Laparoscopic inguinal hernioplasty after robot-assisted laparoscopic radical prostatectomy.

PURPOSE: To evaluate the efficacy and safety of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in patients who have undergone robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: From July 2014 to December 2016, TAPP inguinal hernia repair was conducted in 40 consecutive patients who had previously undergone RALP. Their data were retrospectively analyzed as an uncontrolled case series. RESULTS: The mean operation time in patients who had previously undergone RALP was 99.5 ± 38.0 min. The intraoperative blood loss volume was small, and the duration of hospitalization was 2.0 ± 0.5 days. No intraoperative complications or major postoperative complications occurred. During the average 11.2-month follow-up period, no patients who had previously undergone prostatectomy developed recurrence. CONCLUSIONS: Laparoscopic TAPP inguinal hernia repair after RALP was safe and effective. TAPP inguinal hernia repair may be a valuable alternative to open hernioplasty.

Intra- and postoperative low-dose ketamine for adolescent idiopathic scoliosis surgery: a randomized controlled trial.

BACKGROUND: In this randomized controlled trial, we examined whether intra- and postoperative infusion of low-dose ketamine decreased postoperative morphine requirement and morphine-related adverse effects as nausea and vomiting after scoliosis surgery. METHODS: After IRB approval and informed consent, 36 patients, aged 10-19 years, undergoing posterior correction surgery for adolescent idiopathic scoliosis, were randomly allocated into two groups: intra- and postoperative ketamine infusion at a rate of 2 µg/kg/min until 48 h after surgery (ketamine group, n = 17) or infusion of an equal volume of saline (placebo group, n = 19). All patients were administered total intravenous anesthesia with propofol and remifentanil during surgery and intravenous morphine using a patient-controlled analgesia device after surgery. The primary outcome was cumulative morphine consumption in the initial 48 h after surgery. Pain scores (Numerical Rating Scale, NRS, 0-10), sedation scales, incidence of postoperative nausea and vomiting (PONV), and antiemetic consumption were recorded by nurses blinded to the study protocol for 48 h after surgery. RESULTS: Patient characteristics did not differ between the two groups. Cumulative morphine consumption for 48 h after surgery was significantly lower in the ketamine group compared to the placebo group (0.89 ± 0.08 mg/kg vs. 1.16 ± 0.07 mg/kg, 95% confidence interval for difference between the means, 0.03-0.48 mg/kg, P = 0.019). NRS pain, sedation scales, and incidence of PONV did not differ between the two groups. Antiemetic consumption was significantly smaller in ketamine group. CONCLUSIONS: Intra- and postoperative infusion of low-dose ketamine reduced cumulative morphine consumption and antiemetic requirement for 48 h after surgery.

The role of the renin-angiotensin system in the pathogenesis of preeclampsia - new insights into the renin-angiotensin system in preeclampsia.

The renin-angiotensin system (RAS) plays an important role in the pathogenesis of hypertension. However, the role of RAS in preeclampsia is largely unknown, because the plasma concentration of renin and angiotensin (AII) is lower in preeclampsia than in normal pregnancy, whereas its cardinal sign is hypertension. A pressor response to AII infusions can predict the onset of preeclampsia, resulting in involvement of RAS in the pathogenesis of preeclampsia. It has been reported that patients with preeclampsia exhibit angiotensin type I receptor agonistic autoantibody (AT1-AA), suggesting the involvement of RAS in the pathogenesis of this condition. The physiological action of AT1-AA can explain the various clinical symptoms of preeclampsia. However, the significance of circulatory RAS, including AT1-AA, in the pathogenesis of preeclampsia remains obscure. Since many reports state that circulating RAS is thought to be suppressed in preeclampsia it is difficult to explain the onset of hypertension in preeclampsia by circulating RAS. Therefore, I propose new insights into the role of RAS in preeclampsia to resolve the contradiction as above-mentioned. The recent discovery of tissue RAS, on which prorenin and its receptor act, suggests a promising new direction in understanding the role of RAS in the pathogenesis of preeclampsia.

Aspirin-triggered resolvin D1 reduces mucosal inflammation and promotes resolution in a murine model of acute lung injury.

