Management of a large diffuse maxillofacial arteriovenous malformation previously treated with ligation of ipsilateral arterial supply.

A 32 year-old male presented with a pulsatile facial mass with palpable thrill and audible bruit. Imaging revealed a very large diffuse left-sided facial arteriovenous malformation with extensive bilateral supply, as well as a previously ligated left external carotid artery. Endovascular treatment was required to control associated hemorrhagic events as well as for palliation and was delivered via the contralateral and ipsilateral collateral supply because of ligation of the direct route to the nidus. In addition, the patient received intravenous bevacizumab and intraarterial bleomycin therapy. Under such circumstances, endovascular embolization remains often the only option when emergent therapy for massive haemorrhage is required. Collaboration and treatment planning with head and neck surgery is imperative and should be performed from the onset, avoiding disastrous ligation of arterial feeders.

Beneficial Effects of Necrosis Modulator, Indole Derivative NecroX-7, on Renal Ischemia-Reperfusion Injury in Rats.

Renal ischemia-reperfusion injury (IRI) is involved in multiple diseases, such as kidney transplantation or contrast-induced nephropathy, and leads to acute kidney injury. However, there are no pharmacological agents available to prevent IRI. In this study, we investigated the effects of necroX-7 against renal IRI in a rat model. Seven-week-old male Sprague-Dawley rats were divided into four groups: saline-treated sham or IRI group, necroX-7-treated sham or IRI group. All animals had right nephrectomy and IRI was followed by reperfusion after clamping the left renal vessels for 35 minutes. NecroX-7 or saline was intravenously injected at 5 minutes before reperfusion. The effects of necroX-7 on IRI were evaluated using biochemical, histological, and molecular markers. The serum creatinine level was increased after IRI compared with sham. The necroX-7 significantly decreased creatinine level compared with the saline in IRI (1.36 ± 0.11 vs 2.35 ± 0.42 mg/dL; P < .05). An immunohistochemical study revealed that necroX-7 improved renal tubular injury, and attenuated 8-OHdG-positive cells (P < .001) and high-mobility group Box 1 protein (HMGB1) expression compared with saline treatment in IRI (P < .001). NecroX-7 significantly reduced monocyte chemoattractant protein 1 (MCP-1), tumor necrosis factor (TNF)-α, and interleukin (IL)-1ß in IRI (necroX-7-treated IRI vs saline-treated IRI rats; 1.73 ± 0.42 vs 7.23 ± 0.54-fold for MCP-1, P < .05; 0.79 ± 0.59 vs 3.72 ± 0.37-fold for TNF-α, P < .05; 0.50 ± 0.36 vs 2.43 ± 0.41-fold for IL-1ß, P < .001). In conclusion, necroX-7 improved renal dysfunction after IRI. These effects of necroX-7 occurred with the suppression of reactive oxygen species, HMGB1, and inflammatory responses. We suggest that necroX-7 has potential therapeutic benefits in renal IRI.

Expression of soluble adenylyl cyclase in acral melanomas.

Soluble adenylyl cyclase (sAC) regulates melanocytic cells, and is a diagnostic marker for pigmented skin lesions. Because only a few studies on sAC expression in acral melanomas have been performed, we investigated the histopathological significance of sAC expression in 33 cases of acral melanoma, and assessed its diagnostic value in distinguishing melanoma in situ (MIS, n = 17) from acral invasive melanomas (n = 16) and melanocytic naevi (n = 11). Acral melanomas exhibited more marked nuclear immunopositivity compared with acral melanocytic naevi. sAC expression significantly correlated with the nuclear morphology of melanocytes and melanoma cells, namely, hyperchromatic nuclei and prominent nucleoli within vesicular nuclei. sAC expression was predominantly observed in the hyperchromatic nuclei of MIS and the prominent nucleoli invasive melanomas, respectively. In vitro culture models of melanocytes and melanoma cell lines exhibited sAC staining patterns similar to those of acral melanomas. Differentiation induction showed that nuclear and nucleolar expression varied depending on cell morphology. sAC immunostaining may be useful for the differential diagnosis of acral melanocytic lesions, and sAC expressed in the nucleus and nucleolus might be related to cytological and nuclear changes associated with invasion and progression of acral melanomas.

Two cases of clear cell sarcoma with different clinical and genetic features: cutaneous type with BRAF mutation and subcutaneous type with KIT mutation.

Clear cell sarcoma (CCS), also known as malignant melanoma of soft parts, is a rare malignancy constituting approximately 1% of all soft-tissue sarcomas. It occurs predominantly in the lower extremities of young adults, manifesting as a deep, painless, slow-growing mass. CCS is sometimes confused with other types of melanoma because of its melanocytic differentiation. Although BRAF and KIT mutations are well-known melanocytic tumour-promoting mutations frequently found in cutaneous melanoma, they are rare or absent in CCS. We present two cases of CCS with different clinical and genetic features. Both female patients, aged 25 and 20 years, presented with a palpable nodule on a lower extremity. Biopsies of both tumours revealed features diagnostic of CCS. Each tumour cell was positive for S100 protein and HMB-45. However, one patient's tumour was localized to the dermis, with many multinucleated giant cells, whereas the other was located in the deep subcutaneous fat layer near bone. Fluorescence in situ hybridization demonstrated the presence of a characteristic Ewing sarcoma RNA-binding protein (EWSR)1 gene rearrangement in both cases. Reverse-transcription polymerase chain reaction (PCR) and sequencing of the PCR product revealed an EWSR1-activating transcription factor 1 type 1 fusion transcript in both cases. In addition, we detected BRAF mutation in the dermal type and KIT mutation in the subcutaneous type. It is of interest that the BRAF and KIT mutations are known to be very rare in CCS. On the basis of our observations, we suggest that mutation inhibitors may be useful in selected patients with mutated CCS lineages.

