Circulating inflammatory monocytes oppose microglia and contribute to cone cell death in retinitis pigmentosa

Retinitis pigmentosa (RP) is an intractable inherited disease that primarily affects the rods through gene mutations followed by secondary cone degeneration. This cone-related dysfunction can lead to impairment of daily life activities, and ultimately blindness in patients with RP. Paradoxically, microglial neuroinflammation contributes to both protection against and progression of RP, but it is unclear which population(s) - tissue-resident microglia and/or peripheral monocyte-derived macrophages (mφ) - are implicated in the progression of the disease. Here we show that circulating blood inflammatory monocytes (IMo) are key effector cells that mediate cone cell death in RP. Attenuation of IMo and peripherally engrafted mφ by Ccl2 deficiency or immune modulation via intravenous nano-particle treatment suppressed cone cell death in rd10 mice, an animal model of RP. In contrast, the depletion of resident microglia by a colony-stimulating factor 1 receptor inhibitor exacerbated cone cell death in the same model. In human patients with RP, IMo was increased and correlated with disease progression. These results suggest that peripheral IMo is a potential target to delay cone cell death and prevent blindness in RP.

RECURRENCE RATE OF CYSTOID MACULAR EDEMA WITH TOPICAL DORZOLAMIDE TREATMENT AND ITS RISK FACTORS IN RETINITIS PIGMENTOSA

PURPOSE

To investigate the rate of the recurrence of cystoid macular edema (CME) secondary to retinitis pigmentosa (RP) after the initiation of topical dorzolamide and the recurrence risk factors.

METHODS

We retrospectively analyzed the data of RP patients at Kyushu University Hospital. We included patients who showed a treatment response to 1.0% topical dorzolamide. The day of treatment initiation was set as the baseline. Topical dorzolamide treatment was continued during the follow-up. The recurrence of CME (defined as a >20% increase in central subfield thickness compared to previous visit, or a central subfield thickness value that exceed baseline value) was evaluated at each follow-up visit. Risk factors for RP-CME recurrence were analyzed by Cox proportional hazards modeling. A Kaplan-Meier survival analysis was used to evaluate the time to recurrent RP-CME.

RESULTS

Forty RP-CME patients showed a treatment response to topical dorzolamide. During the mean 3.9-year follow-up, 14 patients exhibited recurrence; its rate was 15.6%, 34.7%, and 48.7% at 1, 3, and 5 years, respectively. A high baseline central subfield thickness was significantly associated with recurrent (hazard ratio 1.11, 95% CI: 1.05-1.18, P = 0.0004).

CONCLUSION

The recurrence rate of RP-CME increased with time. A high baseline central subfield thickness value was a risk factor for recurrence.

Long-term Outcomes of Cataract Surgery in Patients with Retinitis Pigmentosa

PURPOSE

To investigate the long-term outcomes of cataract surgery in patients with retinitis pigmentosa (RP).

DESIGN

Retrospective, observational study.

PARTICIPANTS

Sixty-four patients with typical RP (22 males, 42 females, average age 62.8 ± 10.1 years) who underwent cataract surgery at Kyushu University Hospital between May 2007 and October 2015 and who were followed up for ≥3 years post-surgery.

METHODS

Differences between pre- and post-surgery visual function, including best-corrected visual acuity (BCVA) and parameters in the Humphrey Field Analyzer (HFA) examinations using the central 10-2 program were investigated. The pre-surgery conditions of the foveal ellipsoid zone (EZ) were classified into three grades (grade 1: invisible; grade 2: abnormal; grade 3: normal) based on optical coherence tomography findings.

MAIN OUTCOME MEASURES

BCVA, the retinal sensitivity in HFA 10-2 tests.

RESULTS

Cataract surgery was performed in 96 eyes, with an average follow-up period of 5.8 ± 2.4 years. The mean pre-surgery BCVA was 0.64 ± 0.52 logarithm of the minimum angle of resolution (logMAR), and the final post-surgery BCVA was 0.61 ± 0.67 logMAR (p=0.57). Significant improvement of post-surgery BCVA was observed only in the eyes with preserved foveal EZ (grade 3) (p<0.01). In 62 eyes of the 45 patients who received HFA 10-2 tests, the mean values of deviation, macular sensitivity and foveal sensitivity at the final visit were significantly decreased compared with preoperative values (p<0.01), while those in the grade 3 eyes did not change significantly post-surgery (p=0.13).

CONCLUSIONS

In the long-term course after cataract surgery in RP patients, many cases experienced vision loss with progression of the disease. A preoperative finding of preserved foveal EZ was associated with a better visual prognosis, suggesting that EZ evaluation is useful to predict the long-term visual outcome after cataract surgery in RP patients.

Changes of Serum Inflammatory Molecules and Their Relationships with Visual Function in Retinitis Pigmentosa

Purpose

Retinal degeneration involves neuroinflammation, and pro-inflammatory cytokines/chemokines are markedly increased in the eyes of patients with retinitis pigmentosa (RP). In this study, we investigated the changes of serum cytokines/chemokines in RP, and their relationships with visual parameters.

