Prediction of muscle strength and postoperative function after knee flexor muscle resection for soft tissue sarcoma of the lower limbs.

INTRODUCTION: Oncological margins and prognosis are the most important factors for operative planning of soft tissue sarcomas, but prediction of postoperative function is also necessary. The purpose of this study was to predict the knee flexion strength and postoperative function after knee flexor muscle resection for soft tissue sarcoma of the lower limbs. MATERIALS AND METHODS: Seventeen patients underwent knee flexor muscle resection for soft tissue sarcoma of the lower limbs between 1991 and 2015. The type of resected muscles was surveyed, knee flexion strength (ratio of affected to unaffected side) was evaluated using the Biodex System isokinetic dynamometer, and differences between the type of resected muscles were examined. The Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D), and Short Form 8 (SF-8) were used to assess postoperative function and examine correlations with flexion strength. The cutoff value for flexion strength to predict good postoperative results was calculated by a receiver operating characteristic (ROC) curve and Fisher's exact test. RESULTS: Median flexion strength decreased in the resection of sartorius (97.8%), gracilis (95.4%), gastrocnemius (85.2%; interquartile range (IQR): 85.0-86.2), medial hamstrings (semimembranosus and semitendinosus, 76.2%; IQR: 73.3-78.0), lateral hamstrings (long and short head of biceps femoris, 66.1%; IQR: 65.9-70.4), and bilateral hamstrings (27.3%; IQR: 26.6-31.5). A significant difference was observed between lateral and bilateral hamstrings resection (P=0.049). Flexion strength was associated with lower functional scales (MSTS score, P=0.021; TESS, P=0.008; EQ-5D, P=0.034). Satisfactory function was obtained at a flexion strength cutoff value of 65.7%, and strength remained above the cutoff value up to unilateral hamstrings resection. DISCUSSION: Greater knee flexor muscles resection can result in functional deficits that are associated with decreased flexion strength. If continuity of unilateral hamstrings is maintained, good postoperative results can be expected. LEVEL OF EVIDENCE: IV, retrospective study.

Resection of spinous processes can cause spinal cord injury in patient with ossification of the posterior longitudinal ligament in the thoracic spine.

STUDY DESIGN: Case report. OBJECTIVE: To report intraoperative spinal cord injury by resection of spinous processes in a 73-year-old man with ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine. METHODS: A 73-year-old man presented with cervicothoracic OPLL with bilateral numbness and clumsiness of his hand, weakness of his lower extremities and severe gait disturbance. His Japanese Orthopaedic Association (JOA) score was 7.5 out of 17. Cervical laminoplasty (C2-6), cervicothoracic laminectomy (C7-T10) and posterior fusion (C7-T10) were performed in the prone position with electrophysiologic monitoring of the spinal cord-evoked potentials (SCEPs). RESULTS: The spinal processes with supra- and interspinous ligaments between C7 and T10 were resected. After resection, the amplitude of SCEP waveforms decreased rapidly to <10% of control levels. Laminectomy was performed, and, after 80 min of SCEP deterioration, an instrumented fusion with correction for kyphosis was completed. The SCEP amplitude recovered gradually. Immediately after surgery, the patient suffered severe motor loss in both lower limbs. His neurological recovery progressed gradually from 2 days after surgery, and he was able to walk at 3 months after surgery. At 6 years after surgery, the JOA score was 11. CONCLUSION: Our results suggest that intraoperative spinal cord injury can occur before posterior decompression by resection of spinal processes with supra- and interspinous ligaments. The timing of the instrumented stabilization using a temporary rod is important and should be considered immediately after posterior exposure of the spine.

[An elderly case with impending myocardial infarction of endoventricular circular patch plasty with coronary artery bypass grafting].

An 81-year-old man with anterior impending re-myocardial infarction was urgently operated. Preoperative ECG and UCG examinations showed old myocardial infarction and LV aneurysm, respectively. We chose the Dor method (endoventricular circular patch plasty) and CABG aiming at early recovery from congestive heart failure. He fell into respiratory failure temporarily, but otherwise, the clinical course of this operation was good. He was discharged 47 days after the operation on foot. The Dor method combined with CABG is excellent way to relieve patients from congestive heart failure with LV aneurysm.

Surgical repair of a concealed aortocaval fistula associated with an abdominal aortic aneurysm: report of two cases.

