Isolated Superior Mesenteric Artery Dissection Following Liver Transplant: Report of 3 Cases.

BACKGROUND: Isolated superior mesenteric artery (SMA) dissection (SMAD) is considered a relatively rare disease. Especially, isolated SMAD following liver transplant has been rarely reported. REPORT OF CASES: Among 96 consecutive adult recipients who underwent liver transplant at our institution, 3 recipients (3.1%) demonstrated isolated noncommunicating SMAD, type IV according to Sakamoto's classification. Patient characteristics are the following: mean age, 53 years (range, 49-60 years); male to female ratio, 2:1, right lobe graft to left lobe graft ratio, 2:1; operating time, 760 minutes (range, 614-880 minutes); and blood loss, 6570 mL (range, 2435-13,329 mL). New onset of abdominal pain was noted in 33.3% (1/3). The diagnosis was made by the first follow-up computed tomography scan after liver transplant. The mean distance between the proximal end of SMAD and the root of SMA was 21.3 mm (range, 9-40 mm). There were no signs of ischemic changes in the small intestine in any of the 3 patients. Thus, conservative managements such as anticoagulation therapy were performed without other aggressive interventions. One patient died because of subarachnoid hemorrhage. In the other 2 patients, SMAD disappeared at 6 months following the diagnosis. DISCUSSION: The morbidity of isolated SMAD is around less than 0.1% at the autopsy. Compared with this result, we found significantly higher morbidity rate in liver transplant recipients. It is true that mechanical stress from retraction of the stomach to the caudal end including the root of SMA may play an important role in the onset of SMA dissection. CONCLUSION: Isolated SMA dissection following living donor liver transplant is a rare but potentially life-threatening condition. It is required to ascertain whether emergency revascularization should be considered.

Short- and Long-Term Outcomes of Live Donor Renal Allografts From Older and Younger Donors.

BACKGROUND: The rising demand for living renal donors has led to the recruitment of older donors. Findings vary, but these grafts appear to survive as long as grafts from standard criteria deceased and expanded criteria deceased donors. We investigated the effects of donor age ≥65 years and the presence or absence of donor antihypertensive therapy on patient condition 1 year after transplantation, and retrospectively examined 1-year (273 patients), 3-year (217 patients), and 5-year (140 patients) patient and graft survival. METHODS: We divided 273 donor-recipient pairs into Group Y (donor age <65 years, n = 224) and Group O (donor age ≥65 years, n = 49). Group O was subdivided into donors receiving treatment for hypertension (subgroup O-1, n = 16) and those not receiving treatment for hypertension (subgroup O-2, n = 33). We compared results of 1 hour post-transplant biopsies and looked at a small number of 1 year post-transplant biopsies. RESULTS: Although a significantly larger percentage of recipients from younger donors were undergoing preemptive transplantation, and the incidence of arteriosclerosis was significantly higher in the Group O kidneys, there were no significant differences between the 2 groups in terms of patient or graft survival at 1, 3, or 5 years; serum creatinine levels; or number of episodes of acute rejection. The presence or absence of donor antihypertensive treatment had no effect. CONCLUSIONS: We found that donor age ≥65, with or without antihypertensive treatment, had no effect on graft or patient survival.

Hyperuricemia and Acute Renal Failure in Renal Transplant Recipients Treated With High-Dose Mizoribine.

BACKGROUND: Hyperuricemia is a common adverse event frequently found in renal transplant recipients with mizoribine (MZ). Hyperuricemia itself will be a cause of renal dysfunction, and renal dysfunction also will be a cause of hyperuricemia simultaneously. This study investigates frequency of hyperuricemia and renal failure in renal transplant recipients treated with high-dose MZ. PATIENTS AND METHODS: From December 2007 to October 2015, there was a total of 32 living related renal transplant recipients treated with high-dose MZ. Of the 32 patients, 28 were treated with urate-lowering medications. RESULTS: One patient received allopurinol (AP) and 13 patients received benzbromarone (BB). For 6 of them, their urate-lowering medications were converted to febuxostat (FX) form AP or BB. In the remaining 14 patients, FX was administered from the beginning. In 2 cases of ABO-incompatible living related renal transplant recipients who were maintained with high-dose MZ and BB, severe hyperuricemia and acute renal failure occurred. One patient was a 48-year-old man, and his creatinine (Cr) level increased to 8.14 mg/dL and his serum uric acid (UA) was 24.6 mg/dL. Another patient was a 57-year-old man, and his Cr level increased to 3.59 mg/dL and his UA was 13.2 mg/dL. In both cases Cr and UA were improved, and no finding of acute rejection and drug toxicity was observed in graft biopsy specimens. BB was switched to FX and discontinuance or reduction of MZ was done. CONCLUSION: Combination of MZ and BB has the risk of acute renal dysfunction after renal transplantation. Latent renal dysfunction should be watched for in renal transplant recipients receiving high-dose MZ.

