An unusual case of bone regeneration of a necrotic mandible with pathologic fracture in an elderly hemodialysis patient with medication-related osteonecrosis of the jaw: a case report and review of the literature.

BACKGROUND: Bisphosphonates are frequently used for osteoporosis. Medication-related osteonecrosis of the jaw, a complication of bone-modifying agents, including bisphosphonates or angiogenic inhibitors, can be challenging to treat in elderly patients with numerous preexisting conditions. Achieving good treatment outcomes is especially difficult in patients with pathological fractures accompanied with extraoral fistulae. CASE PRESENTATION: We report an unusual case of prominent bone regeneration following palliative surgical treatment in a 72-year-old Japanese female patient undergoing hemodialysis. She previously had severe osteoporosis due to renal osteodystrophy and was receiving antiresorptive intravenous bisphosphonate. Computed tomography revealed a discontinuous left lower mandibular margin with a pathologic fracture and extensive, morphologically irregular sequestrum formation (80 × 35 × 20 mm). The patient was diagnosed with stage III medication-related osteonecrosis of the jaw and pathologic mandibular fracture. Immediately before the surgery, the anticoagulant used for dialysis was changed from heparin to nafamostat mesylate to reduce the risk of intraoperative bleeding. Sequestrectomy was performed under general anesthesia. Postoperative infection was not observed, the intraoral and submandibular fistula disappeared, and, surprisingly, prominent spontaneous bone regeneration was observed postoperatively at 6 months. Despite the severe systemic condition of the patient, the conservative surgical approach with sequestrectomy has yielded desirable results for more than 6 years since the surgery. CONCLUSIONS: This rare report of spontaneous bone regeneration in a patient of advanced age and poor general condition is the oldest case of mandibular regeneration ever reported.

Ilio-Hepatic Artery Bypass for Hypoplasia of the Celiac Axis and Its Branches with an Inferior Pancreaticoduodenal Artery Aneurysm.

Hemorrhage due to a ruptured pancreaticoduodenal artery aneurysm is potentially fatal. We describe a case of a 51-year-old man, incidentally diagnosed with an inferior pancreaticoduodenal artery aneurysm associated with probable congenital hypoplasia of the celiac axis and its branches. Considering the rupture risk, we performed an ilio-hepatic artery bypass with an autologous vein graft and aneurysmorrhaphy. The postoperative course was uneventful. At the 24-month follow-up, the bypass was patent, with no aneurysm recurrence. The ilio-hepatic artery bypass is effective and preserves visceral blood flow. However, the iliac artery is susceptible to occlusive disease, and long-term follow-up is required.

Acute Type B Aortic Dissection Associated with Acute Pancreatitis, Pancreatic Pseudocysts, and Acalculous Cholecystitis.

Acute aortic dissection can result in fatal conditions when associated with organ malperfusion. A rare complication of aortic dissection with organ malperfusion is ischemic pancreatitis with cholecystitis. Here, we present the case of acute type B aortic dissection complicated by concurrent acute ischemic pancreatitis and acalculous cholecystitis. Prompt diagnosis and specific multidisciplinary treatment are crucial to improving patient outcomes in cases of visceral ischemia.

A Cost-Utility Analysis of Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm.

Objective: To assess medical economic adequacy of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Methods: Cost-utility analysis. A total of 21 patients with AAA treated at Ibaraki Prefectural Central Hospital in 2014 were divided into non-ruptured EVAR (Group E) and open surgery (OS) (Group O), and ruptured OS (Group R) groups, and hospital costs were aggregated with a medical accounting system. Mid-level hospital costs were estimated by a diagnosis-procedure-combination analysis system. Incremental life years were extrapolated from the results of randomized controlled trials in the UK (EVAR Trial 1 and 2), a life table, and the Pancreas Cancer Registry in Japan. Quality-adjusted life years (QALY) were estimated under the assumption of a certain quality weight. Results: Incremental cost-effectiveness ratio (ICER) of EVAR compared with the OS was calculated to be 31.0 million yen/QALY, which is economically inadequate. ICER of EVAR compared with conservative treatment was inadequate in some subgroups of extremely old patients and in patients operated for far-advanced cancer. Conclusion: EVAR is inadequate with respect to medical economics as a substitute for OS for patients in whom both procedures are available. The indication for EVAR in patients ineligible for OS should be different from that for surgery in usual patients with AAA. (This is a translation of J Jpn Coll Angiol 2016; 56: 123-130.).

Isolated spontaneous dissection of the celiac artery: report of two cases.

Isolated spontaneous dissection of the celiac artery (DCA) is extremely rare and its therapeutic strategy is still not established. We report two cases of DCA, in which 58-year-old and 43-year-old male patients with right hypogastralgia and back pain, respectively, were diagnosed by enhanced computed tomography and treated conservatively with antihypertensive agents. They were doing well under circumspect medical management without recurrence of symptoms or progression of dissection after 3.5 years and 3 months, respectively, after detection of DCA. Conservative treatment with blood pressure control and careful surveillance is considered to be applicable in most cases of DCA.