Methods

Forty-five consecutive patients with typical RP aged 20 to −39 years and 28 age-matched and gender-matched controls were included. Fifteen cytokines (interleukin [IL]-1α, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p70, IL-13, 1L-15, IL-17, IL-23, interferon [IFN]-γ, and tumor necrosis factor [TNF]-α, TNF-β) and 9 chemokines (eotaxin, growth-related oncogene [GRO]-α, I-309, IL-8, IFN-γ-inducible protein [IP]-10, monocyte chemotactic protein [MCP]-1, MCP-2, regulated activation normal T-cell expressed and secreted [RANTES], and thymus and activated regulated chemokine [TARC]) in the serum were simultaneously measured by a multiplexed immunoarray (Q-Plex). Relationships between these cytokines/chemokines and indices of central vision, such as visual acuity (VA), the values of static perimetry tests (Humphrey Field analyzer, the central 10-2 program), and optical coherence tomography measures were analyzed in the patients with RP.

Results

Among the 15 cytokines and 9 chemokines, serum IL-8 and RANTES levels were significantly increased in patients with RP compared with controls (IL-8: P < 0.0001; RANTES: P < 0.0001). Among the elevated cytokines/chemokines, the levels of IL-8 were negatively correlated with VA (ρ = 0.3596 and P = 0.0165), and the average retinal sensitivity of four central points (ρ = −0.3691 and P = 0.0291), and 12 central points (ρ = −0.3491 and P = 0.0398), as well as the central subfield thickness (ρ = −0.3961 and P = 0.0094), and ellipsoid zone width (ρ = −0.3841 and P = 0.0120).

Conclusions

Peripheral inflammatory response may be activated and serum IL-8 levels are associated with central vision in patients with RP.

Aqueous Flare and Progression of Visual Field Loss in Patients With Retinitis Pigmentosa

Purpose

To investigate the association between aqueous flare and progression of visual field loss using the Humphrey Field Analyzer in patients with retinitis pigmentosa (RP).

Methods

We examined a total of 101 eyes of 101 patients who were diagnosed with typical RP. Sixty-one percent of the patients were female, and the mean age of the total group was 47.4 years. Aqueous flare, visual field (by an Humphrey Field Analyzer, the central 10-2 SITA-Standard program), and optical coherence tomography measurements were obtained for all patients. The slope, which was derived from serial values of mean deviation, macular sensitivity, or foveal sensitivity for each eye with univariate linear regression, was used for analysis.

Results

Aqueous flare values were significantly correlated with the mean deviation slope (r = −0.20, P = 0.046), macular sensitivity slope (r = −0.28, P = 0.005) and foveal sensitivity slope (r = −0.20, P = 0.047). The values of the retinal sensitivity slope significantly decreased as the aqueous flare level increased (all P < 0.05). These associations remained unchanged after adjustment for age, sex, and posterior subcapsular cataract, and epiretinal membrane.

Conclusions

Elevation of aqueous flare is a risk factor for the decline of central visual function in RP. Aqueous flare may be a useful marker for disease progression in RP.

Direct comparison of retinal structure and function in retinitis pigmentosa by co-registering microperimetry and optical coherence tomography

PURPOSE

To evaluate the retinal structure-function relationships in the macula of retinitis pigmentosa (RP) patients by comparing microperimetry-3 (MP-3) images with co-registered optical coherence tomography (OCT) images.

METHODS

Thirty patients with typical RP were recruited from our hospital. The maculae of patients were examined with MP-3 and OCT. The retinal sensitivity was measured by MP-3 at 40 testing points arranged concentrically in a 16° diameter of the central retina, and we divided the 40 points into four zones according to degree from the fovea (2°, 4°, 6°, and 8°). We analyzed the correlation coefficients between the retinal sensitivity and the total retinal thickness (TRT), the length from the inner limiting membrane to the retinal pigment epithelium (RPE), and between the retinal sensitivity and the outer retinal thickness (ORT), the length from the outer plexiform layer to the RPE at each stimulus point.

RESULTS

TRT showed moderate correlations with the retinal sensitivity at 2° (median ρ = 0.59 interquartile range (IQR) [0.38-0.72]), 4° (ρ = 0.59 [0.55-0.68]) and 6° (ρ = 0.60 [0.54-0.63]), and TRT was weakly-to-moderately related to the retinal sensitivity at 8° (ρ = 0.27 [0.19-0.48]). ORT exhibited strong correlations at 2° (ρ = 0.72 [0.60-0.81]), 4° (ρ = 0.71 [0.75-0.67]) and 6° (ρ = 0.70 [0.54-0.74]), and a weak-to-moderate correlations at 8° (ρ = 0.34 [0.29-0.53]). ORT was more strongly correlated with the retinal sensitivity compared to TRT (p = 0.018).

