Heparin-induced Thrombocytopenia with Anaphylactoid Reaction during Hemodialysis.

We herein report a 64-year-old man with heparin-induced thrombocytopenia accompanied by anaphylactoid reaction during hemodialysis. The patient was admitted to our hospital with acute myocardial infarction and developed acute kidney injury after percutaneous coronary intervention. When maintenance hemodialysis with heparin was initiated, the patient developed an anaphylactoid reaction with dyspnea, hypotension, nausea, and vomiting. Laboratory tests revealed thrombocytopenia. Immunoglobulin G antibodies to heparin-platelet factor 4 complexes were positive, and a functional assay showed heparin-independent platelet activation. These results provide a definitive diagnosis of heparin-induced thrombocytopenia. The onset timing supported a diagnosis of 'rapid-onset' heparin-induced thrombocytopenia.

Pericapsular nerve group block for osteoarthritis-related chronic hip joint pain: a case report.

BACKGROUND: Pericapsular nerve group (PENG) block has shown effectiveness for acute hip pain associated with fractures and surgery. Herein, PENG block was performed for osteoarthritis (OA)-related chronic hip joint pain. CASE PRESENTATION: A 65-year-old woman presented left hip pain. She had bilateral hip osteoarthritis that improved with medications; however, a fall resulted in left hip pain. She experienced severe pain on movements, which required walking aids. To alleviate the hip pain, a PENG block was performed under ultrasound guidance. Transient muscle weakness occurred in 2 of 5 times. After 5 blocks, she regained the ability to walk without assistive devices. Pain did not recur even after 6 months. CONCLUSIONS: Repeated PENG blocks of short-acting local anesthetics alone could be an effective pain management technique for chronic hip pain. For safety, the appropriate injection site and local anesthetic dosage must be carefully considered.

Clinical features of anterior blepharitis after cataract surgery.

We evaluated the clinical features of postoperative anterior blepharitis following cataract surgery and the efficacy of topical azithromycin retrospectively. Thirty eyes of 30 patients with a clinical diagnosis of anterior blepharitis by 6 months postoperatively among those who underwent cataract surgery at our institution between November 2020 and June 2022 were included. The diagnosis of anterior blepharitis and the assessment of objective and subjective findings were based on the American Academy of Ophthalmology Blepharitis Preferred Practice Pattern®. Azithromycin eye drops were prescribed for all patients, and findings and symptoms before and after the drops were reviewed. The time of onset ranged from 2 weeks to 6 months after cataract surgery, with the most common onset at 2 to 3 months postoperatively (mean time of onset 79.4 ± 39.6 days). The type of anterior blepharitis was staphylococcal blepharitis in 26 eyes and seborrheic blepharitis in 4 eyes, while mixed type with posterior blepharitis was noted in 6 eyes. Symptoms at the time of examination included irritation (including foreign body sensation) in 24 eyes, tearing in 4 eyes, and redness in 3 eyes. The findings and symptoms of anterior blepharitis were alleviated or resolved with azithromycin eye drops in 26 of the 30 eyes, but the blepharitis recurred in 6 of these eyes, requiring azithromycin eye drops to be re-prescribed. The onset of anterior blepharitis after cataract surgery may be related to a gradual decrease in postoperative eye drops. Patients tended to complain of irritation and foreign body sensation, and azithromycin eye drops were effective in such cases.

Effects of n-3 polyunsaturated fatty acid supplementation on quadriceps weakness immediately after total knee arthroplasty: a pilot, randomized, open-label clinical trial.