Two cases of a concealed aortocaval fistula (ACF) associated with an abdominal aortic aneurysm (AAA) are presented herein. ACF is a rare complication of AAA and only a few cases have so far shown the triad of symptoms, including congestive heart failure, a continuous abdominal bruit, and a pulsating abdominal mass. Sometimes a definite diagnosis is not made preoperatively and as a result, massive bleeding is encountered. We believe that the presence of a large aneurysm, compression, and involvement of the inferior vena by an aneurysm, and pelvic venous dilatation on abdominal computed tomography and hematuria may additionally suggest the presence of a concealed ACF. A correct preoperative diagnosis will help greatly in selecting the optimal surgical modality and should also reduce the degree of bleeding.

No significant differences were observed in the amounts of DNA strand breaks produced by copper between male and female liver cells of long-evans cinnamon (LEC) strain rats.

The amounts of DNA single strand breaks that are oxidative damage produced by copper were examined by comet assay in the liver cells of an inbred strain of Long-Evans Cinnamon (LEC) rats that spontaneously develops fulminant hepatitis. At 4 weeks of age, copper contents in the liver of LEC rats were approximately 30-fold higher than those of WKAH rats that are control rats used in the present study. Copper accumulated in the liver of LEC rats in an age-dependent manner and no significant differences were observed between copper contents in the livers of males and females at each week of age from 4 to 15 weeks. No significant amounts of DNA strand breaks were found in the liver cells of both male and female WKAH rats from 4 to 15 weeks of age. DNA strand breaks were produced in the substantial population of LEC rat liver cells at 10 weeks of age and induced in an age-dependent manner from 10 to 15 weeks of age. The amounts of DNA strand breaks produced by copper accumulation in the liver cells of female LEC rats are not more abundant than those in the cells of male rats, although it has been reported that hepatitis in female rats is more serious than that in male rats.

Cu-metallothioneins (Cu(I)8-MTs) in LEC rat livers 13 weeks after birth still act as antioxidants.

Redox properties of metallothioneins (MTs) and Cu in the cytosol from Long-Evans Cinnamon (LEC) rat livers 13 weeks after birth were investigated. MTs from LEC rat livers contain 8 g atoms of Cu and 1 g atom of Zn per mole of protein (Cu(I)8-MTs). Titration of Cu(I)8-MTs with CuCl2 indicates that Cu(I)8-MTs were able to reduce further 2-g atoms of cupric ions per mole MTs as bound form. Hg2+-induced hydroxyl radical generation from Cu(I)8-MTs was demonstrated by ESR using the spin trap, 5,5-dimethyl-1-pyrroline N-oxide (DMPO). The intensity of DMPO-OH signal from Cu-loaded MTs was increased with the increasing number of Cu in MTs. The used cytosol fraction contained 1.37 mM total Cu and 5 mM DTNB titrable-SH groups has a potential to reduce 2 mM CuCl2. No ESR signal due to Cu2+ was also detected with LEC rat liver cytosol, whereas strong Cu2+ signal appeared by the addition of HgCl2. The rate constants for the reaction of Cu(I)8-MTs with superoxide and hydroxyl radicals were estimated to be 2 x 10(6) and > or = 10(12) M(-1)s(-1), respectively, from competition kinetics. Cu2+-catalyzed oxidation of DNA was strongly inhibited both in the presence of Cu-unsaturated MTs and GSH. The results suggest that Cu(I)8-MTs from LEC rat livers just before hepatitis still act as antioxidants.

[Surgical treatment for chronic pulmonary thromboembolism in a patient with protein C deficiency].

Medical therapy for chronic pulmonary thromboembolism is limited, and surgical treatment has become more frequent recently. We have performed pulmonary thromboendarterectomy on a patient with chronic pulmonary thromboembolism accompanied by protein C deficiency. The patient was a woman aged 68 years who had protein C deficiency. The preoperative condition was New York Heart Association functional class IV. Hypoxemia, marked pulmonary hypertension, and low cardiac output were observed. After a median sternotomy, moderate hypothermia was induced using a cardiopulmonary bypass, and thromboendarterectomy in the pulmonary artery was performed. The arterial blood oxygen concentration improved, and the mean pulmonary pressure decreased. The cardiac output also increased, and New York Heart Association functional class improved to I. Pulmonary thromboendarterectomy under cardiopulmonary bypass was effective for chronic pulmonary thromboembolism accompanied by protein C deficiency.

The relationship between plasma concentration of mature adrenomedullin and jugular venous oxygen saturation during and after cardiopulmonary bypass.