CONCLUSION

ORT, rather than TRT, within 6° eccentricity was strongly correlated with the retinal sensitivity, suggesting that measuring ORT in those areas will help evaluate the macular status and progression in RP.

[Case of a giant pericardial cyst went under the thoracoscopic surgery using a double-balloon catheter]

A 45-year-old female was referred to our hospital due to right anterior chest pain. A chest X-ray and a computed tomographic examination showed a large cystic lesion in the right pleural cavity above the diaphragm. The internal surface of the cyst seemed to be smooth and the content was homogeneous suggesting clear liquid. Under the diagnosis of the benign pericardial cyst, a thoracoscopic surgery was performed using a double-balloon catheter. Aspiration of the cyst content by the double-balloon catheter minimized the spillage of the content into the thoracic cavity. Furthermore, the double-balloon catheter allowed the cyst wall to be more easily grasped and manipulated. We confirmed the usefulness of a double-balloon catheter for the thoracoscopic resection of giant cystic lesions.

A novel analytical ELISA-based methodology for pharmacologically active saikosaponins

A competitive enzyme-linked immunosorbent assay (ELISA) for saikosaponins was established using monoclonal antibody (MAb) 3G10. Hybridoma 3G10 prepared by fusing splenocytes immunized with saikosaponin a-BSA (SSa-BSA) conjugate and a hypoxanthine-aminopterin-thymidine (HAT)-sensitive mouse myeloma cell line, P3-X63-Ag8-U1, secreted monoclonal antibodies with wide cross-reactivity to saikosaponins including saikosaponin b(2) (SSb(2)), c (SSc) and d (SSd), which are stereo and/or regio isomers of SSa. The method, at an effective measuring range of 0.6 mug /ml to 2.3 mug/ml of SSa, successfully detected total saikosaponins in Bupleuri radix and Kampo medicines prescribed with Bupleuri radix. Good correlation between ELISA and HPLC analyses of total saikosaponin in a crude extract of Bupleuri radix was obtained after hydrolysis of acyl saikosaponins by treatment with a mild alkaline solution.

Bilateral video-assisted thoracoscopic surgery in the supine position for primary spontaneous pneumothorax

On the basis of the bilateral nature of bullous lesions of the lung, the authors have performed single-stage bilateral video-assisted thoracoscopic surgery (VATS) in the supine position for primary spontaneous pneumothorax in five patients since October 1999. All five patients were males with a mean age of 23 years (range 19 to 29 years). The presenting pneumothorax was ipsilateral (right-sided) in four patients and simultaneous bilateral in the one remaining patient. Apart from the one case of simultaneous bilateral spontaneous pneumothorax (SBSP), all patients had a history of at least one pneumothorax episode requiring tube thoracotomy. Bilateral bullae were confirmed in all patients on preoperative chest computed tomography (CT). Bilateral bullectomy was performed by endo-stapler with no difficulties. Mean operating time was 111 minutes (range 85 to 140 minutes). All patients were returned to the surgical ward in good condition from the operating room immediately after extubation. No complications were observed, and duration of postoperative hospital stay was two to four days. All patients were alive without recurrence of pneumothorax after a mean follow-up period of 25 months (range, 9 to 43 months). Single-stage bilateral VATS in the supine position has shown itself to be an excellent approach for the treatment of bilateral bullous lesions, combining both efficacy and low morbidity.

The Figure-L Unilateral Mini-Sternotomy for Anterior Mediastinal Tumor

We performed a figure-L unilateral mini-sternotomy for anterior mediastinal tumor resection in ten patients. Pathological diagnosis among the ten included six thymomas, three mature teratomas including one with a seminoma component, and one thymic cyst. Mean tumor length was 7 x 5 x 4 cm. The required skin incision was 8 cm in mean length. The third intercostal space was transected in six cases, the fourth intercostal space in four cases. Bilateral internal thoracic arteries were preserved in all cases. All tumors were completely resected without complications during the procedure. Mean operating time was 106 minutes (range 85 to 120 minutes). Postoperative hospital stay ranged from three to seven days without any complications. All patients were alive at the end of a mean follow-up period of 39 months (range 3 to 60 months). The figure-L unilateral mini-sternotomy is considered an effective and useful minimally invasive approach for anterior mediastinal tumors.

Placement of the Dumon Stent Using a Flexible Bronchofiberscope via Tracheostomy

In this paper, we report on a new technique of Dumon stent placement using a flexible bronchofiberscope. This procedure was used to insert Dumon stents in two bronchial obstruction and two bronchofistula cases. The stenting technique described here can be used through either a tracheostoma or the oral cavity; it presents a very straightforward and safe procedure that does not require the use of a rigid bronchoscope.