Laryngeal endocrinomas (carcinoids and relevant neoplasms): analysis of 278 reported cases.

This study was carried out to provide extensive information obtained from statistical analysis of laryngeal endocrinomas for the use of investigators working in this particular research field. A total of 278 patients with both typical and atypical varieties of carcinoids, and with small/oat cell carcinomas (SCC/OCC) exhibiting a confirmed endocrine nature were statistically evaluated, and the significance in various clinicopathologic aspects among these three types of such endocrine neoplasms of the larynx was compared. A statistically significant difference between two groups of typical carcinoid and atypical variety was evident only in a few items such as rates of metastases, positive CEA, and multisecretory activity, while a significant difference between the carcinoid groups and SCC/OCC group was demonstrated in numerous areas, among others, e.g. 1) in the overall rates of metastases and at the sites of involvement, 2) in Grimelius argyrophilia, 3) in immunohistochemical demonstration of positive chromogranin, CEA, calcitonin and multisecretory activity, and 4) in the 5-year survival rates. Such a definite difference between the carcinoid groups and SCC/OCC group suggested an apparently different characteristic nature present between these two series of neoplasms. The necessity of an international agreement regarding diagnostic criteria for typical carcinoids and atypical varieties was in particular emphasized from a viewpoint of an exceptionally high incidence of laryngeal atypical carcinoids in comparison to such neoplasms in other organs.

Gut-endocrinomas (carcinoids and related endocrine variants) of the uterine cervix: an analysis of 205 reported cases.

This study was carried out statistically to evaluate the present situation of carcinoids and related endocrine variants in the uterine cervix. A total of 205 patients who had been reported on in world-wide literature were divided into two groups; one, as a carcinoid group, consisting of 81 patients with carcinoids, 49 typical and 32 atypical, and the others, as an endocrine carcinoma (ECC) group, including 124 patients with other remaining endocrine carcinomas variously expressed up to date. A statistical comparison in multiple factors was attempted between these two groups. A statistically significant difference between them was demonstrated in immunochemistry for chromogranin (p<0.05), serotonin (p<0.01), and CEA (p<0.01), but not regarding average age, clinical manifestations, tumor-size categorization, rates of metastases, sites of metastases, argyrophilia or argent affinity, and postoperative five-year survival rates, though the latter disclosed a statistically significant difference (p<0.05) only between the two groups of typical and atypical carcinoids. The results of analysis in the present study disclosing no statistically significant differences in various aspects between the two groups of carcinoids and the remaining endocrine carcinomas strongly suggest that the considerable extent of confusion produced by various different types of terminology for carcinoids and related endocrine variants should be solved by extensive evaluation and discussion on an international scale, and that diagnostic criteria and simplified classification acceptable for these neoplasms are to be established not only for those of the uterine cervix but also for those of all other organs including the digestive system based on a universally acceptable concept for these neoplasms originating in non-endocrine organs.

Simultaneous surgery for ischemic heart disease, type A aortic dissection and abdominal aneurysm.

The patient was a 72-year-old male with three-vessel coronary artery disease, chronic dissecting aneurysm of the ascending aorta with moderate aortic regurgitation, and abdominal aortic aneurysm 7 cm in diameter. Because staged procedure seemed to exacerbate the risk due to the remaining lesion, simultaneous procedures (double coronary artery bypass, aortic root remodeling, tube replacement of the ascending aorta and Y-graft replacement of the abdominal aneurysm) were performed. The patient recovered completely without any serious complication.

Statistical analysis of endocrine granule size in gastrointestinal carcinoids.

