Surgical, endovascular, and hybrid treatment of deep femoral artery aneurysm: Three case reports.

Key Clinical Message: Deep femoral artery aneurysms (DFAA) are extremely rare. We treated four DFAAs with different procedures including surgical, endovascular, and hybrid surgery. The best treatment should be selected for each individual case. Abstract: We report three cases of deep femoral artery aneurysms treated with different techniques. Case 1: A 69-year-old man with a huge deep femoral artery aneurysm underwent open reconstruction using a 6 mm expanded polytetrafluoroethylen graft. Case 2: A 67-year-old man presented with bilateral deep femoral artery aneurysms. The right-sided rupture was treated with hybrid embolization, while the left aneurysm was treated by endovascular stent-grafts deployment. Case 3: A 87-year-old man with a large deep femoral artery aneurysm underwent simply surgical aneurysmectomy. As there are many treatment options for deep femoral artery aneurysms, a comprehensive preoperative assessment is essential, encompassing an evaluation of symptoms, anatomy, and comorbidities.

Synthesis, Properties, and Biodegradation of Sequential Poly(Ester Amide)s Containing γ-Aminobutyric Acid.

Poly(ester amide)s are attracting attention because they potentially have excellent thermal and mechanical properties as well as biodegradability. In this study, we synthesized a series of novel poly(ester amide)s by introducing γ-aminobutyric acid (GABA) regularly into polyesters, and investigated their properties and biodegradabilities. GABA is the monomer unit of biodegradable polyamide 4 (PA4). The new poly(ester amide)s were synthesized from the reaction of ammonium tosylate derivatives of alkylene bis(γ-aminobutylate) and p-nitrophenyl esters of dicarboxylic acids. All the obtained polymers showed relatively high melting temperatures (Tm). Their thermal decomposition temperatures were improved in comparison with that of PA4 and higher enough than their Tm. The poly(ester amide)s exhibited higher biodegradability in seawater than the corresponding homopolyesters. Their biodegradabilities in activated sludge were also studied.

Surgical and endovascular treatment of a bilateral deep femoral artery aneurysm.

We report the rare case of a 68-year-old man with a bilateral deep femoral artery aneurysm. Right-sided rupture was treated via plug embolization of the right deep femoral artery and ligation. In the following year, Viabahn® stent grafts were placed in the left superficial femoral artery to relieve occlusion and in the left deep femoral artery to treat the left aneurysm. The postoperative course of the patient was uneventful.

Life-threatening pyogenic ventriculitis, complicating endocarditis, presenting as sudden hearing loss.

Approximately 70% of sudden sensorineural hearing loss (SSNHL) cases are idiopathic, but SSNHL may occasionally be related to fatality. Here, we report the case of a 54-year-old Asian female who complained of hearing loss as a primary symptom and was diagnosed with pyogenic ventriculitis (PV) derived from Streptococcus agalactiae endocarditis. Both PV and S. agalactiae endocarditis are rare and very severe infections with a high mortality rate. Rapid intensive treatment and surgery were required for successful clinical outcomes.

Poorly differentiated adenocarcinoma of an unknown primary with a thyroid tumour and an aggressive course: thyroid or lung carcinoma?

Cancers of unknown primary (CUPs) are challenging for physicians to diagnose and treat. Metastases to the thyroid gland are rare, representing less than 1% of all thyroid malignancies. Here, we report a case of a 69-year-old Asian man who had both thyroid gland and lymph node enlargement in the neck and shoulders but no nodules/tumours in the lung field. The patient died 51 days after his first visit to our office, although pembrolizumab was administered on day 34 based on programmed cell death-ligand 1 (PD-L1) expression. Immunohistochemistry (IHC) with paired box 8 (PAX8) may be useful to diagnostically distinguish poorly differentiated lung adenocarcinomas from napsin A-positive thyroid carcinomas.

Alanine Aminotransferase as the First Test Parameter for Wilson's Disease.