[Purpose] Severe quadriceps weakness immediately after total knee arthroplasty can be problematic. The n-3 long-chain polyunsaturated fatty acids have antioxidant and anti-inflammatory effects against ischemia-reperfusion injury, whereas n-6 long-chain polyunsaturated fatty acids exert pro-inflammatory effects, thereby promoting ischemia-reperfusion injury. [Participants and Methods] We explored the efficacy of preoperative n-3 long-chain polyunsaturated fatty acid supplementation against early quadriceps weakness among 20 patients scheduled for total knee arthroplasty (intervention group, n=10; control group, n=10). The intervention group received 645 mg of eicosapentaenoic acid) and 215 mg of docosahexaenoic acid daily for 30 days preoperatively. Serum eicosapentaenoic acid, docosahexaenoic acid, and arachidonic acid levels were measured preoperatively. We compared serum derivatives of reactive oxygen metabolites as oxidative stress biomarkers, knee circumference, thigh volume, knee pain during the quadriceps strength test, and quadriceps strength preoperatively and 4 days postoperatively to quantify the change. [Results] Preoperative n-3 long-chain polyunsaturated fatty acid supplementation significantly increased the (eicosapentaenoic acid+docosahexaenoic acid)/arachidonic acid ratio in the intervention group. A significantly lower increase in quadriceps weakness was exhibited in the intervention group than in the control group. However, changes in oxidative stress, knee/thigh swelling, and knee pain during strength testing did not significantly differ between the two groups. [Conclusion] Preoperative n-3 long-chain polyunsaturated fatty acid supplementation exhibited beneficial effects on quadriceps weakness immediately after total knee arthroplasty.

New Miyake-Apple View system using a nasal endoscope.

PURPOSE: To evaluate images and videos behind the anterior segment of cataract surgery with the porcine eye using a new Miyake-Apple View with a nasal endoscope. SETTING: Sugiura Eye Clinic, Fuji, Shizuoka, Japan. DESIGN: Laboratory study. METHOD: A hole was made in a commercially available wooden desk and the nasal endoscope was fixed under the desk. A tunnel for passing the probe of the nasal endoscope was opened on a Styrofoam human-faced base, and the probe was passed through. A 3 mm × 3 mm incision was made behind the globe, and a nasal endoscope probe was inserted to observe the posterior anterior segment of the eye. RESULT: The posterior part of the anterior segment of the eye could be clearly observed, and each procedure (hydrodissection, phacoemulsification, irrigation and aspiration, and insertion and fixation of intraocular lens [IOL]) in normal cataract surgery could be observed from the posterior. Lighting could be improved. CONCLUSIONS: The conventional Miyake-Apple View required a large-scale custom-made device, which was expensive and could not be taken easily, and required to cut the globe and a technique to fix it to the glass plate. However, this method made it easy to prepare for shooting, and the equipment was inexpensive. Furthermore, it had the great advantage of not having to cut the globe. Since the integrity of the globe was maintained, normal cataract surgery could be reproduced and dynamic observation from the back became possible. It was useful for practicing cataract surgery and examining the fixed state of new IOLs.

Long-term outcomes of transsclerally sutured intraocular lens correctly fixed in the ciliary sulcus.

OBJECTIVE: To report the long-term postoperative outcomes of transsclerally sutured intraocular lenses (IOLs), in which the haptics were correctly fixated into the ciliary sulcus using an auxiliary device and endoscope. METHODS AND ANALYSIS: Data were collected from eyes that were followed up for at least 12 months after ciliary sulcus suture fixation of an IOL using an auxiliary device for securely placing the IOL haptics to the ciliary sulcus, which was confirmed using intraoperative endoscopy in all cases. The corrected distance visual acuity (CDVA), refractive error, anterior chamber depth (ACD), IOL decentration and tilt, corneal endothelial cell density (CECD) and postoperative complications were recorded. ACD and IOL deviations were compared with those of normal controls after standard cataract surgery. RESULTS: A total of 146 eyes of 142 patients were included, with a mean follow-up period of 56.0±35.3 (range 12-174) months. Postoperative CDVA from 1 month to 8 years and final CDVA were significantly better, and the mean refraction error, ACD and CECD decline rate were -0.71±0.75 dioptre, 4.01±0.37 mm and -7.4%±16.0%, respectively. Compared with normal controls, ACD was not significantly different but the tilt and decentration were significantly different. The main postoperative complications included vitreous haemorrhage (24.0％), suture thread exposure (19.2%) and corectopia (18.5%). There were no cases of IOL dislocation due to suture breakage or postoperative endophthalmitis CONCLUSION: Long-term postoperative outcomes were favorable with good CDVA and without IOL dislocation and endophthalmitis. The significance and value of fixing haptics to the ciliary sulcus should be re-evaluated.