Regarding the size of endocrine granules in endocrine neoplasms including carcinoids, most authors have reported only the range of granule diameters, and few studies on detailed morphometry of granule sizes have been documented. The statistically comparative study of endocrine granule sizes among such neoplasms, therefore, presented many difficulties. In the present study, we investigated more detailed findings on the endocrine granule sizes by using statistical analyses of diameters of numerous (n > 200 from each tumor) endocrine granules measured randomly throughout the cytoplasm in 18 gastrointestinal carcinoids. The measured data were analyzed statistically to obtain the histogram, distribution curve, mean value, and standard deviation of granule diameters in each carcinoid. It was disclosed by the analyses that all rectal carcinoids possessed uniformly small endocrine granules in contrast to gastric and duodenal carcinoids, which showed wide distribution of granule sizes, having significantly greater diameters than those in the rectal carcinoid series. The correlation between endocrine granule sizes and producing hormone(s) was, however, not confirmed.

Bilateral internal thoracic artery T grafting for coronary artery revascularization. Angiographic assessment and mid-term outcome.

OBJECTIVES: We studied the early outcome of bilateral internal thoracic artery T grafting. METHODS: Coronary artery bypass grafting was studied retrospectively using bilateral internal thoracic artery T grafting in 51 patients. The T graft was made by anastomosing the free right internal thoracic artery to the in-situ left internal thoracic artery. Average patient age was 63.5 +/- 9.9 years, and the average number of anastomoses per patient was 3.6 +/- 0.9. In 35 patients, the right gastroepiploic artery (21 anastomoses in 20 patients), radial artery (1 anastomosis), free left internal thoracic artery (1 anastomosis) and saphenous vein graft (14 anastomoses in 13 patients) were used as additional bypass conduits. RESULTS: Hospital mortality was 0%. The morbidity of stroke was 1.9% (1 patient) and deep sternal infection 0%. Patency of the in-situ left internal thoracic artery was 49/50 anastomoses (98%) and that of the free right internal thoracic artery 81/84 anastomoses (96.4%). Mid-term coronary angiography in 7 patients demonstrated patent anastomosis of the T graft. Acute myocardial infarction unrelated to graft failure occurred in 2 patients during follow-up. Other patients were evaluated by exercise stress tests every year and none exhibited myocardial ischemia in the areas of T graft coronary revascularization. Three-year actuarial survival rate was 100% and freedom from cardiac events 96%. CONCLUSIONS: The bilateral internal thoracic artery T graft provides satisfactory early and mid-term outcomes in properly selected patients.

Quantitative analysis of termination of vagally induced canine atrial fibrillation by mutual information.

Atrial fibrillation (AF) is often described as a disorganized phenomenon, but many features that qualitatively suggest an underlying order have recently been reported. The present study aimed to disclose this underlying order of AF in a quantitative manner, using a new method of mutual information (MI), which is a measure for gauging the general correlation between 2 time series. Frequency analysis and the MI method were used to analyze 5 epicardial potentials on both atria during AF induced by vagal stimulation (Vs) in 15 dogs. Unipolar electrodes were placed on the right atrial appendage (Rap), the high right atrium (HRA), and the left atrial appendage (Lap). The other 2 electrodes were placed equidistantly between HRA and Rap (RA1-RA2). The power spectrum of AF had a discrete peak around 17Hz during Vs. After Vs was stopped, the discrete peak shifted from 17Hz to 7 Hz on all epicardial leads. Taking RA2 as a reference, MI was calculated between RA2 and each of the other electrodes. The MI values (0.066+/-0.005) were greater than 0.047 (the critical value for correlated data) even during Vs. The MI values increased significantly from the highly active process of AF during Vs to the less active one (0.126+/-0.006) before termination of AF. In addition, the MI values increased more at the electrodes close to RA2 (RA1 and Rap) than at those far from it (HRA and Lap). These findings suggest that multiple wavelets, which are not random, progressively organize into a few major waves toward the termination of AF; therefore, AF is not a random phenomenon in this model.

Gut-endocrinomas (carcinoids and related endocrine variants) of the breast: an analysis of 310 reported cases.

