Rocuronium priming for tracheal intubation in COVID-19 patients.

Priming doses of non-depolarising neuromuscular blocking drugs given before administration of anaesthetic agents have been used to hasten the onset of neuromuscular blockade. In the settings of coronavirus disease 2019 (COVID-19), this could be used to reduce the apnoeic, and potentially aerosol-generating, window. To our knowledge, we report the first cases of tracheal intubation with rocuronium for COVID-19 using the priming principle. Both patients needed their tracheas intubated for severe hypoxia using a rapid sequence induction technique with a priming dose of rocuronium. Despite adequate pre-oxygenation a sudden, unexpected fall in arterial oxygen saturations was observed in both patients after administration of a priming dose of 2 mg of rocuronium. Clinicians should consider this possible risk associated with priming doses of neuromuscular blocking drugs in the management of patients with respiratory failure due to COVID-19.

Myelopathy due to lumbar disc herniation in the presence of a tethered cord.

STUDY DESIGN: Single case report. OBJECTIVES: To present a case of lumbar disc herniation causing compression of a tethered cord that was successfully treated with lumbar decompression and fusion. BACKGROUND: A tethered cord is a rare pathology associated with a congenital spinal malformation, spinal dysraphism. Furthermore, myelopathy due to lumbar disc herniation in the presence of a tethered cord is extremely rare. METHODS: Single case report. RESULTS: A 43-year-old male with a history of spina bifida presented to our clinic for an evaluation of a progressive spastic gait disturbance and numbness in the lower limbs. A neurological examination revealed muscle weakness and pyramidal tract signs in the lower limbs. Magnetic resonance imaging of the lumbar spine showed disc herniation at L2-3 causing compression of a low-lying cord. Surgical intervention, including herniotomy via a posterolateral approach and instrumented posterolateral fusion, was performed, and a good outcome was achieved 1 year after the surgery. CONCLUSION: The potential for lumbar disc herniation in the presence of a tethered cord should be taken into account in the differential diagnosis of spinal pathologies causing spastic gait disturbances. Furthermore, posterior decompression and fusion is a useful treatment option in such cases.

Prognostic factors for cervical spondylotic amyotrophy: are signs of spinal cord involvement associated with the neurological prognosis?

OBJECTIVES: The purpose of this study was to clarify the prognostic factors for cervical spondylotic amyotrophy (CSA). METHODS: The authors retrospectively reviewed the medical records of 47 consecutive patients with CSA in whom the presence/absence of the pyramidal tract sign was noted. We analyzed whether the age, sex, presence of diabetes mellitus, medication (vitamin B12), type of the most atrophic and impaired muscle, the muscle strength at the presentation, the presence of the pyramidal tract sign, magnetic resonance imaging (MRI) findings, including the presence and number of T2 high signal intensity areas (T2 HIA) in the spinal cord and the conversion to surgery were associated with the recovery of muscle strength in the patients. In addition, we also investigated whether the duration of symptoms before surgery and the type of surgery were associated with the recovery of muscle strength in patients who required conversion to surgical treatment. RESULTS: The presence of T2 HIA on MRI (P=0.002), the number of T2 HIA on MRI (P=0.002) and conversion to surgery (P=0.015) were found to be significantly associated with a poorer recovery at the observational final follow-up. Further, the presence of the pyramidal tract sign (P=0.043) was significantly associated with a poor recovery at the final follow-up after surgery. CONCLUSION: The presence of a high signal intensity change on T2-weighted MRI and the pyramidal tract sign can be used as prognostic factors for patients with CSA.

[A case of pulmonary actinomycosis radiologically mimicking a lung cancer].

A 59-year-old male clerk consulted in general practitioner due to cough and hemoptysis. A mass shadow was pointed out in the left upper lung field on a chest radiograph. Patient was referred to our hospital for further treatment. Any definitive daiagnosis could not be made after examinations including sputum culture, cytology and TBLB. Because a lung cancer was strongly suspected, an exploratory thoracotomy was performed. Actinomyces was detected by pathological study of excised specimen, with no evidence of cancer. ABPC was administered for two months postoperatively. The patient is doing well without recurrence of actinomycosis 2.5 years after the surgery. Pulmonary actinomycosis presenting a mass shadow on a radiograph may mimick a pulmonary tumor, especially a lung cancer. Pulmonary actinomycosis should be considered in a differential diagnosis of pulmonary lesion thought to be malignant.