Association between Preoperative Long-Chain Polyunsaturated Fatty Acids and Oxidative Stress Immediately after Total Knee Arthroplasty: A Pilot Study.

Quadriceps muscle atrophy following total knee arthroplasty (TKA) can be caused by tourniquet-induced ischemia-reperfusion (IR) injury, which is often accompanied by oxidative stress and inflammatory responses. n-3 long-chain polyunsaturated fatty acids (LCPUFAs), such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), exert antioxidant and anti-inflammatory effects against IR injury, whereas n-6 LCPUFAs, particularly arachidonic acid (AA), exhibit pro-inflammatory effects and promote IR injury. This study aimed to examine whether preoperative serum EPA + DHA levels and the (EPA + DHA)/AA ratio are associated with oxidative stress immediately after TKA. Fourteen eligible patients with knee osteoarthritis scheduled for unilateral TKA participated in this study. The levels of serum EPA, DHA, and AA were measured immediately before surgery. Derivatives of reactive oxygen metabolites (d-ROMs) were used as biomarkers for oxidative stress. The preoperative serum EPA + DHA levels and the (EPA + DHA)/AA ratio were found to be significantly negatively correlated with the serum d-ROM levels at 96 h after surgery, and the rate of increase in serum d-ROM levels between baseline and 96 h postoperatively. This study suggested the preoperative serum EPA + DHA levels and the (EPA + DHA)/AA ratio can be negatively associated with oxidative stress immediately after TKA.

Renal intravascular large B-cell lymphoma predominantly localized in peritubular capillaries.

We report on a 70-year-old woman with intravascular large B-cell lymphoma, in whom the renal lesion was localized in the peritubular capillaries. The patient complained of fatigue, general malaise, and unsteadiness when walking. Laboratory tests showed anemia, increased C-reactive protein, and mild renal failure, with a serum creatinine level of 1.31 mg/dL and no remarkable proteinuria or hematuria. Renal biopsy showed intravascular large B-cell lymphoma. The large atypical cells were mainly accumulated within the peritubular capillaries and no large atypical cells were found in the glomeruli. Skin and bone marrow biopsies confirmed intravascular large B-cell lymphoma. Brain magnetic resonance imaging showed multiple small infarctions in the cerebral white matter. The patient was treated with dexamethasone, methotrexate, and cytarabine followed by CHOP (combined cyclophosphamide, doxorubicin, vincristine, and prednisone) and R-CHOP (CHOP with the recombinant anti-CD20 antibody rituximab), and her renal function improved soon after the start of chemotherapy.

Effects of preoperative low-intensity training with slow movement on early quadriceps weakness after total knee arthroplasty in patients with knee osteoarthritis: a retrospective propensity score-matched study.

