Efficacy of neutrophil elastase inhibitor on type A acute aortic dissection.

BACKGROUND: Surgery for type A acute aortic dissection (AAD) is associated with a high mortality and incidence of postoperative complications, including acute respiratory failure and coagulopathy. Aim of the study was to investigate the effects of sivelestat on pulmonary function and coagulopathy in patients undergoing surgery for AAD. METHODS: Sixty patients undergoing emergency ascending replacement for AAD were divided into two groups. Group I was administered sivelestat intravenously from the beginning of surgery until extubation. Group II was not treated with sivelestat. The platelet count, antithrombin III (AT III) level, leukocyte count, C-reactive protein (CRP) level, prothrombin time (PT), activated partial thrombin time (APTT), and prothrombin time-international normalized ratio (PT-INR) were measured. RESULTS: The postoperative decrease of AT III and the platelet count on admission to the intensive care unit (ICU) and 3 hours later were significantly less in group I. The leukocyte count and the values of CRP, PT, APTT, and PT-INR did not differ significantly between the groups. The duration of mechanical ventilation after surgery tended to be shorter in group I. CONCLUSIONS: Sivelestat significantly reduced the postoperative decreases in AT III and platelet count in patients undergoing emergency surgery for AAD.

Proton pump inhibitors may increase the risk of delayed bleeding complications after open heart surgery if used concomitantly with warfarin.

OBJECTIVES: The American Food and Drug Administration has suggested that proton pump inhibitors increase the international normalized ratio (INR) when used concomitantly with warfarin, by being metabolized by cytochrome P450 2C19. We therefore reviewed patients taking warfarin. METHODS AND RESULTS: Two hundred and forty patients who took warfarin after surgery were divided into two groups: Group I (n = 114) had rabeprazole (10 mg/day) and Group II (n = 126) had lansoprazole (15 mg/day). The initial dose of warfarin was 3 mg and INR was initially assessed on postoperative day 4. Initial INR was significantly lower in Group I (1.66 +/- 0.87) than in Group II (2.06 +/- 1.03, P = 0.0011). Delayed cardiac tamponade and hemothorax occurred as complications in 6 and 1 patients, respectively, in Group II from 5 days to 3 months postoperatively. At the time of the occurrence of complications, the average INR increased to 3.95 (range from 3.11 to 5.86). There were no patients with delayed bleeding in Group I ( P = 0.015). CONCLUSIONS: These results suggest that lansoprazole emphasizes the effects of warfarin. Rabeprazole could be safely used concomitantly with warfarin.

Clinical and immunohistochemical characteristics of benign giant cell tumour of bone with pulmonary metastases: case series.

PURPOSE: Giant cell tumour of bone with pulmonary metastases is rare. However, some patients die of pulmonary metastases, and histological examination cannot distinguish between benign tumour and malignant metastases. In this study, we present clinical and immunohistochemical findings associated with giant cell tumour of bone with pulmonary metastases. METHODS: Five patients with benign giant cell tumour of bone with pulmonary metastases (one man and 4 women) were studied. Patients' ages ranged between 20 and 23 years (mean age, 21.8 years). Tumours were in the distal femur in 2 cases, and in the proximal tibia, distal tibia, and lumbar spine in one case each. The tissue specimens from primary tumours, recurrent tumours, and pulmonary metastases were studied using immunohistochemical techniques. RESULTS: Three of the 5 primary tumours were of the spontaneous regression or growth cessation type, or the continuously slow-growing type, showing 4.2% to 6.2% of positive cells for Ki-67 after immunohistochemical staining. However, 2 patients with the rapid-growing type of disease died of pulmonary metastases; their primary, recurrent, and metastatic tumour specimens contained 9.0% to 11.5% of positive cells for Ki-67. CONCLUSION: Three of the 5 primary tumours had a benign clinical pattern and immunohistochemistry. Two of the 5 patients died of pulmonary metastases, which had an aggressive clinical pattern and a high prevalence of positive cells in Ki-67. Examination of Ki-67 should be carried out for aggressive type of giant cell tumour.

Surgical management of malignant soft tissue tumours in patients aged 65 years or older.