[Combined surgery for cardiovascular disease and general thoracic lesions]

Surgical management of patients with concomitant critical cardiovascular disease and resectable general thoracic lesions is controversial. During a 16-year period (1985 to 2001), 15 patients underwent combined cardiovascular and general thoracic operations, of the 2,459 patients who underwent a cardiovascular operation requiring cardiopulmonary bypass at our institution. Patients had cardiovascular symptoms only and the general thoracic lesions were incidentally found by preoperative chest roentgenograms and/or computed tomography. Because of the cardiovascular disease, a pathological diagnosis was precluded before surgery. All except one descending thoracic aortic operation underwent concurrent pulmonary resection after neutralization of protamine following cardiovascular surgery requiring extracorporeal circulation. Lung pathology consisted of pulmonary bullae (n = 7), primary lung cancer (n = 4), benign lung tumor (n = 2), metastatic lung cancer (n = 1), and thymic cyst (n = 1). The pulmonary operations include bullectomy (n = 7), wedge resection (n = 6), lobectomy (n = 3), and removal of a thymic cyst (n = 1) including 2 staged procedures. The final diagnoses in 4 lung cancer cases were T1. N0M0, stage IA (n = 3) and T2N2M0, stage IIIA (n = 1). All malignancies including metastatic lung cancer, were able to be completely resected. The mean intraoperative bleeding volume for the cases was 997 +/- 221 ml, while mean duration of surgery was 382 +/- 31 minutes. Except for 2 cases required long term ventilatory support, the mean durations of tracheal intubation and ICU stay were 2.2 +/- 0.2 and 3.8 +/- 1.0 days respectively. Except for 1 surgical death, mean survival duration and 5-year survival rate were 59.7 +/- 12.5 (5-177) months and 66.3% respectively. These findings suggest that combined pulmonary resection with cardiovascular surgery is safe and offers a favorable prognosis to a selected group of patients.

Herpes simplex virus pneumonia after cardiac surgery: report of a case

A rare case of a 61-year-old man who developed herpes simplex virus (HSV) pneumonia after cardiac surgery is presented. He was immunocompetent before the operation and had no history of a mucocutaneous herpesvirus infection. This potentially fatal complication was successfully managed with acyclovir treatment after establishing the diagnosis with bronchoalveolar lavage. A depression of the patient's cell-mediated immunity after cardiopulmonary bypass may have been a causative factor. An unusual type of pneumonia such the HSV pneumonia seen in the present case should therefore be considered in patients with severe hypoxemia accompanied with unexplained pulmonary infiltrates after cardiac surgery using cardiopulmonary bypass which does not improve with conventional treatment.

Pulmonary carcinoid found in a patient who presented with initial symptoms of brain metastasis: report of a case

Although atypical pulmonary carcinoids frequently metastasize to regional lymph nodes, they rarely metastasize to the brain. We describe herein an extremely unusual case of a 52-year-old woman who presented with the symptoms of brain metastasis as the initial manifestation of an atypical pulmonary carcinoid. After control of the multiple metastatic brain lesions had been achieved by tumorectomy and stereotactic radiosurgery, a middle lobectomy of the right lung was performed to completely resect the primary pulmonary carcinoid. This aggressive surgical approach was successful in that it prolonged the survival of the patient and enhanced her quality of life.

[Intracranial occlusion of the internal carotid artery after minor closed head injury]

Thrombosis of the extracranial portion of the internal carotid artery as a result of nonpenetrating head and neck injury is not uncommon. However, intracranial occlusion of the internal carotid artery after minor head and neck injury without skull fracture is rare. We report a case of 14-year-old male who suffered a minor head injury during an athletic meeting of his school and developed a right hemiparesis and a lethargy state resulting from thrombosis of the supraclinoid portion of the left internal carotid artery. On admission, skull films and a CT scan revealed no abnormality. One hour later, he fully recovered. One day later, no definite lesions were detected on T1-weighted and T2-weighted image of MRI, but an abnormal high signal lesion in the left frontal lobe was detected on diffusion-weighted image of MRI. On additional MR angiography, intracranial occlusion of the internal carotid artery due to dissection was demonstrated.

[A case of diffuse alveolar hemorrhage developing after open heart surgery]

A 47-year-old man was receiving anticoagulant therapy after coronary artery bypass grafting and mitral valve plasty. A chest roentgenogram disclosed alveolar infiltrates throughout both lung fields 6 months postoperatively. Lung biopsy specimens showed the presence of hemosiderin-laden macrophages in the alveolar spaces, establishing a diagnosis of diffuse alveolar hemorrhage. Anticoagulant therapy may have caused the hemorrhage, because the patient had no immunologic disorder or renal disease. The shadows completely disappeared after steroid therapy and discontinuation of anticoagulant therapy. Diffuse alveolar hemorrhage should be considered, when extensive infiltrates develop on chest roentgenogram in patients receiving anticoagulant therapy after open heart surgery. Lung biopsy is essential, when a bronchoalveolar lavage fails to diagnose the disease.