BACKGROUND: Severe and early quadriceps weakness (QW) after total knee arthroplasty (TKA), which is caused by acute inflammation resulting from surgical trauma and tourniquet-induced ischemia-reperfusion (IR) injury, can be especially problematic. We focused on tourniquet-induced IR injury, because it has been shown to be preventable through ischemic and exercise preconditioning. Low-intensity resistance exercise with slow movement and tonic force generation (LST) share some similarities with ischemic and exercise preconditioning. The present study primarily aimed to clarify the efficacy of preoperative LST program as prehabilitation for early QW among patients with TKA using propensity score matching analysis. METHODS: This single-center retrospective observational study used data from patients with knee osteoarthritis (n = 277) who were scheduled to undergo unilateral TKA between August 2015 and January 2017. Those with missing outcome data due to their inability to perform tests were excluded. The LST group included participants who performed LST and aerobic exercise (LST session) more than seven times for three months prior to surgery. The control group included participants who performed less than eight LST sessions, a general and light exercise or had no exercise for three months prior to surgery. Knee circumference, thigh volume, knee pain during quadriceps strength test (QST) and timed up and go test (TUG), quadriceps strength, and TUG were measured before and 4 days after surgery. Knee swelling, thigh swelling, Δknee pain, QW, and ΔTUG were determined by comparing pre- and postoperative measurements. RESULTS: Propensity score matching generated 41 matched pairs who had nearly balanced characteristics. The LST group had a significantly lower knee and thigh swelling, QW, and ΔTUG compared to the control group (all, p < 0.05). No significant differences in Δknee pain during the QST and TUG were observed between both groups (both, p > 0.05). CONCLUSIONS: The present study demonstrated the beneficial effects of preoperative LST program on knee swelling, thigh swelling, QW, and walking disability immediately after TKA.

A rare case of corneal keloid occurred 30 years after pterygium surgery and 3 years after cataract surgery.

PURPOSE: We report a case of corneal keloid occurring 30 years after pterygium surgery and 3 years after cataract surgery. OBSERVATIONS: The case of a 72-year-old man was referred because of blurred vision and corneal opacity in the right eye. Pterygium surgery had been performed on the right eye 30 years earlier, and bilateral cataract surgery had been done uneventfully via a temporal corneal incision 3 years ago. Deterioration of vision occurred in the right eye from 2 years ago. At the initial visit, his best corrected visual acuity (BCVA) was 20/2000 on the right. A white nodule that was well demarcated from the underlying stroma was seen on the right cornea. The nodule was excised by superficial keratectomy, with BCVA being 180/200 at 1 week after surgery. Pathological examination of the resected specimen revealed proliferation of fibroblasts and haphazard arrangement of collagen bundles, leading to a diagnosis of corneal keloid. Keloid-like lesion was also later noted in temporal corneal incision site of cataract surgery. CONCLUSIONS AND IMPORTANCE: This rare case of corneal keloid occurred as a late complication of pterygium surgery.

Association between serum n-3 polyunsaturated fatty acids and quadriceps weakness immediately after total knee arthroplasty.

OBJECTIVES: Quadriceps weakness (QW) following total knee arthroplasty (TKA) can be elicited by tourniquet-induced ischaemia reperfusion (IR), which causes a vigorous acute inflammatory response. Dietary n-3 polyunsaturated fatty acids (PUFA) are important determinants of organ and tissue protection from IR. This study aimed to examine the association between serum n-3 PUFA levels and QW, knee pain, and knee swelling immediately after TKA. METHODS: A total of 32 patients who underwent unilateral TKA participated in this prospective study. On Postoperative Day 1, serum n-3 PUFA (eicosapentaenoic acid and docosahexaenoic acid) levels were measured. Preoperatively and on Postoperative Day 4, quadriceps strength, knee pain during quadriceps testing, and knee circumference were measured. QW, knee pain, and knee swelling were defined as changes in quadriceps strength, knee pain during quadriceps testing, and knee circumference, respectively, between the preoperative to the postoperative measurement. RESULTS: Mean serum n-3 PUFA levels were 192 µg/mL (standard deviation, 58 µg/mL) on Postoperative Day 1. All measured variables changed significantly between the preoperative and the postoperative measurement time-points (P <0.01). Quadriceps strength decreased from 1.2 to 0.4 Nm/kg (QW = -65%). Knee pain during quadriceps testing increased from 1.1 to 6.0 (knee pain = 4.0). Knee circumference increased from 40 to 44 cm (knee swelling = 10%). Multivariate analysis showed that lower serum n-3 PUFA levels were independently associated with an increased QW after adjusting for the Kellgren-Lawrence grade and the tourniquet time (P = 0.04). No significant relationship was observed between serum n-3 PUFA levels and knee pain or knee swelling. CONCLUSION: Higher serum n-3 PUFA are independently associated with a lower increase in the QW immediately after TKA.