The purpose of this study was to analyze the present status of gut-endocrinomas (carcinoids and related endocrine variants) of the breast, an extremely rare site for primary growth of such neoplasms, and to provide precise and reliable information concerning these neoplasms on varying clinicopathological aspects for investigators engaged in relevant research fields. A total of 310 cases presented in this analysis consisted of 196 carcinoids, 102 typical and 94 atypical, and 114 related endocrine variants; in the last group, the expression of "breast carcinoma with (neuro-) endocrine differentiation" was often used without referring to the term "carcinoid." A statistical evaluation was performed on most occasions based on a comparison among three groups of typical carcinoids, atypical carcinoids and related endocrine variants, or between the former two series of carcinoids and the third series of endocrine carcinomas. Statistically significant differences between the groups of carcinoids and endocrine carcinomas were recognized in terms of average age, tumor size categories of < or = 20 mm and 21-50 mm, rates of metastases, and positive neuron-specific enolase (NSE) immunohistochemistry. Contrary to our expectations no statistically significant difference between these two groups was evident in terms of overall average tumor size, Grimelius argyrophilia for endocrine nature, or postoperative 5-year survival rates in curative resection cases. It seems important to establish more precise diagnostic criteria for "endocrine carcinomas" from the viewpoint of a certain possibility that some of these neoplasms may belong to the atypical carcinoid group.

[Clinical outcome for coronary artery bypass grafting in patients with severe carotid occlusive disease].

OBJECTIVES: To evaluate the management of coexisting severe carotid stenosis in candidates for coronary artery bypass grafting. METHODS: Twenty-six candidates for coronary artery bypass complicated with severe carotid stenosis > or = 70% were analyzed retrospectively. The prevalence of significant carotid stenosis was 6.4%. There were 21 males and 5 females with a mean age of 65.3 +/- 9.3 years. The hemodynamics of cerebral circulation, intervention for carotid stenosis, surgical mortality, morbidity, and long-term survival were analyzed retrospectively. RESULTS: The prevalence of bilateral carotid stenosis was 30.8% (8/26). Nine patients had total occlusion of the internal carotid artery, 10 had carotid stenosis of 90-99%, and 7 had carotid stenosis of 70-89%. Seven patients required mechanical support for cardiopulmonary insufficiency, including six patients requiring simultaneous artificial ventilation and intraaortic balloon pumping, and one requiring intraaortic balloon pumping. Concomitant carotid endarterectomy and coronary bypass grafting was performed in 10 patients, preceding carotid endarterectomy in 1, and preceding coronary bypass grafting with subsequent carotid endarterectomy in 7. Cardiopulmonary bypass was used in 22 patients. There was no surgical death. Although one patient undergoing concomitant carotid endarterectomy and coronary artery bypass grafting had perioperative stroke, the remaining patients recovered without any neurological complication (morbidity of stroke: 3.8%). The five-year survival rate was 71.9 +/- 11.7%. CONCLUSIONS: Coronary artery bypass grafting in candidates with carotid stenosis can be treated safely when appropriate preoperative evaluation and surgical strategies are utilized.

The nature of age-related decline on the reading span task.

We examined the effect of age on working memory with a reading span task (RST) together with other verbal span tasks. Sixty-two participants were divided into three subgroups (young, middle-aged, and elderly). The RST performances were significantly different among all the subgroups. To elucidate which component of the working memory system is affected by age, we performed an analysis of covariance with the scores of simple and complex verbal span tasks as covariates. From the results, we conclude that the difference of the RST performance between the middle-aged and elderly groups reflects a decline in the capacity of the phonological loop, and the difference between the young and middle-aged groups reflects malfunctioning of the central executive system.

Minimally invasive direct coronary artery bypass grafting in a patient with brainstem infarction.

Brainstem infarction associated with the primitive trigeminal artery is rare. We describe the case of a 61-year-old man with an acute myocardial infarction as well as a brainstem infarction. The patient was referred for coronary artery bypass grafting. Minimally invasive direct coronary artery bypass grafting (left internal thoracic artery to the second diagonal branch anastomosis) could be safely performed 10 weeks after an episode of brainstem infarction.

Acute aortic thrombosis after intra-aortic balloon pumping.

Acute aortic occlusion is a rare but devastating complication of intra-aortic balloon pumping. Prompt diagnosis of aortic occlusion and immediate therapeutic decision making are keys for saving patients in such cases. We describe a 72-year-old man who underwent emergency surgical removal of a thrombus and aortoiliac bifurcated grafting for acute aortic occlusion after withdrawal of the intra-aortic balloon pumping catheter. The presence of a small unrecognized abdominal aortic aneurysm was considered to be the cause of thrombosis in this patient. Ultrasonographic screening for an abdominal aortic aneurysm is recommended for patients who require intra-aortic balloon pumping support.

Carcinoids of the ovary: an analysis of 329 reported cases.