Acute lung injury (ALI) is a severe illness with excess mortality and no specific therapy. Protective actions were recently uncovered for docosahexaenoic acid-derived mediators, including D-series resolvins. Here, we used a murine self-limited model of hydrochloric acid-induced ALI to determine the effects of aspirin-triggered resolvin D1 (AT-RvD1; 7S,8R,17R-trihydroxy-4Z,9E,11E,13Z,15E,19Z-docosahexaenoic acid) on mucosal injury. RvD1 and its receptor ALX/FPR2 were identified in murine lung after ALI. AT-RvD1 (~0.5-5 µg kg(-1)) decreased peak inflammation, including bronchoalveolar lavage fluid (BALF) neutrophils by ~75%. Animals treated with AT-RvD1 had improved epithelial and endothelial barrier integrity and decreased airway resistance concomitant with increased BALF epinephrine levels. AT-RvD1 inhibited neutrophil-platelet heterotypic interactions by downregulating both P-selectin and its ligand CD24. AT-RvD1 also significantly decreased levels of BALF pro-inflammatory cytokines, including interleukin (IL)-1ß, IL-6, Kupffer cells, and tumor necrosis factor-α, and decreased nuclear factor-κB-phosphorylated p65 nuclear translocation. Taken together, these findings indicate that AT-RvD1 displays potent mucosal protection and promotes catabasis after ALI.

A mathematical model for predicting outcome in preterm labour.

OBJECTIVE: This study aimed to develop a model for predicting the outcome and evaluating the treatment of patients with threatened of preterm labour. METHODS: Clinical data from 236 patients at <32 weeks gestation who were in preterm labour were analysed to develop a discriminant function using multiple logistic regression to identify significant risk factors. The function was validated retrospectively in a further 501 patients and prospectively in 63 patients with premature labour. RESULTS: Factors that increased the risk of preterm birth were premature rupture of the membranes, intrauterine infection, dilatation of the cervix and uterine bleeding. Factors that decreased the risk of preterm birth were hospital admission after 28 weeks of gestation and intravenous administration of ritodrine. The predictive accuracy of the function was 75.4% in the 236 patients analysed, 84.8% in the further 501 retrospectively studied patients and 85.7% in the prospective group. CONCLUSIONS: The discriminant function described was clinically useful for predicting the outcome of threatened preterm labour before initiating treatment and for determining the medical care of patients, including maternal transfer to a high-level perinatal care centre.

Diaphragmatic repair of hepatic hydrothorax with VATS after abdominal insufflation with CO(2).

Hepatic hydrothorax is defined as the presence of a significant pleural effusion that develops in a patient with cirrhosis of the liver who does not have an underlying cardiac or pulmonary disease. There have been few published case reports dealing with hepatic hydrothorax treated surgically. Recently, we treated a patient with refractory hepatic hydrothorax by directly suturing the diaphragmatic defect during VATS. During surgery, the diaphragmatic defect was identified by using abdominal insufflation with CO(2) . The defect was sutured and the diaphragm was covered by polyglycolic acid felt and fibrin glue. After surgery, the patient's pleural effusion improved, his postoperative course was uneventful and he did not require a drainage tube at discharge.

Effect of transient TCDD exposure on immortalized human trophoblast-derived cell lines.

Low level, antenatal exposure to dioxins is associated with low birth weight, which in turn is associated with long-term sequelae. We exposed the human extravillous cytotrophoblast (EVT) lines HTR-8/SV40 and TCL1 to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and assessed cell growth, invasion, and differentiation. TCDD had no effect on cell proliferation, invasion, or tube formation in Matrigel. The EVT-derived cells expressed a functional aryl hydrocarbon receptor protein; however, TCDD exposure did not alter expression levels of proteins involved in EVT differentiation in early pregnancy, including hypoxia-inducible factor 1A (HIF1A), vascular endothelial growth factor (VEGF), Integrin A1, A6, and AVB3. These results suggest that the reduction in fetal weight induced by dioxin is not the result of vascular remodeling via EVT dysfunction.

The usefulness of serum amyloid A as a postoperative inflammatory marker after posterior lumbar interbody fusion.