OBJECTIVE: With the aim to determine the most effective treatment for primary malignant musculoskeletal tumours in patients aged 65 years or older, we reviewed cases of low- and high-grade neoplasms, surgical margins, surgical methods, and the prognoses of elderly and aged patients at our institution. METHODS: Records of 25 patients aged 65 years or older who had malignant soft tissue tumours from December 1986 to February 1997 were reviewed. Low- and high-grade neoplasms accounted for 8 and 17 patients, respectively. 11 patients were aged 65 to 69 years, while 14 were 70 years or older. Surgical margins were wide in 19 cases, marginal in 4, and intralesional in 2. Reconstruction was done using 6 musculocutaneous flaps and/or 4 vessel grafts. As adjuvant therapy, radiotherapy was used in 5 cases and chemotherapy in 3. There was no recurrence in patients with wide surgical margins (determined on the basis of gross inspection of the excised tumour and the cut surface); but there was recurrence in 4 patients with marginal margins, and one patient with intralesional margin. Two patients with intralesional, 4 with marginal, and 2 with wide margins, died from recurrence at the primary site and metastasis, or from metastasis without recurrence at the primary site. RESULTS: Follow-up periods ranged from 4 months to 180 months (mean, 91.6 months). The overall 5-year survival rate was 79.6%; for low- and high-grade neoplasms, the figures were 100% and 69.7%, respectively; for those aged 65 to 69 years and in their 70's or older, the figures were 90.9% and 70.1%, respectively. CONCLUSION: For geriatric patients, wide surgical margins are required to manage both low- and high-grade neoplasms, in order to avoid multiple surgeries.

[A case of quadricuspid aortic valve associated with coronary artery disease].

A 65-year-old man with aortic regurgitation was found to have a quadricuspid aortic valve. Surgical correction consisted of aortic valve replacement with a 21 mm Hyper dynamic plus St. Jude Medical valve and coronary revascularization of LAD and the first diagonal branch. During the operation, a quadricuspid aortic valve with 1 smaller and 3 larger cusps and normal coronary orifice were noticed. Accurate information by the transesophageal echo proved to be quite valuable. Our case is one of 43 cases which have been reported in Japan.

Effectiveness of manual cleaning and disinfection of gastroendoscopes with 3% glutaraldehyde for decreasing risk of transmission of hepatitis C virus.

OBJECTIVES: The effectiveness of manual cleaning and disinfection of gastroendoscopes with 3% glutaraldehyde in decreasing the risk of transmission of hepatitis C virus (HCV) was examined. METHODS: Gastroendoscopes used for treatment of endoscopic esophageal variceal ligation in patients with HCV infection were manually cleaned and disinfected with 3% glutaraldehyde (n = 25), 2% glutaraldehyde (n = 17), or 0.1% benzethonium chloride (n = 25). Samples were obtained by pouring 20 ml of 0.9% NaCl solution into the biopsy-suction channel of the scope before and after cleaning and disinfection. HCV was detected with the polymerase chain reaction. RESULTS: Of the 25 scopes in 3% glutaraldehyde group, nine (36%) were positive for HCV before cleaning and disinfection, but all became negative after cleaning and disinfection; the difference was statistically significant (p < 0.01). In contrast, in 2% glutaraldehyde group and in the routine cleaning group, there were no significant differences in the number of positive samples between before and after cleaning and disinfection. CONCLUSION: Manual cleaning and disinfection of gastroscopes with 3% glutaraldehyde is useful for decreasing the risk of transmission of HCV among patients.

Immediate and long-term results of coronary artery bypass operation in hemodialysis patients.