Background and Aims: The liver is the first organ affected by toxic copper in the classical and severe hepatic forms of Wilson's disease (WD). Because their associated chronic liver damage is mostly asymptomatic, an intervention using a special test including serum alanine aminotransferase (ALT) activity is needed for detecting WD. Methods: Using the modified international criteria for the diagnosis of WD, 45 patients were selected from the collective databases of our institutions, and 7 infants were reviewed from the literature. Two patients had the severe hepatic form, with normoceruloplasminemia and no mutations in ATP7B. The rapid ALT change during hemolytic anemia was adjusted for a baseline. The diagnostic potential of the ALT test was assessed from the age-dependent natural course of the liver damage of WD. Results: The natural course had three stages. ALTs were still low in some infants younger than 4 years-old. They were high in all children between the ages of 4 and 8 years-old; then, they reduced to low levels in some patients over 9 years of age. The high ALT stage represents chronic active hepatitis, and the subsequent low ALT stage is due to silent cirrhosis. The hepatic copper content is a reliable but invasive test, while urinary copper secretion is an alternative, non-invasive test for copper toxicosis of WD. The serum ceruloplasmin and ATP7B analyses are subtype tests of WD. The response to anti-copper regimens is the final test result. Conclusions: ALT could be the first parameter to test to detect WD in children between the ages of 4 and 8 years.

Promoting notification and linkage of HBs antigen and anti-HCV antibody-positive patients through hospital alert system.

BACKGROUND: In Japan, approximately 0.9% and 1% of the whole population are infected with HBV and HCV, respectively. Doctors from departments other than gastroenterology often order viral hepatitis tests before an invasive examination or an operation. However, the notification of positive results to the patients and linkage to care is not appropriately performed. The in-hospital alert system was constructed to promote the notification and referral to gastroenterologists for patients with positive viral hepatitis tests, and its efficacy was evaluated. METHODS: The patients who tested HBsAg and anti-HCV antibody by chemiluminescent enzyme immunoassays and chemiluminescent immunoassays were investigated for whether they were notified of the positive results and if they were referred to gastroenterologists at our hospital. The notification and referral rate was compared before (from January to December 2014) and after the introduction of the alert system (from February to September 2016). RESULTS: HBsAg-positive rate was 1.1% (69/6543) before the introduction of the alert system and 0.8% (41/5403) after it. The notification rate has significantly improved from 46% to 73% (p = 0.0061) and the referral rate has improved from 16% to 27%, while not significant. Positive rate of anti-HCV antibody was 2.1% (139/6481) before the introduction of the alert system and 2.4% (128/5322) after it. The rate of notification and referral has significantly improved from 35% to 62% (p < 0.0001) and from 6% to 23% (p < 0.0001), respectively. CONCLUSIONS: The in-hospital alert system increased the rates of notification and referral of the patients with positive viral hepatitis tests. Enlightenment of doctors other than gastroenterologists on viral hepatitis and cooperation of medical staffs would be helpful to improve the notification and referral rates.

Association of a unique form of cor triatriatum with tetralogy of Fallot.

Cor triatriatum is a rare cardiac anomaly sometimes associated with tetralogy of Fallot (TOF) and persistent left superior vena cava (PLSVC). We present the case of a 2-year-old girl who was diagnosed with a unique form of cor triatriatum that was associated with TOF and PLSVC. In this case, the abnormal membrane that arose from the posterior wall of the left atrium encircled the left superior vena cava (LSVC) in the left atrial cavity. Here, we discuss this rare case as well as the imaging studies and surgical strategy adopted.

Supravalvular aortic stenosis after arterial switch operation.

Supravalvular aortic stenosis as a late complication of transposition of the great arteries is very rare, and only a few cases have been reported. We describe the case of a 14-year-old girl who developed supravalvular aortic stenosis as a late complication of the arterial switch operation for transposition of the great arteries. The narrowed ascending aorta was replaced with a graft. The right pulmonary artery was transected to approach the ascending aorta which adhered severely to the main pulmonary trunk, and we obtained a good operative field.