The post-operative changes in the serum levels of CRP and serum amyloid A (SAA) were investigated prospectively in 106 patients after posterior lumbar interbody fusion. In 96 patients who did not have complications related to infection within the first year after operation, the median levels of CRP before operation and on days 3, 7 and 13 after were 0.02 (0.01 to 0.03), 9.12 (2.36 to 19.82), 1.64 (0.19 to 6.10) and 0.53 (0.05 to 2.94) mg/dl, respectively and for SAA, 2.6 (2.0 to 3.8), 1312.1 (58.0 to 3579.8), 77.3 (1.8 to 478.4), 14.1 (0.5 to 71.9) mug/ml, respectively. The levels on day 3 were the highest for both CRP and SAA and significantly decreased (p < 0.01) by day 7 and day 13. In regard to CRP, no patient had less than the reference level (0.1 mg/dl) on day 7. In only three had the level decreased to the reference level, while in 93 it was above this on day 13. However, for SAA, the levels became normal on day 7 in 10 cases and on day 13 in 34 cases. The ratios relative to the levels on day 3 were significantly lower for SAA compared with CRP on day 7 and day 13. Of the ten patients with infection in the early stages, the level of CRP decreased slightly but an increase in SAA was observed in six. We concluded that SAA is better than CRP as a post-operative inflammatory marker.

Superiority of radioisotope over blue dye for sentinel lymph node detection in breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is commonly performed using radioisotopes and/or blue dye. However, it is still undefined which reagent is more suitable for identifying sentinel lymph nodes (SLN). PATIENTS AND METHODS: A consecutive series of 640 breast cancer patients who had undergone SLNB at the Keio University Hospital from 2001 to 2006 was analyzed. The SLN was identified by a combination of technetium-99m tin colloid and isosulfan blue dye. The correlation between clinicopathological factors and the distribution of radioisotopes and blue dye was analyzed. The single metastatic lymph node revealed by axillary lymph node dissection (ALND) is the 'true SLN', and the distribution of radioisotopes and blue dye to the 'true SLN' was also analyzed. RESULTS: Blue-dye- and radioisotope-positive SLN were identified in 79.6 and 94.7% of the patients, respectively. Taken together, SLN were identified in 625 patients (97.7%) by radioisotope and/or blue dye. No significant correlation was observed between clinicopathological features and the distribution of the reagents. ALND found 73 patients with single lymph node metastasis, and 73 'true SLN' were identified by blue dye in 65.7% (48/73), and by radioisotope in 95.9% (70/73) of the cases. CONCLUSION: These data suggest that radioisotopes are superior to blue dye in detecting SLN in breast cancer.

Heparin versus danaproid for prevention of venous thromboembolism after hip surgery.

PURPOSE: To compare the prevalence of deep vein thrombosis (DVT), pulmonary thromboembolism (PTE), and bleeding complications in patients receiving heparin or danaproid after hemiarthroplasty or osteosynthesis for hip fractures. METHODS: 37 men and 138 women aged 47 to 100 (mean, 80) years underwent either hemiarthroplasty or osteosynthesis for hip fractures; 5 patients with dementia were excluded. All patients received preoperative elastic stocking and postoperative intermittent pneumatic compression. They were divided into 3 groups based on their admission period: controls (n=71), unfractionated heparin (n=44), and danaproid sodium (n=55). Drugs were administered from postoperative day 1 to 7. At day 7, all patients undertook radioisotope venography of the legs and lung perfusion scintigraphy. RESULTS: In the control, heparin, and danaproid groups respectively, the DVT rates were 31%, 9.1%, and 5.5%, and the PTE rates were 5.6%, 4.5%, and 1.8%. Only the DVT rate in the control group was significantly higher than that in the heparin and danaproid groups. In the heparin group, one patient had gastrointestinal bleeding, 5 developed wound haematomas, and one had leakage from the drain site for 2 weeks. CONCLUSION: Danaproid sodium appeared more effective and safer than heparin, with no bleeding complications occurred.

Gene expression profiles by microarray analysis during matrigel-induced tube formation in a human extravillous trophoblast cell line: comparison with endothelial cells.