This study evaluated the early and late results of coronary artery bypass grafting (CABG) in patients on long-term maintenance hemodialysis (chronic HD) at Teikyo University Ichihara Hospital between January 1996 and June 2000. Thirty-six patients on chronic HD underwent CABG. There were 26 males (72%) and 10 females (28%) ranging from 41 to 81 years (mean +/- SD, 61.8 +/- 9.2 years) of age. Twenty-one patients (58%) had unstable angina, 14 (39%) stable angina, and 1 acute myocardial infarction. Eleven patients (31%) had urgent or emergency CABG. The average graft number was 2.5 +/- 0.8 (arterial graft 1.3 +/- 0.7/patient). Six patients had concomitant cardiac operations. Three patients underwent re- or a second re-CABG. Five patients underwent off-pump CABG. Principally, HD was performed during cardiopulmonary bypass and was followed by continuous hemodiafiltration in the early postoperative period. The early mortality was 11%; 25% in emergency and urgent CABG and 4% in elective CABG. In the follow-up period between 1 and 53 months (mean +/- SD 21.9 +/- 15.1 months), 4 patients died, and 9 patients developed recurrence of angina pectoris (6, occlusion of saphenous vein graft and 3, native coronary progression). Six patients had coronary intervention. The postoperative angiogram showed that all arterial grafts were patent, but the patency of the vein grafts was only 61.5%. The early results of CABG in patients on chronic HD was satisfactory. The late recurrence of angina pectoris mostly was caused by occlusion of the saphenous vein graft. In conclusion, the aggressive use of arterial grafts is crucial in CABG for patients on chronic HD.

Off-pump Coronary Artery Bypass Grafting in patients on chronic hemodialysis.

BACKGROUND: Off-pump Coronary Artery Bypass Grafting(CABG) has gained much support but has been scarcely reported in patients on chronic hemodialysis (HD). The details of CABG for such patients on chronic HD are presented. METHODS: Between January 1998 and December 1999, off-pump CABG was performed in 5 patients on chronic HD. All patients presented with unstable angina pectoris. The indication for off-pump CABG was suitable coronary anatomy (N = 5) and expected high risks associated with cardiopulmonary bypass due to reoperation (N = 1) and impaired cerebral blood flow (N = 2). The approach was median sternotomy (N = 4) and left anterior short thoracotomy (N = 1). The mean graft number was 2.0 +/- 1.0 (range, 1-3). In situ arterial grafts were mainly used: the in situ left internal thoracic artery was used in four patients, the in situ right gastroepiploic artery in two, the in situ right internal thoracic artery in two, and the saphenous vein in two patients. RESULTS: There were no deaths or complications. Nine of 10 grafts were confirmed fully patent by postoperative angiography before hospital discharge. In a mean follow-up of 17.2 months, no patients had developed recurrence of angina or any cardiac symptom. CONCLUSION: Off-pump CABG using in situ arterial grafts can be performed on patients on chronic hemodialysis subject to suitable anatomy of the target coronary arteries.

Hemipelvic allograft reconstruction after periacetabular bone tumor resection.

We reviewed the results of 19 patients with hemipelvic allograft reconstructions after periacetabular tumor resection at Massachusetts General Hospital from 1977 to 1996. Histological diagnosis showed chondrosarcoma (in 7 patients), osteosarcoma in 5, and other tumors in 7. Seventeen patients were continuously disease-free for 12-228 months (mean, 57 months). One patient died of sepsis caused by wound infection after surgery for local recurrence. Results of evaluation (by the Mankin scale) in the 19 patients were: excellent in 1, good in 6, fair in 5, and failure in 7. Of the 19 patients, 5 (28%) had wound infection, and 3 patients had local recurrence. Allograft fracture was observed in 1 patient. Allograft and bipolar prosthesis were used in 11 patients, and migration of the bipolar prosthesis was observed in 4 of these patients. In 7 patients the femoral head was preserved; 2 patients received total hip arthroplasty because of osteoarthrosis in the hip joint or collapsed allograft. Migration of the bipolar prosthesis, with eventual osteoathrosis in the hip joint was also observed. However, hemipelvic allograft was thought to be an alternative useful reconstruction method despite the unresolved problems of loosening, dislocation, and breakage of the custom-made prosthetic hemipelvis.

Interleukin-1 alpha producing synovial sarcoma with prolonged fever: a case report.

The patient had a synovial sarcoma of the monophasic fibrous type accompanied by prolonged spike fever. Wide excision of the tumor resulted in the disappearance of her fever. The tumor cells showed interleukin-1 alpha (IL-1 alpha) expression immunohistochemically. IL-1 alpha cDNA was detected in the tumor by RT-PCR, the sequences of which were identical with those of normal human IL-1 alpha molecules. These results indicated that IL-1 alpha, one of the fever-inducing cytokines, was expressed by sarcoma cells in the present case, which were thought to be a causative factor of the fever.