[Left heart bypass with the bio-medicus centrifugal pump by the use of an antithrombin agent, argatroban].

Seventeen adult patients who underwent surgery for the thoracic or thoracoabdominal aortic disease by the use of left heart bypass with the Bio-Pump were divided into untreated, low-dose heparin treated and argatroban treated groups so as to evaluate the effects of systemic infusion of a newly synthesized antithrombin agent, argatroban, for the prevention of platelet loss and consumption coagulopathy. ACT reached 150 to 250 seconds at doses 0.5-7.5 micrograms/kg/min of argatroban and maximum ACT prolongation was limited to around 250 seconds. ACT spontaneously recovered below 150 seconds within 60 minutes following the end of bypass during which no excessive blood loss developed. In argartoban group, platelet loss during and immediately after surgery was effectively prevented as compared to other groups with significance. Fibrinogen was also preserved to some extent by argatroban treatment without evidence of systemic embolization. Argatroban, as an antithrombotic agent, is worthy of further trial of clinical use in bypass with a centrifugal pump.

[Coronary artery bypass grafting for a patient with single coronary artery].

A 47-year-old man was admitted with suddenly developed chest pain. Coronary arteriography could not identify the right coronary orifice at the right coronary sinus. Left coronary arteriography revealed that the right coronary artery originated from a proximal segment of the left anterior descending artery with subtotal obstruction at the segment just distal to the bifurcation of the right and anterior descending arteries. Coronary artery bypass grafting to the middle segment of the left anterior descending artery was carried out with satisfactory result. To our knowledge, only seven cases with a diagnosis of single coronary artery who underwent coronary artery bypass grafting have been reported.

[Surgical treatment of type A aortic dissection combined with aortic root lesions].

From January 1980 to December 1992, 36 patients with type A aortic dissection were operated on at the St. Marianna University Hospital. Hospital mortality and 10-year survival rate in 26 patients (Group I and II) undergoing replacement of the ascending aorta with or without hemi-arch resection (including one case of aortic wrapping for the closing dissection) were 19.2% and 88.0%, respectively. Among the patients having aortic root destructions due to acute aortic dissection or preexisting annuloaortic ectasia (Group III), 8 patients underwent aortic root reconstruction with a valved conduit and 2 patients supra-coronary aortic resection and graft replacement with concomitant coronary artery bypass grafting with 20.0% of hospital mortality and 55.6% of 10-year cumulative survival rate. Modified Bentall operation using Carrel patch method seems to be preferable to avoid postoperative complications for the case with intimal tear extending to the aortic sinuses, ruptured outer layer of the aortic root or preexisting AAE. If the disrupted coronary artery is concerned, coronary artery bypass grafting is mandatory. In the case of replacement of the ascending aorta for the dissection extending to the aortic sinuses, complete obliteration of the proximal false lumen must be required to avoid uncontrollable bleeding and compromised coronary blood flow.

[Pseudocoarctation associated with dissecting aneurysm of the aorta: a case report].

A case of pseudocoarctation with dissecting aneurysm of the ascending aorta and arch is reported. A 49-year-old man was admitted with chest pain and loss of consciousness. Angiogram showed kinking of the aortic isthmus and dissecting aneurysm of the ascending aorta. There was no pressure gradient between arms and legs. Prosthetic graft replacement of the ascending aorta was successfully performed by the use of total cardiopulmonary bypass with moderate hypothermia. Etiology of the development of pseudocoarctation is unknown, however, hypothesis that embryological abnormality of the aortic arch is one of the contributing factors has been widely accepted. This case was accompanied by bicuspid aortic valve. It is suggested that the developmental etiology of this case seems to be similar to that of classical coarctation of the aorta. Development of the dissecting aneurysm is supposed to be due to hypertension of the upper body during exercise, even though there is no pressure gradient at rest.

[Subarachnoid hemorrhage following commencement of danazol treatment in a patient well controlled on warfarin anticoagulation].