Endovascular differentiation of extravillous cytotrophoblasts (EVT) during placentogenesis induces remodeling of spiral arteries that increases blood flow toward the intravillous space and is required for maintaining pregnancy. To address the molecular mechanisms involved in this differentiation, we investigated the gene expression profile during matrigel-induced tube formation in TCL1 cells, a human immortalized EVT cell line, and HUV-EC-C, human umbilical vessel endothelial cells, and compared their profiles. The numbers of genes that showed significant up-regulation (>3-fold expression at both 3 and 6h, and/or >5-fold expression at either 3 or 6h) during tube formation and significant down-regulation (0.33-fold expression at both 3 and 6h, and/or less than 0.2-fold expression at either 3 or 6h), were 969 and 659 in TCL1, respectively. In HUV-EC-C, the numbers of genes that showed significant up-regulation and down-regulation were 86 and 65, respectively. Only 73 of 1628 genes that showed significant expression changes in TCL1 were common with HUV-EC-C. The genes showing significant expression change specifically in TCL1 were associated with cellular, metabolisms, proliferation, anti-apoptosis, proteolysis adhesion, and some known to be involved in EVT differentiation or related to angiogenesis. The gene expression profile in EVT during tube formation is very different from that of endothelial cells. Further investigations based on the current data may help to elucidate mechanisms of normal and abnormal placentogenesis.

Hypoxia inducible factor 1 alpha regulates matrigel-induced endovascular differentiation under normoxia in a human extravillous trophoblast cell line.

Extravillous trophoblast (EVT) cells mimic endothelial cells during angiogenesis, inducing remodeling of the spiral arteries that increases blood flow toward the intravillous space. We have previously shown that signals involving the vascular endothelial growth factor (VEGF) axis are essential for endovascular differentiation through integrin signaling from the extracellular matrix: This was accomplished with use of the human EVT cell line TCL1, which shows tube formation that specifically recalls morphological changes in endothelial cells. To investigate endovascular differentiation in EVT further, we investigated the role of hypoxia inducible factor (HIF)1A, a subunit of HIF1 transcription factor that regulates not only adaptive responses to hypoxia, but also many cellular functions under normoxia, which was up-regulated in DNA microarray analysis during matrigel-induced endovascular differentiation under normoxia. HIF1A induces VEGF and ITGAV/ITGB3 aggregation, actions known to be important for cellular survival and endovascular differentiation in EVT. Inhibition of HIF1A up-regulation using siRNA introduction or chemical inhibition suppressed hypoxia-responsive element transcriptional activity, VEGF induction, ITGAV/ITGB3 aggregation accompanied by the inhibition of tube formation in TCL1 cells. These results suggest that HIF1A has a crucial role in regulating EVT behavior including matrigel-induced endovascular differentiation under normoxia.

Gallbladder adenoma: report of a case with emphasis on contrast-enhanced US findings.

There is a marked paucity of contrast-enhanced ultrasound (US) findings of gallbladder disease in the literature, and there is only one previous case of gallbladder adenoma. We report such a case. US showed a 2-cm polypoid lesion at the gallbladder body. Color Doppler US showed the hypervascular nature of the lesion, and contrast-enhanced US revealed the lesion to be homogeneously enhanced, suggesting that the lesion was composed of the same pathology. The lesion was surgically resected, and was found to be an adenoma without cancer foci. This case suggests that contrast-enhanced US is an effective tool in diagnosing a gallbladder adenoma.

Duodenal adenoma with production of massive mucus: report of a case with emphasis on US findings.

Duodenal adenoma with massive mucus production is very rare. We report such a case. Ultrasonography (US) showed the presence of massive mucus, and contrast- enhanced US revealed the thickened wall to be homogeneously enhanced, suggesting that the lesion was composed of the same pathology. The US results were confirmed histologically by endoscopically guided biopsy. Thus, contrast-enhanced US helps determine the biopsy point and determine good diagnostic strategies.

Immunohistochemical localization of cyclooxygenase-1 and -2 in synovial tissues from patients with internal derangement or osteoarthritis of the temporomandibular joint.