Liver abscessation and multiple septic pulmonary emboli associated with Lemierre's syndrome: a case report.

BACKGROUND: In Lemierre's syndrome, patients first exhibit pharyngitis and peritonsillar abscessation, followed by the development of anaerobic bacterial (usually Fusobacterium necrophorum) septicemia and metastatic infections throughout the body. However, these infections rarely affect the liver. We describe a case of Lemierre's syndrome, in which the first disease manifestation was liver abscess, for drawing attention of emergency physicians to this rare but fatal disease. CASE PRESENTATION: A 28-year-old Asian ethnicity Filipino male, who was previously healthy, entered the emergency department presenting with fever and pharyngeal pain that had persisted for 5 days. Contrast-enhanced abdominal computed tomography revealed a 3-cm area of low density in segment 6 of the liver, consistent with an abscess. Chest computed tomography also revealed that multiple nodes in both lungs were enlarged, and septic emboli were suspected. The patient was hospitalized and antibiotic treatment was initiated. On hospital day 6, blood culture results confirmed Fusobacterium necrophorum septicemia. The patient was diagnosed with Lemierre's syndrome, as pharyngitis developed into bacteremia associated with hepatic and pulmonary lesions. The patient's condition improved with antibiotics and he was discharged following three weeks of treatment in the hospital. CONCLUSION: With the widespread use of antibiotics, Lemierre's syndrome is rarely encountered anymore, but it can be fatal if not properly diagnosed. It is a crucial differential diagnosis in young patients exhibiting septicemia or multiple metastatic infection of unknown origin.

[Successful management of nonocclusive mesenteric ischemia after aortic valve replacement;report of a case].

Non-occlusive mesenteric ischemia (NOMI) is a fatal complication after cardiovascular surgery, but early diagnosis is difficult because the clinical symptoms are not specific. We report a case of NOMI with successful management due to early diagnosis and treatment. A 78-year-old male complained of sudden abdominal pain after aortic valve replacement. NOMI was suspected because his laboratory work-up showed elevated serum transaminase, and computed tomography showed no mesenteric artery obstruction. We started a continuous intravenous infusion of prostaglandin E1, and performed emergency arterial angiography. Since angiography showed vasospasm of the mesenteric artery, we also started a continuous intra-arterial infusion of papaverine. Each vasodilator drug was started within a few hours after the onset of NOMI. His subsequent hospital course was uneventful, and he was discharged without enterectomy or fatal intestinal necrosis.

[Adult coarctation of aorta repaired under partial selective cerebral perfusion].

We report a case of an adult coarctation of aorta in a 46-year-old woman repaired with partial selective cerebral perfusion. Preoperative cardiac catheterization revealed that pressure gradient between the upper and lower limb was more than 60 mmHg. Under general anesthesia, we entered the left thoracic cavity through standard thoracomy, and removed the coarctation of aorta under partial selective cerebral circulation. The left common carotid artery and the descending aorta were cannulated and perfused, and the main pulmonary artery was cannulated for venous drainage. The aortic arch was cross-clamped just proximal to the left common carotid artery. Reconstruction was carried out by graft replacement using a side armed 16 mm Dacron graft between the aortic arch and the descending aorta, and the left subclavian artery was connected to the side arm of the graft. Postoperatively, there is no pressure difference between the upper and lower extremities.

Rupture of right sinus of Valsalva aneurysm into the pulmonary artery.

Rupture of a sinus of Valsalva aneurysm is an uncommon lesion that can occur in any cardiac chamber since the aortic valve occupies a central position in the base of the heart. However, rupture into the pulmonary artery is extremely rare. We describe a case of rupture of an aneurysm of right sinus of Valsalva into the pulmonary artery of a 51-year-old woman. She had been treated by patch closure of a sub-pulmonary ventricular septal defect and aortic valve replacement due to right coronary cusp prolapse 26 years previously. A massive shunt from Valsalva sinus into pulmonary artery indicated the need of radical operation. The defect in the pulmonary artery wall was closed through a pulmonary arteriotomy with a satisfactory outcome. As far as we know, a case of rupture of a sinus of Valsalva aneurysm into pulmonary artery after the previous operation for VSD has not been reported.

