Use of bispectral index for detection of partial cerebral hypoperfusion during cervical spine surgery: A case report.

The BIS value may decrease by cerebral hypoperfusion. We report a case in which the BIS value suddenly decreased during cervical spine surgery, which led us to find cervical screws compressing the vertebral arteries. In a 79-year-old man undergoing cervical spine surgery, the BIS suddenly decreased from about 40 to 10-20, about 4 h after the start of surgery. Intraoperative 3-dementional computed tomography indicated that both the two tips of cervical screws inserted in the 6th cervical vertebra were within bilateral transverse foramens. These cervical screws were removed, and the BIS increased immediately. The cervical screws were re-inserted again thorough the same vertebra into the bilateral transverse foramens, and the BIS decreased immediately. Postoperatively, cerebral hypoperfusion due to compression of bilateral vertebral arteries by two cervical screws was identified. The BIS may be a useful to detect cerebral hypoperfusion due to compression of the vertebral artery by a cervical screw.

Pseudoentropy in dS/CFT and Timelike Entanglement Entropy.

We study holographic entanglement entropy in dS/CFT and introduce timelike entanglement entropy in CFTs. Both of them take complex values in general and are related with each other via an analytical continuation. We argue that they are correctly understood as pseudoentropy. We find that the imaginary part of pseudoentropy implies an emergence of time in dS/CFT.

Epstein-Barr virus-related diffuse large B-cell lymphoma type methotrexate-associated lymphoproliferative disorders presenting in the adrenal gland.

Introduction: Methotrexate-associated lymphoproliferative disorders appear during treatment with methotrexate as an immunosuppressive drug. However, the mechanism and frequency are still unknown, and the treatment is undefined. Case presentation: A 76-year-old woman was admitted to the hospital with back pain, and magnetic resonance imaging showed a tumor in the right adrenal region. She had received methotrexate for rheumatoid arthritis. Enhanced computed tomography showed a tumor of 90 mm in diameter on the dorsal side of the liver abutting to the inferior vena cava. The preoperative diagnosis was a hepatic invasion of right adrenocortical carcinoma and right adrenalectomy was performed. The histopathological diagnosis was diffuse large B-cell lymphoma. The final diagnosis was methotrexate-associated lymphoproliferative disorders. Conclusion: It is important to consider methotrexate-associated lymphoproliferative disorders before surgery when neoplastic lesions are found in patients taking methotrexate.

Dynamic changes in insulin requirements with post-operative time using bedside artificial pancreas to maintain normoglycemia without hypoglycemia after cardiac surgery.

It is difficult to manage postoperative blood glucose levels without hyperglycemia and hypoglycemia in cardiac surgery patients even if continuous intravenous insulin infusion is used. Therefore, the insulin requirements for maintaining normoglycemia may be difficult to evaluate and need to be elucidated. In this single-center retrospective study, 30 adult patients (age 71.5 ± 9.0 years old, men 67%, BMI 22.0 ± 3.1 kg/m2, diabetes 33%) who underwent cardiac surgery and used bedside artificial pancreas (STG-55) as a perioperative glycemic control were included. We investigated the insulin and glucose requirements to maintain normoglycemia until the day after surgery. The bedside artificial pancreas achieved intensive glycemic control without hypoglycemia under fasting conditions for 15 h after surgery (mean blood glucose level was 103.3 ± 3.1 mg/dL and percentage of time in range (70-140 mg/dL) was 99.4 ± 2.0%). The total insulin requirement for maintaining normoglycemia differed among surgical procedures, including the use of cardiopulmonary bypass during surgery, while it was not affected by age, body mass index, or the capacity of insulin secretion. Moreover, the mean insulin requirement and the standard deviation of the insulin requirements were variable and high, especially during the first several hours after surgery. Treatment using the bedside artificial pancreas enabled intensive postoperative glycemic control without hypoglycemia. Furthermore, the insulin requirements for maintaining normoglycemia after cardiac surgery vary based on surgical strategies and change dynamically with postoperative time, even in the short term.

Pathological complete response after nivolumab therapy following angiogenesis inhibitors in a patient with metastatic renal cell carcinoma.

INTRODUCTION: Nivolumab is effective for advanced renal cell carcinoma; however, reports are limited wherein nivolumab is combined with sequential therapy of angiogenesis inhibitors and metastasectomy. CASE PRESENTATION: A 65-year-old man was diagnosed with left renal cell carcinoma of cT2aN0M1 with lung metastasis. The patient underwent nephrectomy and sequential therapy with interferon-α and angiogenesis inhibitors. Lung metastasis decreased by angiogenesis inhibitors, but new right adrenal gland metastasis appeared. Nivolumab as the fifth systemic therapy remarkably shrank the metastasis. After discontinuing nivolumab therapy, the metastasis continued to shrink. The patient underwent adrenalectomy, and pathological analysis revealed no remnant cancer cells in the specimen, confirming a pathological complete response. Twenty months postoperatively, he remains in good health without recurrence. CONCLUSION: We report a rare case with renal cell carcinoma of a pathological complete response by nivolumab after angiogenesis inhibitors.