Balloon catheter for cyst aspiration in a thoracoscopic resection of mediastinal cysts

In a thoracoscopic resection of mediastinal cysts, aspiration of the cyst contents at the beginning of the procedure is often helpful because it allows the cyst to be more easily grasped and manipulated. Spillage of the cyst contents into the thoracic cavity may, however, occur during aspiration when an ordinary aspiration needle is used. If the cyst contents are infective, then a subsequent contamination of the thoracic cavity may develop. We therefore use a specially designed double-balloon catheter for aspiration to minimize spillage of the cyst contents into the thoracic cavity. We describe herein the usefulness of this aspiration technique.

Thermodynamics of fluid turbulence: a unified approach to the maximum transport properties

Dissipative properties of various kinds of turbulent phenomena are investigated. Two expressions are derived for the rate of entropy increase due to thermal and viscous dissipation by turbulence, and for the rate of entropy increase in the surrounding system; both rates must be equal when the fluid system is in a steady state. Possibility is shown with these expressions that the steady-state properties of several different types of turbulent phenomena (Bénard-type thermal convection, turbulent shear flow, and the general circulation of the atmosphere and ocean) exhibit a unique state in which the rate of entropy increase in the surrounding system by the turbulent dissipation is at a maximum. The result suggests that the turbulent fluid system tends to be in a steady state with a distribution of eddies that produce the maximum rate of entropy increase in the nonequilibrium surroundings.

[Multiple brain abscesses associated with Rendu-Osler-Weber disease: report of two cases]

Two cases of multiple brain abscesses associated with congenital pulmonary arteriovenous fistula are reported. A 57-year-old male with Rendu-Osler-Weber disease complicated by pulmonary arteriovenous fistula developed multiple brain abscesses in the right parietal region. He responded well to surgical drainage and antibiotic therapy, and the pulmonary arteriovenous fistula, located in the left lower lobe, was resected. A 26-year-old female with Rendu-Osler-Weber disease complicated by pulmonary arterivenous fistula developed recurrent multiple brain abscesses in both the frontal and right parietal regions. The brain abscesses were successfully treated with aspiration and antibiotic therapy. She had a history of two previous brain abscesses in the right parietal regions that were excised on separate occasions at 16 and 23 years of age. Although pulmonary arteriovenous fistula was confirmed by angiography, in this case surgical removal of the pulmonary lesions was not indicated due to multiple vascular shunting. The patient had no recurrence of brain abscess with oral antibiotic therapy.

A new recombinant human bone morphogenetic protein-2 carrier for bone regeneration

A gelatin sponge was formed by foaming and heat treating a gelatin solution, followed by coating the solid with poly(D,L-lactic-co-glycolic acid) to reinforce the gelatin framework. This sponge was tested for its suitability as a biodegradable porous, recombinant human bone morphogenetic protein (rhBMP)-2 carrier. Incorporation of rhBMP-2 into the sponge was closely related to its bulk density of gelatin sponge. The calcium content in the sponges, as assessed by an ectopic bone formation assay in rats, increased with the increasing sponge bulk density. Histologic and peripheral quantitative computed tomography analysis of implants in this ectopic assay system revealed cell growth throughout the carrier in 4 weeks after implantation regardless gelatin bulk density. The carrier containing rhBMP-2 maintained its three-dimensional structure after implantation; the carrier resisted collapse caused by soft tissue pressure during rapid bone formation as assessed by soft X-ray photographs. These results indicate that this newly developed sponge has excellent carrier characteristics to introduce rhBMP-2 into areas needed for bone regeneration.

Clinical experience with temporary vena cava filters

An experience with temporary filter placement, which seems to be safe and effective for temporarily preventing pulmonary embolism, is reported. Since October 1997, six patients had temporary filters. There were two men and four women, with a mean age of 37 years. Three filters were placed at the infrarenal inferior vena cava, two at the suprarenal inferior vena cava, and one at the superior vena cava. All filters were placed before various surgical interventions. During filter placement, anticoagulation therapy was routinely performed. There were no complications at and during filter placement. No pulmonary emboli occurred during surgical intervention. All filters were successfully removed, two of which were exchanged for permanent filters. All patients are alive and well without recurrent deep vein thrombosis and/or pulmonary emboli during a follow-up period of 11 to 25 months. Although this experience is small, temporary filter placement is safe and effective for short-term prevention of pulmonary emboli even in older patients or those with malignant disease. Veins of the upper part of the body may be more favorable than the femoral vein for insertion of a temporary filter. Temporary filters can be safely placed not only at the infrarenal inferior vena cava, but also at the suprarenal inferior vena cava or superior vena cava.

The use of a Dumon stent for the treatment of a bronchopleural fistula

We report the successful management of a bronchopleural fistula with bronchial stent placement combined with irrigation of the empyema cavity. A bronchopleural fistula occurred in a 67-year-old man after a right upper lobectomy for lung cancer. Resuturing of the bronchial stump plus omental wrapping and subsequent closure of the open stump with a pedicled flap of intercostal muscle were not effective. Consequently, we placed a Dumon stent in the right main bronchus to close the stump.

