Long-term postoperative prognosis and associated risk factors of chronic subdural hematoma in the elderly.

Surgical treatment for chronic subdural hematoma（CSDH）has contributed to good outcome. However, several recent studies have revealed that surgical outcomes for elderly patients were not decisively good. In this study, prognosis of CSDH patients in elderly were analyzed. This study included 232 CSDH patients who were treated in our department and 2 affiliated hospitals, and poor prognosis was defined as aggravation of modified Rankin scale (mRS) at examination comparing with that at discharge, or mRS 3 and higher at examination. We collected data from medical records and questionnaires on the following clinical characteristics of patients: age, sex, findings at admission, medication of antiplatelets and anticoagulants, radiological findings on computed tomography, recurrence, place of discharge, perioperative systemic complications, and mRS at discharge and at examination. The cut-off value of age for poor prognosis of all CSDH patients was 74 years old in this study. In multivariate analysis of all cases, age was prognostic factor for poor outcome:75 years old or higher（p=0.0002）. In this group, mRS at discharge(p=0.0184) and postoperative medical diseases(p<0.0001) were the risk factors of poor prognosis. In this present study, high age and activities of daily life（ADL） at discharge were significant prognostic factors for poor outcome of CSDH. Improvement of ADL at discharge with care for postoperative systemic complications and careful rehabilitation can contribute to good prognosis for CSDH in elderly patients.

Spontaneous remission of skull Langerhans cell histiocytosis that had developed by repeated head injury: illustrative case.

BACKGROUND: Langerhans cell histiocytosis (LCH) was previously characterized as the proliferation of Langerhans-type histiocytes with a wide range of clinical presentations that arise mostly in children. The typical presentation is a gradually enlarging, painless skull mass. Rapid clinical deterioration is rare. OBSERVATIONS: A 3-year-old boy who had incurred a right frontal impact head injury demonstrated no apparent neurological deficits. He subsequently bruised the same region multiple times. The right frontal swelling gradually increased over the course of 6 days after the initial injury. Skull radiography showed no bony lesion. The same site enlarged markedly 12 days after the initial injury. Magnetic resonance imaging revealed a frontal bony tumorous lesion associated with multiple subcutaneous cystic mass lesions. The patient underwent open biopsy of the skull lesion and evacuation of the subcutaneous lesions. Histopathological examination confirmed the diagnosis of LCH. Immunohistochemical evaluation revealed positivity for CD1a and langerin and no immunopositivity for BRAF V600E. The skull lesion spontaneously disappeared 30 days after the biopsy without recurrence. LESSONS: Physicians should be aware of this rare clinical manifestation of LCH that developed by a repeat head injury.

Verification of a Three-day Hospitalization Protocol for Chronic Subdural Hematoma Surgery.

Chronic subdural hematoma (CSH) is predominantly a disease of the elderly. Aging societies in advanced countries are seeing the number of CSH cases increasing. We applied a three-day hospitalization protocol for CSH surgery to reduce healthcare costs and more efficiently manage hospital beds. We investigated the clinical factors that influenced prolonged hospitalization. From January 2015 to December 2020, we performed irrigation, evacuation, and drainage of CSH cases in 221 consecutive patients. The χ2 test and logistic regression analysis were conducted to detect clinical factors influencing prolonged hospitalization. A p-value below 0.05 was considered statistically significant. Applying a three-day hospitalization protocol showed no adverse outcomes. Fifty-two (24%) of 221 patients experienced prolonged hospitalization. The χ2 test showed that female gender, atrial fibrillation, alcohol abuse, preoperative consciousness level, verbal function disturbance, and perioperative activities of daily living were significantly related to prolonged hospitalization. Female gender, atrial fibrillation, and alcohol abuse were significant factors in the logistic regression analysis. A three-day hospitalization protocol for CSH is suitable for patient care; however, particular attention needs to be focused on the female gender, atrial fibrillation, and alcohol abuse, all three of which prolong hospitalization.

Epidural intracranial abscesses and multiple bone metastases caused by disseminated Mycobacterium avium complex infection: illustrative case.

BACKGROUND: Mycobacterium avium complex (MAC) generally causes localized pulmonary infections in immunocompromised hosts, but rarely in other organs and tissues, which is called disseminated MAC infection. OBSERVATIONS: The authors herein present a 48-year-old male patient with disseminated MAC infectious lesions in the lungs and on the cranial, vertebral, femoral, and pelvic bones, a normal CD4 count, and immunopositivity for the interferon-ɤ (IFN-ɤ) neutralization antibody. Cranial lesions were multiple osteolytic lesions associated with abscesses in the cranial bones. The patient initially received conservative treatment with multiple antibiotics; however, cranial lesions worsened. Therefore, multiple cranial lesions were removed via osteoplastic craniectomy and the postoperative course was uneventful. Pathological findings revealed MAC infection. The patient was discharged without recurrence or complications. LESSONS: Multiple cranial MAC dissemination with immunopositivity for the IFN-ɤ antibody is rare. The authors herein present the clinical course of a rare surgical case of MAC dissemination with a literature review.