Foxp3(+) regulatory T cells are increased in the early stages of halo nevi: clinicopathological features of 30 halo nevi.

BACKGROUND: There have been few clinical studies of the role of regulatory T cells (Tregs) in halo formation of halo nevus. OBJECTIVE: To evaluate the clinicopathologic features and the presence of Tregs in halo nevi. METHODS: We analyzed 30 halo nevi and performed immunohistochemical analysis using antibodies against CD4, CD8, CD25 and Foxp3. We also performed double immunohistochemical staining for Foxp3 and CD25. RESULTS: We found significant increases in Foxp3(+) Tregs, and the shorter the halo nevus duration, the more Foxp3(+) Tregs were detected. Also, the ratio of Foxp3 to CD8 T cells was increased in early stages of halo nevi. Double immunohistochemical staining suggested that the Tregs in the halo nevi were CD25(+)Foxp3(+) T cells. CONCLUSIONS: Foxp3(+) Tregs were greatly increased in the halo nevi. The shorter the halo nevi duration, the more Foxp3(+) Tregs were involved in the earlier developmental stages of halo nevi.

Experimental study of high-frequency two-way jet ventilation.

BACKGROUND AND METHODS: A new mode of jet ventilation, high-frequency two-way jet ventilation, was devised and introduced to increase CO2 elimination. High-frequency two-way jet ventilation was achieved by adding reverse jet pulses inside the trachea through an intratracheal reverse jet system to the expiratory phase of common high-frequency jet ventilation. The ventilatory efficiency and features of high-frequency two-way jet ventilation were investigated and compared with those features of high-frequency jet ventilation in ten dogs in the same experimental condition. Random sample selection and randomized crossover trial were used for comparison between high-frequency two-way jet ventilation and high-frequency jet ventilation. Peak inspiratory pressure, end-expiratory pressure, and the arterial blood gas variables (PaO2, PaCO2, and pH) were measured during the study. RESULTS: PaCO2 with high-frequency two-way jet ventilation was about 35% lower than that with high-frequency jet ventilation (from 45 to 29 torr [6.0 to 3.9 kPa], p less than .01). Simultaneously, peak inspiratory pressure and end-expiratory pressure during high-frequency two-way jet ventilation were significantly lower than those same variables measured during high-frequency jet ventilation. End-expiratory pressure of high-frequency two-way jet ventilation was a negative pressure (-2.45 +/- 0.45 cm H2O). The pH of high-frequency two-way jet ventilation was significantly higher than that of high-frequency jet ventilation. CONCLUSIONS: Compared with high-frequency jet ventilation, high-frequency two-way jet ventilation demonstrated a ventilatory feature of increasing CO2 elimination and simultaneously decreasing airway pressure.

Clinical studies on high frequency two-way jet ventilation.

A new mode of jet ventilation, high frequency two-way jet ventilation (HFTJV) was devised and introduced to increase carbon dioxide elimination during jet ventilation. Its ventilatory efficiency and features were investigated and compared with those of high frequency jet ventilation (HFJV) in 10 patients with normal cardiopulmonary function. Random sample selection and randomized cross-over trial were used for comparison between HFTJV and HFJV at the same ventilatory settings of driving pressure 1 kg/cm2 (14.22 Psi), respiratory rate 100/min and I/E ratio 1:2. Peak inspiratory pressure (PIP), end-expiratory pressure (EEP) and main variables of air blood gas analysis (PaO2, PaCO2, pH) were measured and recorded during the use of HFJV and HFTJV. PIP and EEP were significantly lower than with HFTJV than with HFJV. EEP of HFTJV showed a slightly negative pressure (-0.17 +/- 0.03 kPa). PaCO2 with HFTJV was significantly lower than that with HFJV, but PaO2 and pH with HFTJV were significantly higher than those with HFJV. HFTJV was shown to have a ventilatory feature of decreasing airway pressure and simultaneously increasing carbon dioxide elimination, as compared with HFJV. Whether this ventilatory feature of HFTJV can be utilized for various respiratory support in patients with abnormal cardiopulmonary function needs to be further studied.

Hemodynamic effects of high frequency jet ventilation during acute hypovolemia.

The hemodynamic effects of high frequency jet ventilation (HFJV) at three different rates (60, 100, 200/min) and at rate 200/min combined with jet sighs 12/min (HFJV-200 + 12S) during two degrees of hemorrhagic hypovolemia were investigated in dogs. Also, the results were compared with those of intermittent positive pressure ventilation (IPPV). Two degrees of hypovolemia were produced by bleeding dogs until mean arterial pressure was 25% or 50% lower than basic value respectively. At both periods of hypovolemia, HFJV at rate 60 or 100 were found to have better hemodynamic effects than IPPV due to their lower airway pressures. However, HFJV at rate 200 or HFJV-200 + 12S did not demonstrate the same superiority because of their higher airway pressure, the latter even represented a tendency of worse hemodynamic effect than IPPV. The best cardiovascular effect was seen during HFJV at rate 100. Our study indicated that the hemodynamic effect of HFJV better than that of IPPV during acute hypovolemia can be seen only when proper ventilatory settings are chosen. Jet sighs at 12/min added to usual HFJV are not beneficial to circulatory function. It is recommended that HFJV at a rate below 200/min without jet sighs be used in patients who need respiratory support during acute hypovolemia or shock.