UNLABELLED: Adrenomedullin (AM), a vasodilatory peptide, increases during cardiac surgery. However, the physiological role of AM during cardiac surgery remains unclear. AM dilates cerebral arterioles and increases cerebral blood flow in rats. Therefore, we investigated whether AM is related to cerebral oxygen balance during cardiac surgery. In nine patients undergoing coronary artery bypass grafts, plasma concentrations of mature AM from the radial artery (mAMa) and jugular bulb (mAMj) were measured, and jugular venous oxygen saturation was obtained before surgery (baseline), before aortic cross-clamp (preclamp), after aortic declamp (postclamp), and 20 min after weaning from the cardiopulmonary bypass (post-CPB). Plasma concentrations of mAMa and mAMj were significantly increased at postclamp (P < 0.01 for both) and post-CPB (P < 0.01 for both) compared with baseline values. SjO(2) correlated with plasma mAMj concentrations at preclamp (r = 0.79, P < 0.01), postclamp (r = 0.71, P < 0.05), and post-CPB (r = 0.72, P < 0.05), as well as with mAMa concentrations at preclamp (r = 0.79, P < 0.01) and postclamp (r = 0.72, P < 0.05). This suggests a relationship between AM and cerebral oxygen balance during cardiac surgery. IMPLICATIONS: Plasma concentrations of mature-form adrenomedullin, a vasodilatory peptide, was correlated with jugular venous oxygen saturation during cardiac surgery. This suggests a relationship between adrenomedullin and cerebral oxygen balance during cardiac surgery.

Hepatic copper accumulation induces DNA strand breaks in the liver cells of Long-Evans Cinnamon strain rats.

Effects of accumulation of copper and iron on the production of DNA strand breaks were investigated in Long-Evans Cinnamon (LEC) strain rats that spontaneously develop fulminant hepatitis. Copper and iron accumulated in the liver of LEC rats in an age-dependent manner from 4 to 15 weeks. Low-copper food prevented the accumulation of copper in the liver, but did not prevent accumulation of iron. When the amounts of DNA single strand breaks were estimated by comet assay, the number of DNA strand breaks in the liver cells of rats fed standard food increased with age from 4 to 15 weeks. The number of DNA strand breaks in the liver cells from rats fed low-copper food were the same as those of rats at 4 weeks of age. Thus, the copper accumulation in the liver of LEC rats induced DNA strand breaks, but accumulation of iron did not.

[A case of systemic lupus erythematosus with pulmonary hypertension].

A 15 year-old girl was admitted to the hospital because of fever, polyarthlargia, dry cough, dyspnea, butterfly rash and multiple oral aphthas. The diagnosis of systemic lupus erythematosus (SLE) was made based on renal disorders, pancytopenia, positive antinuclear antibody and positive for antibodies to double-stranded DNA. On admission, she developed progressive dyspnea with highly active SLE. The patient was complicated with both pulmonary hypertension (PH) and interstitial pneumonitis (IP), judging from increased pulmonary sound by an auscultation, interstitial shadows especially at bilateral lower lung and enlarged shadow of right atrium in a chest rentgenogram, ground glass pattern of bilateral middle to lower lung in a chest computed tomographic scan, increased pulmonary artery pressure, 53 mmHg, by an ultrasound cardiograph (UCG). Combination of methylprednisolone pulse therapy, cyclosporin A and plasma exchanges was effectively administered, which resulted in improvement of disease activity of SLE, IP and PH. However, two months later, although disease activity of SLE was completely reduced, recurrence of PH by UCG and multiple pulmonary embolism (PE) which was observed by a chest rentgenogram and a pulmonary blood flow scintigraphy was further complicated. Administration of cyclophosphamide pulse therapy and warfarin therapy improved both PE and PH. The patient had PH at the different clinical course of SLE; 1) PH maybe induced by severe IP at the active phase of SLE and 2) PH brought about from multiple PE at the inactive phase of SLE. Thus, the case is thought to be suggestive of elucidating the pathogenesis of PH of several systemic autoimmune diseases including SLE.

Revascularization of femoropopliteal artery occlusion in Werner's syndrome. Report of a case and review of surgical literature in cardiovascular lesions.

A patient with Werner's syndrome suffering from a chronic ulcer on the right ankle joint underwent femoropopliteal bypass and patch angioplasty combined with endarterectomy of the distal popliteal artery. Postoperative angiography showed satisfactory graft patency and distal run-off, and the ulcer improved. Femoropopliteal occlusive disease in Werner's syndrome tends to have poor run-off and the internal diameter of the popliteal artery with diffuse arteriosclerotic lesion is often too small to facilitate distal anastomosis. Therefore, a conventional bypass procedure is not always effective and an aggressive attitude is essential to obtain sufficient ankle blood pressure and improve the leg ulcer in Werner' syndrome.

[Differential effects of ketamine enantiomers on anesthetic levels and glutamate release in the hippocampus].