A 45-year-old woman with prosthetic valves replacement, was admitted with severe headache and vomiting one month after starting danazol treatment at 300 mg per day. She was receiving long-term anticoagulation with warfarin and dipyridamole, taking 3.5 mg and 300 mg per day respectively. The patient's thrombotest value was less than 6% at the time of admission. Cranial CT revealed subarachnoid hemorrhage. Warfarin and danazol treatment ware discontinued with replenishment of vitamin K. Recovery was uneventful. Danazol is 2, 3 isoxazol derivative of 17-alpha-ethinyl testosterone. As such, it shares the property of C 17 alkylated steroids in potentiating the action of coumarin. It is suggested that danazol affects the turnover of vitamin-K-dependent clotting factors, an impairment of synthesis being a likely mechanism. The possible hazard of the potentiating effect of danazol on warfarin should be widely appreciated.

[Right ventricular myxoma complicated by paroxysmal atrial tachycardia: a surgical case report].

A rare case of right ventricular myxoma complicated by paroxysmal atrial tachycardia (PAT) is presented. A 13-year-old boy was referred to our hospital because of the recurrent episodes of PAT. Every available medical treatment was tried to reverse the PAT, during which an abnormal mass in the right ventricle was found by echocardiography. Subsequently magnetic resonance imaging computed tomography demonstrated that the tumor developed from the anterior wall of right ventricle with a pedicle. A 10 g of reddish myxomatous mass originating from the base of anterior papillary muscle was resected including the stalk during total cardiopulmonary bypass. The transient paroxysmal atrial tachycardia developed shortly after operation, however, tachycardic episode has never recurred after that. It is noteworthy that intracardiac evaluation is necessary when there is longstanding and inveterate tachyarrhythmia in otherwise healthy children.

[Surgical treatment of aortic root aneurysm associating with infectious endocarditis].

From 1979 to 1989, aortic root aneurysms were encountered in 6 of the 30 patients who underwent surgical treatment for infectious endocarditis. Four patients underwent aortic valve replacement and direct or patch closure of the orifice of aortic root aneurysm. In additional 2 patients with infected aneurysm of right coronary sinus of Valsalva rupturing into the right ventricle, the aneurysm and infected tissue in the right ventricular outflow tract were completely resected and the defect of aortic sinus and VSD were closed with double Teflon fabric patches. All patients survived postoperatively, however, one patients died 1.5 months after the operation probably due to rupture of mycotic aneurysm of cerebral artery. Another late death seemed to be concerned with recurrent aortic root aneurysm, in which case direct closure of aneurysm had been performed. We believe that even if the aneurysm seems to be small, its orifice should be closed with the use of a fabric patch to prevent recurrent aneurysm formation.

Surgical experience with traumatic rupture of the thoracic aorta.

Nine cases of traumatic thoracic aortic rupture (TAR), operated on at St. Marianna University Hospital between July 1980 and December 1988, were reviewed in order to evaluate the role of contrast-enhanced CT in the early diagnosis of TAR. The absence of mediastinal hematoma on CT eliminated the need for aortography in 30 (38.5%) of the 78 patients suspected of having TAR on the basis of chest roentgenograms. The presence of mediastinal hematoma necessitated aortography in 48 patients. However, operative treatment was carried out without aortography in 3 patients who had specific signs of rupture on CT. CT proved to be a reliable indicator for the selection of the patients who need aortography. As a rule, emergency operations were performed in these patients. Simple aortic crossclamping was employed in 4 patients, and heparinless left heart bypass with the BioPump was performed for spinal cord protection in 2 recent patients without complication of embolization. Use of the BioPump as an adjunct in the repair of TAR appears to be promising.

[The results of bypass with the BioPump in the surgery of traumatic rupture of the thoracic aorta without heparin].

In surgery of the traumatic rupture of descending thoracic aorta, external shunt without systemic heparinization is commonly employed to avoid the bleeding of other injured organs as well as the ischemic injury of spinal cord. However, it provides no means of controlling the flow. We employed the BioPump without heparinization in 2 cases of traumatic rupture of descending thoracic aorta and additional 2 cases of aneurysm of thoracic aorta. Significant platelet loss occurred immediately after operation, however, there was no postoperative evidence of the organ failures due to microembolization. Heparinless bypass with the BioPump is considered to be safe and simple as an adjunct means in surgery of the traumatic rupture of thoracic aorta.