Essential amino acids as diagnostic biomarkers of hepatocellular carcinoma based on metabolic analysis.

Metabolomics, defined as the comprehensive identification of all small metabolites in a biological sample, has the power to shed light on phenotypic changes associated with various diseases, including cancer. To discover potential metabolomic biomarkers of hepatocellular carcinoma (HCC), we investigated the metabolomes of tumor and non-tumor tissue in 20 patients with primary HCC using capillary electrophoresis-time-of-flight mass spectrometry. We also analyzed blood samples taken immediately before and 14 days after hepatectomy to identify associated changes in the serum metabolome. Marked changes were detected in the different quantity of 61 metabolites that could discriminate between HCC tumor and paired non-tumor tissue and additionally between HCC primary tumors and colorectal liver metastases. Among the 30 metabolites significantly upregulated in HCC tumors compared with non-tumor tissues, 10 were amino acids, and 7 were essential amino acids (leucine, valine, tryptophan, isoleucine, methionine, lysine, and phenylalanine). Similarly, the serum metabolomes of HCC patients before hepatectomy revealed a significant increase in 16 metabolites, including leucine, valine, and tryptophan. Our results reveal striking differences in the metabolomes of HCC tumor tissue compared with non-tumor tissue, and identify the essential amino acids leucine, valine, and tryptophan as potential metabolic biomarkers for HCC.

A pyruvate carbon flux tugging strategy for increasing 2,3-butanediol production and reducing ethanol subgeneration in the yeast Saccharomyces cerevisiae.

BACKGROUND: The yeast Saccharomyces cerevisiae is a promising host cell for producing a wide range of chemicals. However, attempts to metabolically engineer Crabtree-positive S. cerevisiae invariably face a common issue: how to reduce dominant ethanol production. Here, we propose a yeast metabolic engineering strategy for decreasing ethanol subgeneration involving tugging the carbon flux at an important hub branching point (e.g., pyruvate). Tugging flux at a central glycolytic overflow metabolism point arising from high glycolytic activity may substantially increase higher alcohol production in S. cerevisiae. We validated this possibility by testing 2,3-butanediol (2,3-BDO) production, which is routed via pyruvate as the important hub compound. RESULTS: By searching for high-activity acetolactate synthase (ALS) enzymes that catalyze the important first-step reaction in 2,3-BDO biosynthesis, and tuning several fermentation conditions, we demonstrated that a stronger pyruvate pulling effect (tugging of pyruvate carbon flux) is very effective for increasing 2,3-BDO production and reducing ethanol subgeneration by S. cerevisiae. To further confirm the validity of the pyruvate carbon flux tugging strategy, we constructed an evolved pyruvate decarboxylase (PDC)-deficient yeast (PDCΔ) strain that lacked three isozymes of PDC. In parallel with re-sequencing to identify genomic mutations, liquid chromatography-tandem mass spectrometry analysis of intermediate metabolites revealed significant accumulation of pyruvate and NADH in the evolved PDCΔ strain. Harnessing the high-activity ALS and additional downstream enzymes in the evolved PDCΔ strain resulted in a high yield of 2,3-BDO (a maximum of 0.41 g g-1 glucose consumed) and no ethanol subgeneration, thereby confirming the utility of our strategy. Using this engineered strain, we demonstrated a high 2,3-BDO titer (81.0 g L-1) in a fed-batch fermentation using a high concentration of glucose as the sole carbon source. CONCLUSIONS: We demonstrated that the pyruvate carbon flux tugging strategy is very effective for increasing 2,3-BDO production and decreasing ethanol subgeneration in Crabtree-positive S. cerevisiae. High activity of the common first-step enzyme for the conversion of pyruvate, which links to both the TCA cycle and amino acid biosynthesis, is likely important for the production of various chemicals by S. cerevisiae.

Determination of amino acids in urine by cyclodextrin-modified capillary electrophoresis-laser-induced fluorescence detection.

Capillary electrophoresis (CE) combined with laser-induced fluorescence detection is applied to the determination of amino acids in urine samples. The urine samples are first ultrafiltered, to remove proteins and large peptides, and the filtrates are then directly labeled by reaction with fluorescein isothiocyanate (FITC). Cyclodextrin-modified CE using alpha-cyclodextrin is employed for the separation of the FITC-labeled amino acids. Seven amino acids are clearly separated from side reaction products produced during the labeling reaction, when an 80 mM borate buffer containing 45 mM alpha-cyclodextrin is used as the running buffer. For quantitative analysis, rhodamine B is added to the labeled urine samples as an internal standard. The calibration curves for phenylalanine, glutamine, proline, glycine, serine, alanine, and valine are linear in the range of 10 microM to 100 microM. The concentration limits of detection for all of the amino acids are estimated to be 160-330 nM. Conversely, the limit of quantitation (LOQ) was approximately 10 microM and the limitations are due to the labeling efficiency rather than the sensitivity of the detector. Three amino acids in urine samples, glutamine, glycine, and alanine, are readily quantitated, while the concentrations of the others are below the LOQ. The present method would permit the determination of seven amino acids in urine successfully.