Hemophagocytic syndrome with acute kidney injury accompanied by erythrophagocytic macrophages in the tubular lumen.

Hemophagocytic syndrome (HPS) is a life-threatening syndrome involving excessive immune activation. It is often accompanied by renal involvement known as acute kidney injury (AKI), which is a poor prognostic factor of HPS. Thus, early diagnosis and treatment are very important. However, it is rarely identified in renal biopsy specimens, and its major manifestation is acute tubular necrosis. We report a rare case of erythrophagocytic macrophage presence in the tubular lumen of a patient with HPS-associated AKI. A kidney biopsy showed acute tubular necrosis, interstitial massive macrophage infiltration, and phagocytic macrophage casts without glomerular change. Some arteriolar vascular smooth muscle cells showed vacuolization because they were positive for α-smooth muscle actin. The patient's renal function improved after methylprednisolone pulse therapy followed by oral prednisolone after a month. Our case presents a new pathologic pattern of HPS. Careful urinalysis could suggest renal involvement with HPS. Having knowledge of this pathologic pattern of HPS is important to recognize the disease and to treat it appropriately.

Ciliary sulcus suture fixation of intraocular lens using an auxiliary device.

We developed an injector with a tip that matches the shape of the ciliary sulcus (Ciliary Sulcus Pad Injector) and is used in ciliary sulcus suture fixation of intraocular lenses. The injector is inserted through the corneal incisions and slid along the posterior surface of the iris to the opposite side. When the tip of injector is fitted in the ciliary sulcus, the plunger is pressed, causing the needle to pierce the ciliary sulcus. A suture is inserted in the ciliary sulcus without direct observation. In 91.4% of cases, the needle correctly pierced the ciliary sulcus in a single attempt. The difference between the preoperative expected refractive power and the postoperative spherical equivalent power was -0.63 diopter 6 months after surgery.

Anatomy of the ciliary sulcus and the optimum site of needle passage for intraocular lens suture fixation in the living eye.

PURPOSE: To determine the relationship of the anatomic position of tissue surrounding the ciliary sulcus using ultrasound biomicroscopy (UBM) for measurement of ciliary sulcus parameters and the surrounding tissue after intracapsular cataract extraction (ICCE) and determine the correct suture site for intraocular lens (IOL) suture fixation. SETTING: Sugiura Eye Clinic, Asahi General Hospital, Shizouka-ken, Japan. DESIGN: Prospective case series. METHODS: Using UBM, the angle of the ciliary sulcus and several areas of the tissue surrounding the ciliary sulcus were measured from 8 orientations in eyes after ICCE. These measurements and endoscopic observation of the ciliary sulcus indicated the optimum points of needle insertion and needle emergence on the sclera for IOL suture fixation. Endoscopic observation of the ciliary sulcus also showed its shape. RESULTS: The shape of the surrounding tissue of the ciliary sulcus was measured in 16 eyes after ICCE, and endoscopy was used to observe the ciliary sulcus during surgery in 150 eyes. For ab interno ciliary sulcus suture fixation, the correct point of needle emergence on the sclera was 2.5 mm from the posterior surgical limbus when a straight needle was used. For ab externo pars plana suture fixation, the correct point of needle insertion on the sclera was 3.0 mm from the posterior surgical limbus. Endoscopic observation showed that the lower surface of the ciliary sulcus was formed by the fusion of neighboring ciliary processes. CONCLUSION: Knowing the detailed shape of ciliary sulcus will allow for more precise IOL suture fixation.

Two Cases of Duchenne Muscular Dystrophy That Showed Different Reactions to Nerve Stimulation During Peripheral Nerve Block: A Case Report.

In recent years, the technique of combined ultrasound and electrical stimulation-guided nerve block has been recommended. We present 2 patients with Duchenne muscular dystrophy who exhibited different muscle responses to nerve stimulation during the performance of peripheral nerve blocks for surgeries. Whereas a 2-year-old boy without severe disability showed the expected muscle contraction to electrical nerve stimulation, a 14-year-old boy with severe disability showed no muscle response. Our experience suggests that muscle responses to electrical nerve stimulation will vary with the stage of Duchenne muscular dystrophy.