This evaluation was undertaken to supply precise and reliable detailed information to investigators actively working in carcinoid and related gynecological research fields. A statistical evaluation was performed on 329 cases of ovarian carcinoid registered in the Niigata Registry where world-wide information of gut-pancreatic endocrinomas has been maintained by a computer-analyzing system. Cases without individual identification or those recorded in groups were excluded. The evaluation was carried out mainly by a comparison between two groups of cases with cystic teratoma/dermoid (Group A) and those without such lesions (Group B). The former group consisted of 189 cases (57.4%) and the latter of 140 (42.6%). Statistically significant differences between these two groups were recognized in tumor size (44.7 mm vs 89.8 mm), rate of metastases (5.8% vs 22.1%), rate of hepatic involvement (2.1% vs 15.0%), incidence of associated carcinoid syndrome (13.8% vs 22.9%) and 5-year survival rate (93.7% vs 84.0%). Insular type and trabecular type carcinoids were recorded at an almost equal rate of one fourth ranging between 22% and 26% in either group. Another significant difference in the incidence of carcinoid syndrome was evident between the series of insular type and trabecular type carcinoids (38.9% vs 7.8%). The present evaluation on ovarian carcinoids disclosed definite, statistically significant differences in various clinical and pathophysiologic aspects between Group A and Group B, as well as between insular type and trabecular type histologic structures.

Evaluation of 342 cases of mediastinal/thymic carcinoids collected from literature: a comparative study between typical carcinoids and atypical varieties.

This study is aimed to provide extensive and useful information based on an analysis of a large and reliable series of cases regarding mediastinal/thymic carcinoids, both typical and atypical. It also serves to assist investigators to improve their research activities in this particular field. In the present study, 342 patients (3.8%) with mediastinal/thymic carcinoids from amongst a total series of 8,970 patients with carcinoids, registered in the Niigata Registry for gut-pancreatic endocrinomas, were analyzed to clarify their detailed clinicopathological characteristics. Added to an analysis of mediastinal/thymic series including a comparison between typical and atypical carcinoid varieties, another comparative study was performed between the present series and a bronchopulmonary series. Mediastinal/thymic carcinoids may be briefly characterized by 1) no significant difference in major factors statistically demonstrable between typical carcinoids and atypical varieties, 2) a male preponderance, 3) difficult (delayed) preoperative diagnosis, 4) a high rate of metastasis, 5) a large tumor size on average (delayed detection), 6) a low rate of the carcinoid syndrome, 7) a high rate of association of the Cushing syndrome, and 8) low postoperative survival rates.

Individual differences in working memory and the peak alpha frequency shift on magnetoencephalography.

The effect of the working memory demands on the peak alpha frequency of the power spectrum of magnetoencephalography (MEG) was investigated. There were one control condition and four listening span test (LST) conditions demanding the use of working memory. The results showed that the peak alpha frequency of the averaged MEG power shifted to the higher frequency region in the LST condition dominantly in the fronto-temporal region. Individual differences in working memory capacities were observed in the shift of peak alpha frequency of MEG.

Dedifferentiation of neoplastic cells in medullary thyroid carcinoma: report of a case.

We report herein the unusual case of a man who was diagnosed as having sporadic medullary thyroid carcinoma (MTC) at the age of 29 years, and subsequently followed up for a period of 18 years. A total thyroidectomy with radical neck dissection was initially performed, followed by a stable interval of 16 years with regional metastases. He then developed widely disseminated metastases resulting in death within 2 years at the age of 47 years. While the neoplastic tissue from localized metastases in the soft tissue of the neck expressed strong immunohistochemical positivity to calcitonin (CT), calcitonin gene-related peptide, carcinoembryonic antigen, neuron-specific enolase, and chromogranin A during the stable interval, extremely weakened immunoreactivity to those markers was observed in samples from the disseminated metastases in the subcutaneous tissue after his clinical deterioration. Furthermore, only a few neoplastic cells in specimens obtained at postmortem sampling exhibited a weak response to CT. Ultrastructurally, the characteristic secretory granules in the neoplastic cells decreased remarkably in number, consistent with the immunohistochemical findings. These granules also diminished in diameter and intracytoplasmic small lumina and intercellular clefts with microvilli, interpreted as an attribute of anaplastic thyroid carcinomas, were frequently observed in tissues obtained after his clinical deterioration or at postmortem sampling. These cytological changes might represent dedifferentiation of the neoplastic cells or the anaplastic transformation of MTC.