This study examined the immunohistochemical expression and localization of cyclooxygenase-1 and -2 (COX-1 and COX-2) in synovial tissues from patients with internal derangement (ID) or osteoarthritis (OA) of the temporomandibular joint (TMJ). Synovial tissues from patients with condylar fractures of the mandible were studied as control. Synovial tissues from 13 TMJs of 10 patients with ID or OA and from 5 TMJs of 4 patients with fractures were examined for COX-1 and COX-2 expression by immunohistochemical staining using two monoclonal antibodies. In addition, whether the COX-2 expression grade correlated with the synovitis score and clinical findings was assessed. COX-2 was expressed in the synovial lining, infiltrating mononuclear cells, fibroblast-like cells, and blood vessels, including CD31-positive endothelial cells, in the synovium of patients with ID or OA. Expression levels of COX-1 in synovial lining cells and endothelial cells were similar in the specimens obtained from the patients with ID or OA and those obtained from the controls. The expression of COX-2 positively correlated with arthroscopic findings of synovitis (p = 0.55, P = 0.023) and with joint pain (p = 0.56, P = 0.021). These results suggest that up-regulation of COX-2 in synovium may play a part in the pathogenesis of synovitis in patients with ID or OA of the TMJ.

Formant interaction as a cue to vowel perception: a case report.

Accumulating evidence indicates that cerebral processing of consonants and vowels is separable. It has been shown that disordered temporal acuity leads to disturbed consonant perception in cases with pure word deafness. In contrast, there has been no clear explanation of how vowel perception is impaired. We examined a patient with auditory agnosia, who showed a differential ability to identify the five Japanese vowels after bilateral cerebral lesions. He correctly identified the vowel [a] in more than 70% of auditory presentations, whereas he identified [i] in only about 30% of presentations. The difference between the first and second formant frequencies "F2-F1" and an artificially defined value "F1-(F2-F1)" for each vowel correlated significantly with the percentage of correct identifications. These findings support the hypothesis that vowel perception is based on formant interactions.

Small hypervascular hepatocellular carcinoma versus hypervascular pseudolesions: differential diagnosis on MRI.

BACKGROUND: We wanted to differentiate small hypervascular hepatocellular carcinoma (HCC) from hypervascular pseudolesion (HPL) on magnetic resonance imaging (MRI). METHODS: We reviewed small hypervascular foci (< or = 2 cm in diameter) on dynamic MRI in patients with chronic liver disease, which were followed-up with serial MRI examinations. RESULTS: Twenty of 34 hypervascular foci were larger at follow-up; 19 of 20 foci had characteristics suggesting HCC; and 14 foci did not grow or disappeared and were judged to be HPLs. There were no differences in the initial sizes and follow-up periods between HCCs and HPLs. On initial MRI, nine of 19 HCCs (47%) and one of 14 HPLs (7%) appeared hyperintense on T2-weighted images. The difference between HCCs and HPLs on T2-weighted images was statistically significant (p = 0.039). CONCLUSION: HPLs are seen frequently as small hypervascular foci on dynamic MRI in patients with chronic liver disease. Hyperintensity of the foci on T2-weighted images differentiates HCCs from HPLs.

Callus resection for brachial plexus compression following stress-induced first rib fracture.

A 27-year-old man presented with a lower trunk brachial plexus injury due to excessive callus formation following a stress-induced first rib fracture. The callus, but not the first rib, was resected through a supraclavicular approach. His symptoms resolved in 2 months, and no recurrence was seen at 2 years follow-up.

Long-term treatment with nicardipine for severe pre-eclampsia.

OBJECTIVE: To evaluate the safety of long-term nicardipine treatment in severely pre-eclamptic women and their fetuses/newborns. METHODS: We divided 50 pregnant women into three groups according to the length of their treatment: short-term treatment of severely pre-eclamptic women (7 days or less, n=20); medium-term treatment also of severely pre-eclamptic women (8-28 days, n=20); and long-term treatment of women with severe superimposed pre-eclampsia (29 days or more, n=10). RESULTS: Nicardipine significantly lowered both systolic (P<0.01) and diastolic blood pressures (P<0.025) in all three groups. The incidence of delivery before 28 weeks of gestation was very low in all three groups. There were no maternal or fetal/neonatal adverse effects. CONCLUSION: Our results suggest that long-term treatment with nicardipine for severe pre-eclampsia is as effective and safe as a short- and medium-term treatment.