The anesthetic effects of ketamine enantiomers (40 and 100 mg.kg-1, i.p.) were evaluated in the rat by behavioral parameters such as the orienting response, the tail-pinch test and the spontaneous motor behavior including stereotyped behavior (circling and nodding). The intercellular glutamate concentration in the dorsal hippocampus was measured by brain microdialysis method. The analgesic and sedative effects of the S(+)-ketamine were more potent than those of the R(-)-ketamine at each dose. The incidence of stereotyped behaviors in R(-)-ketamine groups was higher than that of S(+)-ketamine groups. The basal release of glutamate under perfusion with normal artificial cerebrospinal fluid (ACSF) was unchanged after the administration of these enantiomers. Repeat perfusion with high-potassium ACSF (100 mM K+) for 20 min increased the glutamate content in vehicle-treated rats. This depolarization-related glutamate release was suppressed by ketamine, except in the 100 mg R(-)-ketamine group in which the stimulated glutamate release tended to increase after the treatment. The inhibitory effect on this stimulated glutamate release was marked in S(+)-ketamine groups. These results suggest that the anesthetic effects of ketamine enantiomers may be mediated at least in part, via regulation of depolarization-released glutamate release.

Additive combination of actarit and methotrexate in the treatment of refractory rheumatoid arthritis.

Abstract The objective of this study was to evaluate the efficacy and safety of an additive combination of a disease-modifying antirheumatic drug (DMARD) actarit and low-dose methotrexate (MTX) in patients with active rheumatoid arthritis (RA) unresponsive to MTX. Thirty-four patients with active RA, who had been unsuccessfully treated with MTX for at least 3 months were enrolled on a 24-week course of actarit (300 mg/day) and MTX (2.5-10 mg/week). Disease activity was evaluated by physical global assessments using conventional measures (Japan Rheumatism Association), and the American College of Rheumatology (ACR) criteria of improvements in RA. Thirty-two patients completed this study. No severe adverse drug reactions were seen. Patients whose RA did not respond to MTX alone responded to the combination therapy, with a significant improvement in the duration of morning stiffness, grip strength, swollen joint counts, patient's articular pain score, modified health assessment questionnaire (M-HAQ) score, score of both patient's and physician's global assessments, and C-reactive proteins (CRP). Sixteen patients (50.0%) and 9 patients (31.0%) showed a significant improvement in overall conventional measures, and ACR response criteria, respectively, and 60.0% of RA patients who received MTX for more than 1 year showed improvement in ACR definition. Patients who responded to the combination treatment within the first 12 weeks showed persistent improvement for the remaining part of the 24 week period. Our results indicate that the additive combination of actarit and MTX is safe, and without serious adverse effects, and has an excellent efficacy in patients with active and refractory RA.

[Post aortic left innominate vein in a patient with a surgically corrected double outlet right ventricle].

We report the presence of a post aortic left innominate vein (PALIV) in a patient with a surgically corrected double outlet right ventricle. A 30-year-old male was admitted to our hospital with exertional dyspnea. The patient had undergone right ventricular outflow tract reconstruction and closure of ventricular septal defect at the age of 14. Echocardiography and cardiac catheterization showed severe pulmonary regurgitation and a residual ventricular septal shunt. After resternotomy, right ventricular outflow tract reconstruction and residual shunt closure were performed. During the operation, the left innominate vein was not found in front of the aorta. Postoperative cardiac catheterization and computed tomography showed that the left innominate vein was positioned behind the ascending aorta draining to the superior caval vein.

Bleeding through the fiber interstices of a knitted dacron graft 12 years after its implantation: report of a case.

We present herein the case of a 65-year-old man who suddenly developed fresh perigraft bleeding into the space between a knitted Dacron bifurcated graft and the aneurysmal sac, 12 years after undergoing graft replacement. Intraoperative findings did not show Dacron fiber degeneration at the nonanastomotic sites or a pseudoaneurysm at the anastomotic site. Widened Dacron fiber interstices resulting from graft dilation without sufficient graft healing was thought to have caused delayed hemorrhage through the macroscopically intact graft material, followed by massive clot retention between the graft and the aneurysmal sac. This case report serves to demonstrate that careful long-term follow-up is essential for patients who have undergone vascular graft replacement.

[Two cases of thoracic aneurysm with aberrant origin of the aortic branches: diagnosis and strategy].

