Dialysis-induced Subdural Hematoma in an Arachnoid Cyst Associated with Autosomal Dominant Polycystic Kidney Disease.

Arachnoid cyst (AC) is a neurological complication of autosomal dominant polycystic kidney disease (ADPKD). Although an AC can increase the risk of a subdural hematoma, the clinical presentation of bleeding into an AC associated with ADPKD is not well known. We herein report the case of a 59-year-old woman in whom the initiation of hemodialysis for renal failure led to AC bleeding. A change of anticoagulant from heparin to nafamostat mesilate allowed dialysis to continue without rebleeding. These findings suggest that hemodialysis in patients with an AC associated with ADPKD may increase the risk of bleeding. Nafamostat mesilate may be useful in such cases.

The close relationship between life-threatening breathing disorders and urine storage dysfunction in multiple system atrophy.

Survival of multiple system atrophy (MSA) depends on whether a variety of sleep-related breathing problems as well as autonomic failure (AF) occur. Since the brainstem lesions that cause respiratory and autonomic dysfunction overlap with each other, these critical manifestations might get worse in parallel. If so, the detection of AF, which is comparatively easy, might be predictive of a latent life-threatening breathing disorder. In 15 patients with MSA, we performed autonomic function tests composed of postural challenges and administered a questionnaire on bladder condition, as well as polysomnography and laryngoscopy during wakefulness and under anesthesia. Polysomnographic variables such as the apnea-hypopnea index (AHI) and oxygen saturation (SpO(2)) and the findings of laryngoscopy were compared with the degree of cardiac and urinary autonomic dysfunction. AHI, mean SpO(2) and the lowest SpO(2) showed significant correlations with urine storage dysfunction. In addition, patients with vocal cord abductor paralysis (VCAP) or central sleep apnea (CSA) contributing to nocturnal sudden death had more severe storage disorders than those without. On the other hand, no significant relationship between polysomnographic variables and orthostatic hypotension was observed except in the case of mean SpO(2). These results indicate that life-threatening breathing disorders have a close relationship with AF, and especially urine storage dysfunction. Therefore, longitudinal assessment of deterioration of the storage function might be useful for predicting the latent progress of VCAP and CSA.

Paraneoplastic necrotizing myelopathy in a patient with advanced esophageal cancer: An autopsied case report.

We report the first autopsied case of paraneoplastic necrotizing myelopathy associated with esophageal cancer in the literature. The patient had acute flaccid paraplegia and urinary retention, and had a good recovery of strength of both legs in response to corticosteroids. MRI showed a characteristic lesion with post-gadolinium enhancement of the cervical to mid-thoracic spinal cord at the onset, which has never been reported. Taken together, these results suggest that there is an underlying autoimmune mechanism in paraneoplastic necrotizing myelopathy.

[Efficacy of continuous intraoperative administration of low-dose milrinone during the circumflex artery anastomosis of off-pump coronary artery bypass].

BACKGROUND: We have experienced instability of hemodynamic state during off-pump coronary artery bypass (OPCAB), especially, circumflex (Cx) artery anastomosis. Although some reports have implied the efficacy of mirlinone in OPCAB anastomosis due to its characteristic inotropic effect without increasing myocardial oxygen consumption, we examined the effect of smaller doses of mirlinone during Cx anastomosis. METHODS: Fourteen patients received milrinone (M group) continuously at a rate of 0.15-0.30 microg x kg(-1) min(-1) after sternotomy until the end of operation. Sixteen patients in the control group (C group) received saline. Norepinephrine was concomitantly administered for maintaining systolic blood pressure above 100 mmHg. We measured hemodynamic parameters during Cx anastomosis and postoperative myocardial isozymes, and examined arrhythmias. RESULTS: In the M group mean pulmonary arterial pressure (MPAP) decreased significantly and cardiac index (CI) and SvO2 increased significantly, compared with C group. M group showed lower incidence of atrial fibrillation for 2 days. CONCLUSIONS: We conclude that low-dose milrinone has a good influence on intraoperative and postoperative managements of OPCAB surgery.

Low-dose tacrolimus for two cases of myasthenia gravis with invasive thymoma that relapsed shortly after thymectomy.

Two patients with myasthenia gravis (Ossermann IIb) involving invasive thymoma who underwent extensive thymectomy manifested myasthenic crisis shortly after the procedure; however, both patients were treated with intravenous immunoglobulin and recovered from myasthenic crisis that had been deteriorating for about 1 week. Subsequently, the patients were administered a low-dose of tacrolimus (3 mg/day) in addition to prednisolone. Several months later, tacrolimus continued to control fluctuations of myasthenic symptoms and maintained remission in these patients. The serum titer of anti-Ach-receptor antibodies decreased in parallel with clinical improvement due to tacrolimus, and we accordingly reduced the dosage of prednisolone. Tacrolimus is a new immunosuppressive agent acting through the selective inhibition of helper-T-cell activation that can be reduced dosage of steroids and can maintain remission of myasthenia gravis with invasive thymoma.

Anaphylactic transfusion reactions in haptoglobin-deficient patients with IgE and IgG haptoglobin antibodies.

BACKGROUND: Patients with haptoglobin deficiency associated with haptoglobin IgG antibodies, who experienced severe nonhemolytic transfusion reactions (NHTRs), have been identified in Japan. Haptoglobin deficiency therefore might be a risk factor for NHTRs. STUDY DESIGN AND METHODS: A total of 4138 cases of voluntarily reported NHTRs in Japan, including 367 cases of immediate-onset anaphylactic NHTRs, were examined to identify haptoglobin deficiency. Serum haptoglobin IgG and IgE antibodies were determined in haptoglobin-deficient patients to elucidate the mechanism underlying the transfusion reactions. RESULTS: Seven patients with haptoglobin deficiency were identified. Six of them experienced severe and acute NHTRs. Six of them were identified to be homozygous for the Hpdel allele of the haptoglobin gene. Both haptoglobin IgG and IgE antibodies were detected in serum samples of all the patients. The stimulative effects of blood transfusion on the production of hap- toglobin antibodies in the patients and the relation- ship between the presence of the antibodies and the occurrence of the transfusion reactions were observed. CONCLUSION: Anaphylactic NHTRs in these patients with haptoglobin deficiency associated with serum haptoglobin antibodies were suggested to be prevalent in Japan. In addition to IgG antibodies, IgE haptoglobin antibodies detected in the sera of such patients were suggested to play a role in the occurrence of the reactions.