Detection of Epstein-Barr virus-encoded small RNA 1 and latent membrane protein 1 in synovial lining cells from rheumatoid arthritis patients.

Several investigators have demonstrated an association between Epstein-Barr virus (EBV) and the pathogenesis of rheumatoid arthritis (RA). However, there is no direct evidence that this virus exists in the synovial cells of patients with RA. We attempted to detect EBV in synovial cells from RA patients. Specimens of synovial tissues from 34 patients with RA and from 20 patients with osteoarthritis (OA), and from one patient with psoriatic arthritis as controls, were examined for evidence of the EBV by in situ hybridization. The specimens were also tested by immunoperoxidase staining for expression of the CD21 molecule (EBV receptor), EBV nuclear antigen (EBNA)-2 and latent membrane protein (LMP)-1. EBV-encoded small RNA-1 (EBER) was demonstrated in synovial lining cells from eight (23.5%) out of 34 RA patients but in none of 20 OA patients (P < 0.05) nor in the one psoriatic arthritis patient. Interestingly, EBER localized in synovial lining cells that were located at the apex of villus proliferating lesions. Furthermore, LMP-1 was also detected in synovial lining cells at the top of villus lesions. Nevertheless, CD19 and CD21 molecules, and EBNA-2 were not demonstrated in such lesions. The incidence of EBV-positive in synovial lining cells with severely infiltrated lymphocytes tended to be higher than that in moderately infiltrated ones. This is the first evidence that EBV exists in chronically inflamed synovial lining cells of human joints in RA.

Analysis of giant cell tumor of bone with pulmonary metastases.

The authors reviewed 6 cases of giant cell tumor of bone with pulmonary metastases, analyzed the growth rate of the metastases, and performed flow cytometry on paraffin blocks from primary and metastatic lesions. Surgery on the pulmonary metastases was done in 3 cases. Chemotherapy was administered in all 6 cases. If the doubling time of the pulmonary metastases was more than 80 days, the case was considered to be slow growing or in regression. However, if the doubling time was approximately 30 days, the prognosis was poor. The cases were divided into 3 types according to the prognosis. After chemotherapy (cyclophosphamide), the pulmonary metastases decreased in size in 2 cases. In 2 other cases, the metastases were slow growing, and the remaining 2 patients died early. Flow cytometric analysis was performed on primary and metastatic lesions, which showed a diploid pattern in most cases, but a tetraploid pattern in 1 recurrent case. Pulmonary metastatic lesions displayed a diploid pattern in 4 cases from which materials were taken either at surgery or autopsy.

Description of new composite tissue transfer for salvage of a complex hand defect.

Leiomyosarcoma of the soft tissue involving bones is an extremely rare tumor. In the past, a hand tumor of this type required amputation. Presently, with improved chemotherapy and reconstruction, the hand and its dexterity sometimes can be saved. In this case, after chemotherapy, the authors opted for wide excision including the skin, tendons, muscles, and bones. The large defect was reconstructed with an iliac crest autograft and a dorsalis pedis free flap including tendons. Functional result was excellent in this patient. The pathologic results also were reviewed by histology, immunohistochemistry for muscle marker, and electron microscopy.

[The effects of preoperative drinking and H2 blocker on gastric acid secretion].

We studied the effects of preoperative drinking and H2 blocker on gastric acid secretion in 63 patients (ASA I-II, > 18yrs) scheduled for afternoon surgery. Group A (n = 20), as a control, was not permitted to eat and drink from 9 pm, the day before surgery, and was then given 500 ml of maintainance fluid before anesthesia. Group B (n = 20) fasted from 9 pm the day before surgery, and was allowed to drink clear fluids until 2hs before anesthesia. Group C (n - 23) followed the same guidelines as group B, and was given famotidine (20mg) orally at 9 pm the day before and 2hs before anesthesia. After induction, a Salem sump tube was inserted into the stomach and a gastric fluid aspiration was performed. The fluid volume and pH were measured after collection. Gastric pH was significantly higher (P < 0.001) in group C (6.4 +/- 0.9) than in groups A (3.1 +/- 1.8) and B (2.7 +/- 1.8). Fluid volume was similar in each group (A; 11 +/- 9/B; 12 +/- 9/C; 12 +/- 13ml). The dilution of gastric acid by the ingested fluid was not observed. We conclude that preoperative drinking does not affect gastric contents in elective operative patients. To reduce the risk of developing aspiration pneumonia, we recommend that every patient should receive an oral H2 blocker.