We present two cases of thoracic aortic aneurysms with anomalous origin of the aortic arch branches. One was a 72-year-old female with a ruptured descending thoracic aneurysm and aberrant origin of the right subclavian artery. The other was a 64-year-old male with a saccular distal arch aneurysm and aberrant origin of the left vertebral artery. Preoperative examinations included angiography, computed tomography (CT), three dimensional enhanced CT (3DCT), digital subtraction angiography (DSA), and magnetic resonance imaging (MRI). Understanding the structure of neck vessels is important in deciding where to clamp or to reconstruct in surgical repair of the aortic arch. 3DCT was the most useful examination for this understanding.

A double bifurcated graft for abdominal aorta and bilateral iliac artery reconstruction.

Revascularization of the hypogastric artery often tends to be neglected in aortoiliac reconstructive surgery; however, its incomplete revascularization can result in unfavorable complications such as buttock claudication or necrosis, vascular impotence, and colonic ischemia. Multiple vascular lesions in the abdominal aorta and bilateral iliac arteries were reconstructed using a newly designed double bifurcated graft in five male patients. All five patients demonstrated excellent graft limb patency and postoperative improvement of the ankle-brachial pressure index without any clinical signs of ischemia in regions of the hypogastric artery. Thus, we conclude that an aggressive approach toward hypogastric circulation maintenance is essential in aortoiliac reconstructive surgery. By using this double bifurcated graft, rapid and safe revascularization of the bilateral hypogastric arteries concomitant with the external iliac or femoral arteries can be performed.

Angle-adjustable sheath for a dual-stage venous cannula.

The dual-stage venous cannula is widely used but can obstruct the surgeon's view and interfere with operative procedures in the aortic root. We designed a new stainless steel sheath for a dual-stage venous cannula that enables the cannula to bend and maintain the appropriate angle for the surgical procedures. We suggest that operative procedures in the aortic root can be performed faster during safety cardiopulmonary bypass by use of a dual-stage venous cannula bent by application of this new sheath.

[A successful repair of infective endocarditis accompanied by a pseudoaneurysm of the left ventricle].

The present paper reports a successful surgical treatment of a 47-year-old male with a pseudoaneurysm of the left ventricle. The patient has also been administered Penicillin G for 5 months to treat endocarditis. Cardiac catheterization showed severe aortic stenosis and a pseudoaneurysm of the left ventricle which was dilating in systole. The patient underwent patch closure of the pseudoaneurysm whose ostium was situated at the miral-aortic inter valvular fibrosa followed by aortic valve replacement and direct closure of a right Valsalva sinus aneurysm. His postoperative course was uneventful. The patient had no recurrence of endocarditis nor malfunction of the prosthetic valve for one year postsurgery. This is the first report in Japan of successful surgical treatment of a pseudoaneurysm of the left ventricle due to perforation of the miral-aortic intervalvular fibrosa after endocarditis.

Heparan sulfate proteoglycan on endothelium efficiently induces integrin-mediated T cell adhesion by immobilizing chemokines in patients with rheumatoid synovitis.

OBJECTIVE: To clarify the role of heparan sulfate proteoglycan (HSPG) and chemokines in integrin-mediated T cell adhesion to endothelial cells in the synovium of patients with rheumatoid arthritis (RA). METHODS: Endothelial cells were purified from RA synovium. Expression of heparan sulfate, chemokines, and adhesion molecules on the endothelium was assessed by immunohistochemical analysis or flow cytometry. The effects of chemokines and heparan sulfate on T cell adhesion to RA endothelium were estimated with relevant antibodies and signaling inhibitors. Production of chemokines from synovial T cells was detected by Northern blotting and enzyme-linked immunosorbent assay. RESULTS: The endothelium in RA synovium highly expressed HSPG. The soluble form of chemokines, macrophage inflammatory protein 1beta (MIP-1beta), induced T cell adhesion to the endothelial cells. When MIP-lalpha and MIP-1beta were immobilized on RA endothelial cells, a more efficient integrin-mediated adhesion of T cells was induced compared with their soluble form. The induced T cell adhesion was reduced by pretreatment with either heparitinase, anti-MIP-lalpha antibody, or anti-MIP-lbeta antibody, indicating that these chemokines were bound to heparan sulfate on the cells. T cell adhesion was also inhibited by pertussis toxin, wortmannin, and cytochalasin B. MIP-lalpha and MIP-1beta were found on vessels in RA synovium in vivo, which were spontaneously produced from T cells purified from RA synovium. CONCLUSION: Endothelial cells in RA synovium characteristically express HSPG, which is involved in T cell integrin triggering by "posting" chemokines, which are produced by synovial T cells, and by "relaying" them to their receptors on T cells, which activate G protein-dependent phosphoinositide 3-kinase and actin-dependent integrin triggering.