Simplified model for end-stage liver disease score predicts mortality for tricuspid valve surgery.

OBJECTIVES: The model for end-stage liver disease score (MELD = 3.8*LN[total bilirubin] + 9.6*LN[creatinine] + 11.2*[PT-INR] + 6.4) predicts mortality for tricuspid valve surgery. However, the MELD is problematic in patients undergoing warfarin therapy, as warfarin affects the international normalized ratio (INR). This study aimed to determine whether a simplified MELD score that does not require the INR for calculation could predict mortality for patients undergoing tricuspid valve surgery. Simplified MELD score = 3.8*LN[total bilirubin] + 9.6*LN[creatinine] + 6.4. METHODS: A total of 172 patients (male: 66, female: 106; mean age, 63.8 ± 10.3 years) who underwent tricuspid replacement (n = 18) or repair (n = 154) from January 1991 to July 2011 at a single centre were included. Of them, 168 patients in whom the simplified MELD score could be calculated were retrospectively analysed. The relationship between in-hospital mortality and perioperative variables was assessed by univariate and multivariate analysis. RESULTS: The rate of in-hospital mortality was 6.4%. The mean admission simplified MELD score for the patients who died was significantly higher than for those surviving beyond discharge (11.3 ± 4.1 vs 5.8 ± 4.0; P = 0.001). By multivariate analysis, independent risk factors for in-hospital mortality included higher simplified MELD score (P = 0.001) and tricuspid valve replacement (P = 0.023). In-hospital mortality and morbidity increased along with increasing simplified MELD score. Scores <0, 0-6.9, 7-13.9 and >14 were associated with mortalities of 0, 2.0, 8.3 and 66.7%, respectively. The incidence of serious complications (multiple organ failure, P = 0.005; prolonged ventilation, P = 0.01; need for haemodialysis; P = 0.002) was also significantly higher in patients with simplified MELD score ≥ 7. CONCLUSIONS: The simplified MELD score predicts mortality in patients undergoing tricuspid valve surgery. This model requires only total bilirubin and creatinine and is therefore applicable in patients undergoing warfarin therapy.

[Different sensitivity to chemotherapy between adenocarcinoma and adenosquamous carcinoma in a case of synchronous multicentric gastric cancer].

A 60-year-old man presented with upper gastrointestinal bleeding. We diagnosed double gastric cancer (adenocarcinoma and adenosquamous carcinoma) based on an endoscopic examination. Due to uncontrollable bleeding, total gastrectomy was performed after 4 courses of chemotherapy with S-1+cisplatin. Histological investigation revealed that no obvious anti-cancer effect was observed in adenosquamous carcinoma (Grade 1), while tumor cells were eliminated in the area of adenocarcinoma (Grade 3). This case clearly demonstrated that sensitivity to chemotherapy was different between adenocarcinoma and adenosquamous carcinoma of the stomach.

[Acute pancreatitis associated with the administration of ceftriaxone in an adult patient].

We report a case of a 35-year-old patient with acute pancreatitis after administration of ceftriaxone. She was given ceftriaxone (2g/day) for 9 days because of diverticulitis of the colon. She was admitted to our hospital again because of epigastralgia 12 days after the first administration of ceftriaxone. Laboratory examination showed markedly elevated serum amylase, and CT scan demonstrated findings consistent with acute pancreatitis, in addition to sludge in the common bile duct and gall bladder, which was not identified before the administration of ceftriaxone. We should be aware of the fact that administration of ceftriaxone sometimes results in the formation of biliary sludge and can cause severe adverse events such as cholecystitis and pancreatitis, not only in children, but also in adult patients.