[A case of aneurysm of the peripheral middle cerebral artery undetectable on preoperative angiogram]

The authors describe a rare case of an aneurysm of the peripheral middle cerebral artery. A 63-year-old female with a past history of hypertension suddenly fell into a comatose state, and was brought to our hospital. On admission, CT scan showed intracerebral hematoma located in the right putamen with diffuse subarachnoid hemorrhage. To exclude vascular lesions, an angiography was performed just after admission. The right carotid angiogram showed an aneurysm at the cavernous portion of the internal carotid artery (ICA), but failed to show any aneurysms in the rest of the intracranial circulation. Just after the angiography, emergent operation was performed for the main purpose of evacuation of the hematoma, and with only the secondary purpose of searching for undetectable aneurysms. The patient underwent a right frontotemporal craniotomy. After partial evacuation of the hematoma through the corticotomy of the right frontal operculum, the Sylvian fissure was opened widely. No aneurysm was observed either in the main trunk of the right ICA or the middle cerebral artery (MCA). During the final stage of evacuation of the hematoma through the corticotomy, arterial bleeding occurred. While evacuating the blood, we detected a saccular aneurysm arising from MCA branch (M2-M3 junction) and we clipped the aneurysm. We discuss peripheral MCA aneurysms with a review of the literature.

Three-dimensional magnetic resonance imaging of lung and liver tumors in mice by use of transversal multislice magnetic resonance images

PURPOSE

To diagnose lung and liver tumors experimentally induced in mice in three-dimensional magnetic resonance (MR) images constructed by superimposing transversal multislice MR images of thoracic and abdominal regions taken under a high magnetic field of 7.05 tesla (T).

METHODS

Lung and liver tumors were induced by administration of urethane to A/J mice and implantation of transplantable colon-26 cells into BALB/c mice, respectively. Two-dimensional (2-D) multislice MR images from the thoracic to abdominal regions were taken under the proton density-weighted conditions. Each organ in the 2-D MR images was pseudocolored, and a three-dimensional (3-D) image was constructed by superimposing them on a UNIX computer, using volume-rendering software.

RESULTS

In the normal mouse, each organ in the thoracic and abdominal regions was three-dimensionally imaged and was clearly distinguished from the others. In mice with tumors in the lung or liver, the pathologic changes in the tissue could be visualized in 3-D images.

CONCLUSIONS

The MR images three-dimensionally constructed by use of a method combining MR imaging under a high magnetic field of 7.05 T and a computer technique using volume-rendering software was useful for diagnosis of lung and liver tumors experimentally induced in mice.

[Degradation of thiometon in ethyl acetate]

When performing multiresidue analysis of pesticides, the recovery of thiometon was less than 20% from carrots and eggplants, but about 100% from garlic chives and welsh onions. The recovery of thiometon was found to depend on the lot of ethyl acetate. A 2-year-old lot of ethyl acetate caused degradation of thiometon, but a fresh lot of ethyl acetate did not. Analysis showed that ethyl acetate stored for 2 years contained about 5 microL/mL of acetaldehyde. Thiometon was also degraded by acetone or acetonitrile, when acetaldehyde was added to them, in the same manner as by aged ethyl acetate. The fact that the recovery of thiometon from welsh onions was about 100% indicated that some of the mercaptans in allium vegetables may prevent thiometon degradation. Mercaptans such as L-cysteine and 3-mercaptoproionic acid were confirmed to prevent the degradation of thiometon and disulfoton. These findings show that mercaptans may be useful additives for analyzing thiometon and disulfoton.

[Experience of four cases of postoperative pulmonary embolism requiring surgical treatment]

Four patients underwent a pulmonary embolectomy using cardiopulmonary bypass for acute pulmonary embolism which had occurred after various operations. In two cases, dehydration due to either diabetes insipidus or ileus had existed. In two cases, pulmonary embolism suddenly occurred in our hospital. In the remainder, the disease occurred in the previous hospitals and its diagnosis was established on the 6th and 7th postoperative days, respectively. In massive pulmonary embolism, echocardiography and/or enhanced chest CT are useful for prompt and noninvasive diagnosis. Thrombolytic therapy was performed in only one case before surgical embolectomy, which was not effective. Three patients were discharged without any postoperative complications, but one requiring preoperative external cardiac massage died of multiple organ failure 9 days after operation. Acute pulmonary embolism is one of the fatal postoperative complications. Recognition of this entity, and prompt diagnosis and treatment are essential for managing the fatal disease. Even in the early postoperative period, embolectomy using cardiopulmonary bypass is a safe and effective treatment.

