental herbal medicines

Sulfite was detected in 7 varieties of Oriental herbal medicines (Pueraria radix, Zingiberis rhizoma, Platycodon radix, Adenophora radix, Pinellia tuber, Astragalus radix, and Paeonia radix) on the Korean market. Sulfiting of commercial Oriental herbal medicines by fumigation with burning bituminous coal was simulated, and the accumulation of sulfite was investigated by using fresh Platycodon radix roots obtained from a growing field. The sulfite level reached a plateau in 9 h, and the maximum sulfite level found by the Monier-Williams (MW) method (AOAC 990.28) was 1020 ppm. The sulfite content in the simulated Platycodon radix sample determined by alkali extraction followed by ion-exclusion chromatography with electrochemical detection (AOAC 990.31) was approximately 17% lower on average than the MW results. Free-sulfite levels determined by acid extraction and ion-exclusion chromatography with electrochemical detection were between 19 and 49% of the MW results. The advantages of different methods for sulfite determination and the significance of the results are discussed.

Fas-mediated apoptosis in adriamycin-induced cardiomyopathy in rats: In vivo study

BACKGROUND

The precise molecular mechanism of Adriamycin-induced cardiomyopathy (ADR-CM) is still unknown. We address the demonstration of apoptotic myocardial cell death and the apoptosis-inducing molecules in ADR-CM induced in rats.

METHODS AND RESULTS

Until 8 weeks after the first administration of ADR, there was no increase in the number of labeled cells by terminal deoxynucleotidyl transferase assay (TUNEL method). Apoptotic indices increased significantly at weeks 9 and 10 in hearts of the ADR-treated group but not in those of the control group (0.42+/-0.12% versus 0.10+/-0.02% and 0.86+/-0.11% versus 0.09+/-0.04% at weeks 9 and 10, respectively). DNA ladder formation was also observed in the myocardial tissues during the late stages of the ADR-CM of rats. There was no significant difference in expression of p53 gene between the ADR group and the control group at either the message or the protein level. An overexpression of Fas antigen was shown in myocardial cells of ADR-treated hearts at weeks 9 and 10 by both Western blotting and immunofluorescent staining. Furthermore, we confirmed that neutralization of anti-Fas ligand antibody inhibited ADR-induced apoptosis.

CONCLUSIONS

Apoptotic cell death was observed in the hearts of ADR-CM rats, and the number of apoptotic myocardial cells increased with the deterioration of morphological findings and cardiac function, indicating that apoptosis may be an important mechanism of loss of myocardial cells and cardiac dysfunction in ADR-CM. Apoptosis in ADR-CM rats is not p53-dependent but rather is executed through a Fas-mediated pathway.