Preparation, Structural Determination, and Characterization of Electronic Properties of [5,6]- and [6,6]-Carbosilylated Sc3 N@Ih -C80.

Photochemical carbosilylation of Sc3 N@Ih -C80 with silirane 1 afforded two corresponding [5,6]-adducts, 2 and 3, and a [6,6]-adduct, 4. The structural and electronic properties of these products were characterized by means of spectroscopic, electrochemical, and theoretical methods. The structure of 2 was disclosed by means of single-crystal X-ray crystallographic analysis. Thermal isomerization of 3 to 2 was observed, whereas that of 2 to 3 proceeded less efficiently at 100 °C. Upon heating under the same conditions, adduct 4 underwent facile decomposition to afford Sc3 N@Ih -C80 , or isomerized into small amounts of 2 and 3. The relative stabilities of 2, 3, and 4 were rationalized through the results of theoretical calculations. In contrast, adducts 2, 3, and 4 were stable under the photolytic conditions employed for carbosilylation. The photochemical functionalization of Sc3 N@Ih -C80 represents a convenient synthetic method to obtain thermally labile fullerene-based products.

GM1 gangliosidosis in a Japanese domestic cat: a new variant identified in Hokkaido, Japan.

A male Japanese domestic cat with retarded growth in Hokkaido, Japan, showed progressive motor dysfunction, such as ataxia starting at 3 months of age and tremors, visual disorder and seizure after 4 months of age. Finally, the cat died of neurological deterioration at 9 months of age. Approximately half of the peripheral blood lymphocytes had multiple abnormal vacuoles. Magnetic resonance imaging showed bisymmetrical hyperintensity in the white matter of the parietal and occipital lobes in the forebrain on T2-weighted and fluid-attenuated inversion recovery images, and mild encephalatrophy of the olfactory bulbs and temporal lobes. The activity of lysosomal acid ß-galactosidase in leukocytes was negligible, resulting in the biochemical diagnosis of GM1 gangliosidosis. Histologically, swollen neurons characterized by accumulation of pale, slightly granular cytoplasmic materials were observed throughout the central nervous system. Dysmyelination or demyelination and gemistocytic astrocytosis were observed in the white matter. Ultrastructually, membranous cytoplasmic bodies were detected in the lysosomes of neurons. However, genetic analysis did not identify the c.1448G>C mutation, which is the single known mutation of feline GM1 gangliosidosis, suggesting that the cat was affected with a new variant of the feline disease.

The prediction of the palatability of orally disintegrating tablets by an electronic gustatory system.

In this study, the human gustatory palatability sensation of taste-masked famotidine and amlodipine orally disintegrating tablets (ODTs) was quantitatively predicted by an electronic gustatory system (α-Astree e-Tongue). Furthermore, its use in formulation design was evaluated. The famotidine- and amlodipine-containing ODTs, which were bitter- and highly bitter-tasting, respectively, were prepared using a physical (granules spray-coated with ethyl cellulose) or organoleptic (the addition of a sweetener and a flavor) masking method and combinations thereof. The taste-masking effects of different masking methods on the ODTs were investigated in a human gustatory sensation test. In the test, volunteers scored the overall palatability using a 100mm visual analog scale (VAS). The electronic gustatory system was evaluated using the Euclidean distance (the distance between each drug-containing ODT and its corresponding placebo) and partial least squares (PLS) regression analysis of the sensor response values. A good linear relationship was observed between each ODT's Euclidean distance analysis, PLS regression analysis, and clinical VAS scores. Cross-validation verification of each analysis confirmed the model's predictive power. This study suggests that the α-Astree can quantitatively evaluate physical and organoleptic taste masking and that the palatability of unknown formulations can be predicted by Euclidean distance and PLS regression data analysis.