Agonist- and T(H)2 cytokine-induced up-regulation of cysteinyl leukotriene receptor messenger RNA in human monocytes.

BACKGROUND: The cysteinyl leukotrienes (CysLTs) are lipid mediators that have been implicated in the pathogenesis of allergic diseases, and their actions are mediated via specific receptors named CysLT1 receptor (CysLT1R) and CysLT2 receptor (CysLT2R). Little information is known about the role of T(H)2 cytokines in the regulation of both CysLT1R and CysLT2R expression. OBJECTIVE: To investigate the possible modulation of both CysLT1R and CysLT2R messenger RNA (mRNA) expression, we have developed a real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR) assay based on the TaqMan fluorescence method to quantify CysLT1R and CysLT2R mRNA in human monocytes. METHODS: Human monocytes were stimulated with leukotriene D4 or interleukin (IL) 4 or IL-13, and the levels of CysLT1R and CysLT2R mRNA were measured by the quantitative RT-PCR. RESULTS: CysLT1R and CysLT2R mRNA was increased after stimulation with leukotriene D4. CysLT1R mRNA was augmented 150-fold after treatment with IL-4; however, no significant increase was observed in CysLT2R mRNA level. IL-13 could induce a biphasic augmentation of CysLT1R mRNA level. In contrast to IL-4, IL-13 enhanced CysLT2R mRNA level, with a maximal effect at 2 hours of incubation. CONCLUSIONS: CysLT1R and CysLT2R expression can be regulated by CysLT itself and T(H)2 cytokines at the transcriptional level.

Expression and localization of the thromboxane A2 receptor in human nasal mucosa.

Thromboxane A2 (TXA2) has been thought a potent mediator involved in allergic rhinitis, because TXA2 was recovered from the nasal lavage fluid of allergic rhinitis patients after allergen provocation and TXA2 receptor antagonists relief nasal allergic symptoms. In order to clarify the expression of TXA2 receptor in human nasal mucosa, we investigated TXA2 receptor mRNA expression and its protein localization by polymerase chain reaction (PCR) and immunohistochemistry, respectively. Human turbinates were obtained after turbinectomy from 10 patients with nasal obstruction refractory to medical therapy. RT-PCR analysis of total RNA from nasal mucosa demonstrated the expression of TXA2 receptor alpha mRNA. The immunohistochemical studies revealed that anti-TXA2 receptor alpha antibody labeled vascular smooth muscle cells, vascular endothelial cells, epithelial cells and submucosal glands in the nasal mucosa. The results may have an important clinical implication for understanding the role of TXA2 receptor on upper airway diseases such as allergic rhinitis and non-allergic rhinitis.

Distribution of specific binding sites for cysteinyl leukotriene 1 receptor antagonist in human nasal mucosa.

CONCLUSION: The high density of [3H]-pranlukast binding sites on the local leukocytes in human nasal mucosa suggests that CysLT1 receptor antagonists may directly modulate cellular function of the local leukocytes through binding to CysLT1 receptor on allergic nasal mucosa. OBJECTIVES: The cysteinyl leukotrienes (CysLTs) are lipid mediators that have been implicated in the pathogenesis of allergic diseases. Pharmacological studies using CysLTs indicate that two classes of receptors named CysLT1 and CysLT2 receptor exist. The former is sensitive to the CysLT1 receptor antagonist currently used to treat asthma and allergic rhinitis. To confirm the binding sites of CysLT1 receptor antagonist in human nasal mucosa, the autoradiographic distribution of CysLT1 receptor was studied in human nasal inferior turbinates. MATERIALS AND METHODS: Cryostat sections were incubated with [3H]-pranlukast for autoradiography. Nonspecific binding was determined by adding unlabelled pranlukast. RESULTS: Autoradiograms indicated [3H]-pranlukast densely labeled on the interstitial cells. Blood vessels were sparsely labeled. There was no specific labeling in the submucosal glands or epithelium. These results support our previous report from in situ hybridization and immunohistochemistry of CysLT1 receptor.