Impact of serum flecainide level on control of atrial fibrillation in a case treated with cardiac resynchronization therapy.

A 72-year-old male patient with dilated cardiomyopathy was treated with oral flecainide (100 mg/day) for persistent atrial fibrillation (AF) that could not be converted to sinus rhythm by electrical cardioversion. Initiation of flecainide treatment provided sinus rhythm without prolongation of QRS and QTc, bradycardia and first-degree atrioventricular block at a serum flecainide level of 438 ng/mL. Then, he received cardiac resynchronization therapy (CRT). Dose reduction to 50 mg/day because of stabilization of heart rate after CRT produced AF at a serum flecainide level of 270 ng/mL. Electrical cardioversion did not restore the AF to a sinus or pacing rhythm. Dose escalation of flecainide (to 100 mg/day) restored the pacing rhythm at a serum flecainide level of 401 ng/mL. This case suggests that in the Japanese population, serum flecainide level should be maintained at >300 ng/mL to control AF even after effective CRT.

Long-term management of a glaucomatous eye in a dog treated with medical therapy alone.

An acute open angle glaucoma of the right eye was diagnosed in an 8-year-old male Yorkshire terrier which was presented with anorexia, depression, and trembling. Abnormal findings of the right eye on admission included elevated intraocular pressure (IOP; 40 mmHg), the presence of fibrin and flare in the anterior chamber, and immature cataract. Morphological abnormalities of the iridocorneal angle were not detected, and an open angle was seen in the eye. Although an elevated IOP was observed at one year after admission, lowering IOP (< or = 24 mmHg) was maintained with medical therapy using dichlorphenamide (DCPA) and timolol maleate, DCPA alone, or no-treatment for 1973 days. This case suggests that lower IOP can be maintained with medical therapy alone for a long period in a patient with open angle glaucoma.

Early lymphoma coexisting with reactive lymphoid hyperplasia of the stomach.

A 55-year-old woman with a small focus of malignant lymphoma, 6 mm in diameter, arising within an area of reactive lymphoid hyperplasia (RLH) of the stomach is reported. The diagnosis of lymphoma was suspected by the preoperative endoscopic biopsy. This is the case of this association with an unusually small lymphoma in the early stage, in support of the view that there may be an intimate histogenetic relationship between lymphoma and RLH.

[Phase II study on peplomycin for esophageal cancer].

For the purpose of verifying the effectiveness of peplomycin, one of the derivatives of bleomycin, against carcinoma of the esophagus and the safety of it, the analysis of the data for total 113 cases collected from 25 institutions in Japan was made. The results are as follows. It was effective in 19 out of 74 evaluable cases of carcinoma of the esophagus (25.7%). In case of treatment with peplomycin alone, it was effective in 6 out of 39 cases (15.4%). In case of the combination treatment with peplomycin and some other therapy, it was effective in 13 out of 35 cases (37.1%). As for the side effects, the incidence of fever was the highest in both the cases of peplomycin alone and the combination treatment such as 39.6% and 37.0%, respectively. Anorexia, nausea, vomiting, respiratory symptoms and tiredness were found in relatively many cases. In the clinical laboratory tests, the vital capacity after the treatment tended to be lower than that before the treatment, but there was little change in the hematological tests, pulmonary function test and renal function test.

Single layer suture by manual or mechanical stapling technique in esophagojejunostomy after total gastrectomy.

Manual single layer suturing procedures were used for esophagojejunostomy in end-to-side fashion after total gastrectomy in 30 patients with upper gastric carcinoma involving the esophagus. Only one minor suture line leak was observed in spite of the anastomosis without any other seromuscular reinforcing sutures. Transabdominal, highly placed intramediastinal esophagojejunostomy was made by mechanical suturing; the instrument proved simple to use and produced a reliable closure of good quality in 14 patients with esophgogastric cancer. Suture line leak was seen in two patients in whom this one layer inverting stapling suture technique was used. Post-operative barium roentgenography of the anastomosis by these two methods showed a stoma wide enough to pass any kind of food without stenosis in all successful cases.

Lymph node metastases in cancer of the thoracic esophagus.

Curettage of lymph nodes in 36 patients with cancer of the thoracic esophagus was performed in the bilateral supraclavicular, right intrathoracic and abdominal regions. The overall metastatic ratio in lymph nodes was 52.8 percent (19 of 36). It was particularly high in the right supraclavicular nodes (26.7 percent), the paracardial (27.8 percent) nodes, and nodes of the arch of the left gastric artery (19.4 percent) and the celiac axis (16.7 percent). Metastatic lesions were limited to the intrathoracic lymph nodes in 1 of 19 patients with positive nodal metastasis and were accompanied by metastases of the supraclavicular or abdominal nodes in the other 18 patients. In eight (88.9 percent) of nine patients in whom intrathoracic nodal metastases were confirmed, the supraclavicular or abdominal lymph nodes were involved by metastatic lesions. On the other hand, jumping metastasis to the neck or the abdominal lymph nodes without intrathoracic involvement was observed in 27.8 percent.

Fatal interstitial pneumonitis induced by low dosage of bleomycin in an esophageal cancer patient.

One-shot intratumor injection of 60 mg oil-bleomycin prior to subtotal esophagectomy induced fatal, acute interstitial pneumonitis in a 53 year-old esophageal circinoma patient. The progression of bleomycin-induced pneumonitis was rapid and the patient succumbed to respiratory insufficiency 41 days after surgery (58 days after bleomycin administration). Autopsy revealed bilaterally increased lung weight and the organ was of rubbery consistency and anthracotic. Histology showed advanced interstitial fibrosis, numerous lymphocytes in alveolar septi and fibrinous exudate, macrophages and desquamative cells within the alveolar spaces. In the present case, pneumonitis was due not to patient age or dosage level of bleomycin, but rather to the administration method.

Mechanical suture methods in esophago-gastrointestinal anastomosis.

Mechanical suturing procedures have been performed in 10 patients for total gastrectomy, 6 for proximal partial gastrectomy and 7 for esophageal transection. The instrument (SPTU all-round type made in Russia) proved simple to use and produced reliable good quality closures without any other inforcement. There was one minor suture leak in 10 patients with intramediastinal esophagojejunostomy and in 6 with proximal partial gastrectomy respectively, but neither leak nor other problem has been arisen in esophageal transection for varices. It is believed that this staple suturing methods used SPTU all-round type apparatus are safe from anastomotic failure and useful for secure intramediastinal anastomosis in high level, and they represent a significant advance in the technique of thoraco-abdominal surgery.