Addition of cisapride shortens colonoscopy preparation with lavage in elderly patients.

METHODS: The effect of pre-treatment with cisapride on colonoscopy preparation with lavage solution was compared in 120 out-patients less than 60 years and 73 out-patients 60 years or older, who were scheduled for total colonoscopy. By random allocation, patients were assigned to receive cisapride 10 mg or placebo 30 minutes before ingesting the magnesium citrate lavage solution. RESULTS: The cleansing results and patients' acceptance did not differ significantly in the two treatment groups in either age group. The time from the start of ingesting magnesium citrate until the rectal effluent became clear was significantly shorter in cisapride-treated patients of 60 years or more. Moreover, the residual fluid volume removed by suction during colonoscopy was significantly less in the patients above aged 60 years who received cisapride. CONCLUSION: These findings indicate that the combination of cisapride and magnesium citrate is more effective than magnesium citrate alone in cleansing the colon for colonoscopy in elderly patients.

[Growth rate analysis of pulmonary metastases in giant cell tumor of bone].

We reviewed six cases with pulmonary metastases in giant cell tumor of bone. The growth rate and the doubling time of pulmonary metastases was measured and compared to the clinical course. The six cases were classified into two each of the following three types: 1) spontaneous remission, 2) continuously slow growing and 3) rapid growing. A favorable factor was a doubling time of more than 80 days in pulmonary metastases. A poor prognosis was indicated by a doubling time of around 30 days. Aggressive primary lesions should be excised widely.

[Malfunction of mitral and tricuspid Ionescu-Shiley pericardial xenografts].

We report a case of the malfunction of Ionescu-Shiley pericardial xenografts (ISPX) in the mitral and tricuspid positions at 6 years after implantation. The patient underwent an emergency operation successfully despite his high age (75 years) and extremely poor preoperative condition. The valve extracted from the mitral position showed spontaneous disruption of the leaflet, while the tricuspid valve graft was entangled with the preserved native septal leaflet around the stents. This former complication is now widely recognized, but the latter one appears to be rare. Care should be taken in replacing the atrioventricular valve with a bioprosthesis when the native valve leaflets are not removed. Although the ISPX is no longer in clinical use, careful follow-up is mandatory in patients with this prosthesis especially when it was implanted in the mitral position.

Nasu-Hakola disease. A case accompanied by abnormalities in fatty acid composition of serum total lipids and amino acid analysis.

A case of Nasu-Hakola disease (membranous lipodystrophy) was reported. The patient is a 33-year-old man who started to have pathological fractures at the age of 24 years. Then, neurological symptoms such as dementia appeared gradually. A biopsy specimen of the bone showed membranocystic changes of the adipose tissue. T2-weighted magnetic resonance images of the head showed low intensity in bilateral putamens, internal capsules, globi pallidi and caudate nuclei. One of his brothers has the same disease. In both patients, fatty acid composition of serum total lipids showed increased nervonic acid and plasma amino acid analysis showed decreased glutamine.

[Treatment and prognosis of giant cell tumor in the sacrum--study of Bone Tumor Registry in Japan].

The prognosis of giant cell tumors arising in the sacrum is difficult to ascertain. Because of the low incidence in Japan there are scanty statistics. We selected 14 cases from the Bone Tumor Registry in Japan. Questionnaires were sent to hospitals which had submitted cases, regarding Enneking's staging, surgical approach, surgical procedure, radiotherapy, chemotherapy, complications and prognosis of this tumor. The results of the questionnaire show that surgery alone gives better results than combined surgery and radiotherapy. Good prognosis called for surgery alone. Curettage resulted in no evidence of disease (NED) in four cases. Bad prognosis called for combined surgery, radiotherapy and chemotherapy. If we surmise from the biological behavior of the giant cell tumor, that the tumor mass extends out extraosseously en-bloc excision with nerve roots is indicated. Extensive curettage will be adequate if the tumor is confined intraosseously. Radiotherapy should not be selected except for inoperative cases.