Superior vena caval placement of a temporary filter: a case report

Placement of permanent filters in the superior vena cava (SVC) for preventing pulmonary embolism (PE) arising from thrombi superior to the right atrium has rarely been performed. The authors report the first case of temporary filter insertion in the SVC because of upper extremity thrombosis accompanied with PE. After thrombectomy, the temporary filter was successfully removed. It is recommended to use a temporary filter, especially in young patients with upper extremity thrombosis requiring temporary prophylaxis against PE.

Ruptured thymoma causing mediastinal hemorrhage resected via partial sternotomy

A case of a ruptured thymoma causing mediastinal hemorrhage and hemothorax that was electively resected by a partial sternotomy approach is presented. This case and others previously reported illustrate that a sudden onset of dyspnea and chest pain accompanied by acute mediastinal widening on chest roentgenogram in a previously healthy patient should suggest the diagnosis of a ruptured thymoma. An upper part sternotomy approach may be as safe and effective as a less invasive surgical procedure in resection of noninvasive thymomas, even if dense tumor adhesion exists.

[Surgical treatment for malignant pleural mesothelioma in eight cases]

Between 1987 and March 2000, we have operated on eight patients for malignant mesothelioma which consisted of four of localized type and four of diffuse type. We have aggressively resected mesothelioma combined with chemotherapy whether the tumor was primary or recurrent, and concluded the following. 1) In localized malignant mesothelioma, en-bloc primary tumor resection was possible and additional resection for recurrence was effective and useful for long time survival. 2) In diffuse malignant mesothelioma, complete tumor resection was impossible to even perform pleuropneumonectomy accompanied with partial resection of pericardium and diaphragm and, therefore, the prognosis was poor in four patients and all died around one year. 3) Because recurrent pattern for localized type was diffuse type, diagnosis and surgical treatment in early stage was essential for long time survival.

Preoperative autologous donation of blood for a simple cardiac anomaly: analysis of children weighing under twenty kilograms

OBJECTIVE

Preoperative autologous donation of blood has been expanded to cardiac operations in children. However, because of problems such as lack of cooperation and hemodilution during cardiopulmonary bypass, its efficacy in small children is unclear. This study clarifies the clinical significance of preoperative autologous donation of blood in small children.

METHODS

Thirty-seven patients weighing under 20 kg (age range, 3-9 years; weight range, 13-20 kg) underwent preoperative autologous donation and cardiac operations to treat a simple anomaly. Twenty-five age- and weight-matched patients who were not cooperative or refused preoperative autologous donation served as control subjects. Autologous blood was collected by the simple or leapfrog method and stored as blood components. Each collecting volume was 5 to 10 mL/kg.

RESULTS

The donation was performed 6+/-2 times during 50+/-16 days, and the whole storage volume was 48+/-17 mL/kg. There was no serious complication. The minimum hematocrit level negatively correlated with the priming volume of cardiopulmonary bypass (preoperative donation patients: P<.01, r(2) = 0.4; control subjects: P =.5, r (2) = 0.03). Blood loss did not significantly differ between preoperative donation patients and control subjects, and the transfused blood volumes were 43+/-13 mL/kg and 29+/-22 mL/kg, respectively. All of the autologous blood products but fresh frozen plasma were reinfused. Use of homologous blood was significantly less in preoperative donation patients than in control subjects (0% vs 80%, P <.01). In preoperative donation patients postoperative recovery in hemoglobin level was significantly better, which is concurrent with a higher reticulocyte level.

CONCLUSION

Preoperative autologous donation can be performed safely with clinical efficacy, even in children under 20 kg. This can be improved further through coupling with another procedure.

The influence of human T lymphotropic virus type I infection on the outcome of cardiovascular surgery

OBJECTIVE

Human T lymphotropic virus type I infects CD4(+) T cells and affects cell-mediated immunity. Cardiopulmonary bypass transiently alters lymphocyte subsets, resulting in a reduction in CD4(+) T cells and an increase in CD8(+) T cells. We proposed that cardiovascular operations and human T lymphotropic virus type I infection may act synergistically, resulting in serious damage to cell-mediated immunity.

METHODS

A total of 517 consecutive patients who were preoperatively screened for anti-human T lymphotropic virus type I antibody and underwent cardiovascular operations with cardiopulmonary bypass were enrolled in this study. Of the 517 patients, 82 (16%) had positive test results for anti-human T lymphotropic virus type I antibody. The surgical outcome of patients with positive and negative results for anti-human T lymphotropic virus type I antibody was analyzed retrospectively.

RESULTS

There was no difference between the 2 groups with respect to early mortality. Distribution of survival curve was also not significantly different (P =.5; mean follow-up duration, 2.4 +/- 1.8 years [range, 0-9.4 years] and 3.2 +/- 2.8 years [range, 0-9.8 years]) in the groups with positive and negative antibody results, respectively). In particular, long-term follow-up did not reveal adult T-cell leukemia or human T lymphotropic virus type I-associated myelopathy, and occurrence of neoplasm did not differ between groups. Early infectious complication was, however, significantly higher in the group with positive antibody results than in the group with negative results (P =.02). Logistic regression analysis revealed human T lymphotropic virus type I infection as a significant risk for this complication (P =.04; odds ratio, 2.5; 95% confidence interval, 1. 0-5.8).