Rupture of abdominal aortic aneurysm with shrinkage after endovascular repair.

An 85-year-old man, who had undergone endovascular abdominal aortic aneurysm repair 8½ years earlier, was transferred to the emergency department with chest pain and transient loss of consciousness. Computed tomography revealed a ruptured abdominal aortic aneurysm with a stent graft inside. His aneurysm was 62 mm in diameter at the endovascular repair, but 45 mm at the rupture site. He was rescued by emergency aneurysmectomy.

A delayed recall battery as a sensitive screening for mild cognitive impairment: follow-up study of memory clinic patients after 10 years.

OBJECTIVE: I examined the predictive value of the combination of three delayed recall tests to distinguish (1) those with probable Alzheimer's disease (AD) from those within normal range, and (2) those with Mild cognitive impairment (MCI) from those within normal range. The data from 90 visitors to a memory clinic in Tokyo was used. I first examined patients clinically, neuroradiologically, and excluded the mental and neurological illness. AD was diagnosed according to the NINCDS-ADRDA criteria, MCI according to the criteria of Petersen et al.. Normal must be free from any disease examined above. METHODS: After the diagnosis, the baseline neuropsychological tests were performed for all participants; the Mini Mental State Examination, Raven's Colored Progressive Matrices, the Stroop Test, a 10-words list learning and recall test, a story recall test, and the Rey-Osterrieth Complex Figure Test. After 10 years, all patients were reassessed and diagnosed again. RESULTS: Of the MCI patients for follow-up (n=29), 19 were converted to AD, while 5 not. One died. 4 lost. All AD patients (n=30) remained as AD. The combination of 3 delayed recall battery provides clinically useful predictive values for both AD and MCI in a memory clinics and dementia research clinics.

[A detection of very mild Alzheimer's disease and MCI by memory complaints and deterioration of IADL in a questionnaire for a memory clinic].

BACKGROUND AND PURPOSE: There have been very few studies trying to explain about daily life features of patients with very mild Alzheimer disease (AD) and of those with mild cognitive impairment (MCI). The purpose of this study was 1) to clarify characteristics of very mild AD and MCI in their daily life, and 2) to examine items in a questionnaire that can be useful for detecting subjects of suspected AD. SUBJECTS AND METHODS: Subjects were 111 patients of the memory clinic in National Center Hospital for Mental, Nervous, and Muscular Disorders, National Center of Neurology and Psychiatry, Japan; 39 normal range, 28 MCI, and 44 very mild AD. On their first visits, they were asked to fill out a questionnaire consisted of 103 items. Thirty five items in a questionnaire were selected, 15 memory-complaint items and 20 items of instrumental activities of daily living (IADL), and examined retrospectively. At first we compared each set of groups using the chi-square test. Then a logistic regression analysis was used to observe which items contributed to judge a person to be suspected of AD. And further, sensitivity and specificity for discriminating between an AD suspected and a normal range were examined. RESULTS: None of the items showed statistical significance between MCI group and very mild AD group. Then, we combined these two groups into one group (n = 72), and made comparison between this new group and normal range group (n = 39). There were 18 items that showed statistical significance between the two groups. And five of them, 'dysfunction of memory: noticed by others', 'dysfunction of memory: getting worse', 'unable to utilize the memorandum', 'forget incidents occurred a few days ago' and 'unable to locate unfamiliar places' showed significantly high odds ratio in judgment on a person to be suspected of AD. In addition to preceding 5 items we adopted two items, 'dysfunction of memory: unnoticeable by her/himself' and 'unable to manage household expenses', which were not included in the logistic regression analysis, but were essential for the discrimination between the two groups. The sum of score of these 7 items showed high specificity and sensitivity for dividing between the two groups. CONCLUSION: These findings indicated that an exploration of memory complaints and deteriorations of IADL was useful for the detection of MCI and very mild AD, especially 7 items described above could be used as a simple questionnaire for the elderly.

Effect of benzodiazepine hypnotic triazolam on relationship of blood pressure and Paco2 to cerebral blood flow during human non-rapid eye movement sleep.

We sought to clarify the effect of short-acting benzodiazepine hypnotic on the relationship of arterial blood pressure and arterial partial pressure of carbon dioxide (Paco2) to regional cerebral blood flow (rCBF) during human non-rapid-eye-movement (non-REM) sleep. Nine young normal volunteers were treated in a randomized, crossover design with triazolam or placebo and underwent positron emission tomography at night. During wakefulness and stage 2 and slow wave (stages 3 and 4) sleep, we measured mean arterial blood pressure (MAP), Paco2, and absolute CBF. With triazolam compared to placebo, MAP reduced gradually. During stage 2 sleep, Paco2 increased and whole-brain mean CBF decreased. With triazolam, relative rCBF of the left orbital basal forebrain decreased more during stage 2 than slow wave sleep, whereas absolute CBF of the occipital cortex and cerebral white matter remained constant. During triazolam-induced stage 2 sleep, absolute CBF of the cerebral white matter correlated more strongly to both MAP and Paco2 than during placebo sleep and also correlated more strongly to both MAP and Paco2 than absolute CBF of the occipital cortex. In the frontal white matter, during triazolam-induced stage 2 sleep compared to wakefulness, absolute CBF was significantly better correlated to MAP, but not to Paco2. During triazolam-induced stage 2, the cerebral white matter may receive a modulated CBF regulation having the strengthened relationship of Paco2 to CBF and, more locally, the frontal white matter may depend precariously on CBF regulation.

Cerebral white matter blood flow is constant during human non-rapid eye movement sleep: a positron emission tomographic study.

This study aimed to identify brain regions with the least decreased cerebral blood flow (CBF) and their relationship to physiological parameters during human non-rapid eye movement (NREM) sleep. Using [(15)O]H(2)O positron emission tomography, CBF was measured for nine normal young adults during nighttime. As NREM sleep progressed, mean arterial blood pressure and whole brain mean CBF decreased significantly; arterial partial pressure of CO(2) and, selectively, relative CBF of the cerebral white matter increased significantly. Absolute CBF remained constant in the cerebral white matter, registering 25.9 +/- 3.8 during wakefulness, 25.8 +/- 3.3 during light NREM sleep, and 26.9 +/- 3.0 (ml.100 g(-1).min(-1)) during deep NREM sleep (P = 0.592), and in the occipital cortex (P = 0.611). The regression slope of the absolute CBF significantly differed with respect to arterial partial pressure of CO(2) between the cerebral white matter (slope 0.054, R = - 0.04) and frontoparietal association cortex (slope - 0.776, R = - 0.31) (P = 0.005) or thalamus (slope - 1.933, R = - 0.47) (P = 0.004) and between the occipital cortex (slope 0.084, R = 0.06) and frontoparietal association cortex (P = 0.021) or thalamus (P < 0.001), and, with respect to mean arterial blood pressure, between the cerebral white matter (slope - 0.067, R = - 0.10) and thalamus (slope 0.637, R = 0.31) (P = 0.044). The cerebral white matter CBF keeps constant during NREM sleep as well as the occipital cortical CBF, and may be specifically regulated by both CO(2) vasoreactivity and pressure autoregulation.

Deactivation by benzodiazepine of the basal forebrain and amygdala in normal humans during sleep: a placebo-controlled [15O]H2O PET study.

OBJECTIVE: The authors' goal was to identify differences in regional brain activity between physiological and benzodiazepine-induced sleep to clarify the brain structures involved in the drug's hypnotic effect. METHOD: Using positron emission tomography, they compared regional cerebral blood flow during non-REM sleep in nine volunteers treated with placebo or triazolam, a short-acting benzodiazepine, in a double-blind, crossover design. RESULTS: Blood flow in the basal forebrain and amygdaloid complexes was lower during non-REM sleep when subjects were given triazolam than when they were given placebo. CONCLUSIONS: The hypnotic effect of the benzodiazepines may be mediated mainly by deactivation of the forebrain control system for wakefulness and also by the anxiolytic effect induced by deactivation of the emotional center.

Neural mechanism of propofol anesthesia in severe depression: a positron emission tomographic study.

BACKGROUND: The precise neural mechanisms of propofol anesthesia in humans are still unknown. The authors examined the acute effects of propofol on regional cerebral blood flow (rCBF) using positron emission tomography in patients with severe depression. METHODS: In six severely depressed patients (mean age, 55.0 yr) scheduled for electroconvulsive therapy, anesthetic levels were monitored by electroencephalography, and rCBF was serially quantified in the awake, sedated, and anesthetized states. The authors used high-resolution positron emission tomography with 15O-labeled water and statistical parametric mapping 99 for imaging and analysis of the data. RESULTS: Global cerebral blood flow showed sharp decreases from the awake level during the administration of propofol, decreasing 26.8% in the sedated state and 54.4% in the anesthetized state. Moreover, a dose effect was seen in both parietal cortices and the left lateral prefrontal region with larger regions of relative decrease in rCBF at higher propofol doses. At the higher dose, the values of rCBF in the pulvinar nucleus of the thalamus, the pontine tegmentum, and the cerebellar cortex were also affected. Meanwhile, there were few changes of relative rCBF in the basal frontal lobes during both sedated and anesthetized states. CONCLUSIONS: As in earlier studies using normal subjects, pronounced suppression in rCBF in the brain stem reticular formation, the thalamus, and the parietal association cortex occurred even in severely depressed patients. However, previously reported decreases in rCBF in the basal frontal lobe were absent in depressed patients.