CONCLUSION

A combination of human T lymphotropic virus type I infection and cardiovascular operation is believed to increase the potential risk of infectious complications shortly after the operation. However, this synergistic effect seems to be transient and has little influence on long-term prognosis.

Intracranial dural metastasis of mediastinal seminoma--case report

A 24-year-old male presented with a rare intracranial dural metastasis from a mediastinal germ cell tumor infiltrating the superior vena cava, pericardium, ascending aorta, and lung. Routine chest radiography incidentally revealed the abnormal mediastinum, which was partially resected after median sternotomy, followed by radiotherapy. One year after the radiotherapy, magnetic resonance imaging revealed a right parasagittal tumor mimicking a meningioma. Partial tumor removal was performed. Two cycles of chemotherapy with carboplatin and etoposide were then performed, and the residual tumor almost completely disappeared. The histological diagnosis of both the mediastinal and intracranial tumors was pure seminoma. Sections of metastatic tumor revealed several thick fibrous septa and numerous epithelioid granulomas infiltrated by plasma cells, intermingled between the clusters of tumor cells. Follow up of patients apparently in remission from mediastinal seminoma without evidence of advanced or recurrent disease at other sites is recommended.

The management of patients with dissection of the descending thoracic aorta: a comparison between closing and nonclosing dissections

This study was designed to clarify and compare the clinical characteristics and prognoses of patients with closing and nonclosing dissection of the descending thoracic aorta. Between January 1991 and December 1994, 19 patients with closing dissection (Group A) and 20 with nonclosing dissection (Group B) underwent surgical repair or medical treatment at our institution. There were 29 men and 10 women, aged between 37 and 74 years, with a mean age of 62 years. There was a significant difference in age between the two groups, being 67 +/- 7 and 58 +/- 12 years for Groups A and B, respectively (P = 0.009). The presence of a concurrent abdominal aortic aneurysm was confirmed in 32% and 10% of Groups A and B, respectively (P = 0.095). A total of 15 patients experienced a variety of complications related to the dissection, but there were no significant differences in the morbidity rate between the two groups. Visceral ischemic disorders such as renal failure, leg ischemia, and ileus were the most common complications. The overall survival rate 4 years after the development of dissection was 80%, with no significant difference between the two groups. These findings led to the establishment of our policy to place all patients with dissection of the descending thoracic aorta on careful antihypertensive therapy and frequent follow-up imaging studies to assess the aorta, regardless of the condition of the false lumen.

Involvement of the right atrium by malignant lymphoma as a cause of right cardiac failure: report of a case

We describe herein a rare case of malignant lymphoma occupying almost the entire space of the right atrial cavity and causing low cardiac output syndrome. A life-saving emergency operation was carried out after the establishment of a temporary bypass between the axillary and femoral veins to prevent exacerbation of the patient's condition during the induction of anesthesia. Cardiopulmonary bypass was commenced and the right atrium was opened. A large tumor in the right atrium could not be completely removed due to invasion of the atrial wall. A bypass from the left innominate vein to the pulmonary arterial trunk was constructed with a prosthetic graft to convert the blood flow directly from the systemic vein to the pulmonary artery. Postoperative radiation treatment was given, which resulted in reducing the size of the tumor considerably, and the patient is doing well 1 year after his operation.

[Simultaneous operation for lung tumor and cardiovascular disease]

Successful simultaneous operation for lung tumor and cardiovascular disease was performed in three cases. A 76-year-old man with stage I lung cancer and ischemic heart disease underwent a partial lobectomy following single coronary artery bypass grafting through a median sternotomy. A 62-year-old man with stage I suspected lung cancer and thoracic aortic aneurysm underwent a partial segmentectomy before aneurysmectomy and patch closure using vascular prosthesis through a left posterolateral thoracotomy. These two cases were performed under extracorporeal circulation. A 69-year-old man with bronchogenic carcinoma and abdominal aortic aneurysm underwent a left upper lobectomy with standard lympho node dissection following aneurysmectomy and grafting using vascular prosthesis. As a simultaneous procedure, limited operation for lung tumor, especially for stage I non-small cell lung cancer, is acceptable for cases in using extracorporeal circulation. On the other hand, except emergency ruptured cases of abdominal aortic aneurysm, standard radical operation for lung cancer as a simultaneous procedure is preferred for cases such as lung cancer accompanied with abdominal aortic aneurysm without extracorporeal circulation.

Watershed infarction after combined coronary and axillobifemoral bypass surgery

Watershed infarction sometimes causes a neurological disorder due to hypoperfusion of the brain during cardiac surgery. Here we report a case in which watershed infarction developed after combined coronary artery bypass and axillobifemoral bypass surgery.