Control of cerebrospinal fluid otorrhea via C-arm-guided reduction of the zygomatic arch as a part of the temporal bone: interdisciplinary approach to an unusual craniomaxillofacial fracture.

Maxillofacial fractures are often associated with blunt head injuries, of which skull base trauma is a common component. However, most oral and maxillofacial surgeons do not provide definitive management of temporal bone fractures involving the skull base and their sequelae. Persistent cerebrospinal fluid (CSF) leakage that is refractory to conservative measures usually requires surgical closure to decrease the risk of meningitis. In general, reduction of the displaced fragment of the skull base in temporal bone fractures is not considered a priority. We describe an unusual case of craniomaxillofacial injury exhibiting CSF otorrhea because of a temporal bone fracture with a fragment that included the zygomatic arch. The persistent traumatic leakage was stopped after C-arm-guided reduction of the depressed zygomatic arch. This technique facilitated minimal and only necessary manipulation, without overcorrection, thereby avoiding additional damage to the surrounding tissues. The present case illustrates the definitive contribution of therapeutic measures based on maxillofacial surgery as part of an interdisciplinary approach to the management of the complications of severe head injuries; more invasive neurosurgery was thus avoided.

Association of postalimentary lipemia with atherosclerotic manifestations

We identified different lipemic and metabolic responses after the ingestion of a standardized meal by healthy adults and related them to atherosclerotic markers. Samples from 60 normolipidemic adults were collected before and after a liquid meal (40 g fat/m² body surface) at 0, 2, 4, 6, and 8 h for measurements of lipids, free fatty acids (FFA), insulin, cholesteryl ester transfer protein (CETP), autoantibodies to epitopes of oxidized LDL (oxLDL Ab), lipolytic activities, and apolipoprotein E polymorphism. Mean carotid intima-media thickness (cIMT) was determined by Doppler ultrasound. The volunteers were classified into early (N = 39) and late (N = 31) triacylglycerol (TAG) responders to the test meal. Late responders showed lower HDL cholesterol concentration at fasting and in the TAG peak, lower insulin and higher FFA concentrations compared to early responders. Multivariate regression analyses showed that mean cIMT was associated with gender (male) and age in early responders and by cholesterol levels at the 6th hour in late responders. oxLDL Ab were explained by lipoprotein lipase and negatively by hepatic lipase and oxLDL Ab (fasting period) by CETP (negative) and FFA (positive). This study is the first to identify a postalimentary insulin resistance state, combined with a reduced CETP response exclusively among late responders, and the identification of the regulators of postalimentary atherogenicity. Further research is required to determine the metabolic mechanisms described in the different postalimentary phenotypes observed in this study, as well as in different pathological states, as currently investigated in our laboratory.

Association of postalimentary lipemia with atherosclerotic manifestations.

We identified different lipemic and metabolic responses after the ingestion of a standardized meal by healthy adults and related them to atherosclerotic markers. Samples from 60 normolipidemic adults were collected before and after a liquid meal (40 g fat/m² body surface) at 0, 2, 4, 6, and 8 h for measurements of lipids, free fatty acids (FFA), insulin, cholesteryl ester transfer protein (CETP), autoantibodies to epitopes of oxidized LDL (oxLDL Ab), lipolytic activities, and apolipoprotein E polymorphism. Mean carotid intima-media thickness (cIMT) was determined by Doppler ultrasound. The volunteers were classified into early (N = 39) and late (N = 31) triacylglycerol (TAG) responders to the test meal. Late responders showed lower HDL cholesterol concentration at fasting and in the TAG peak, lower insulin and higher FFA concentrations compared to early responders. Multivariate regression analyses showed that mean cIMT was associated with gender (male) and age in early responders and by cholesterol levels at the 6th hour in late responders. oxLDL Ab were explained by lipoprotein lipase and negatively by hepatic lipase and oxLDL Ab (fasting period) by CETP (negative) and FFA (positive). This study is the first to identify a postalimentary insulin resistance state, combined with a reduced CETP response exclusively among late responders, and the identification of the regulators of postalimentary atherogenicity. Further research is required to determine the metabolic mechanisms described in the different postalimentary phenotypes observed in this study, as well as in different pathological states, as currently investigated in our laboratory.

Expression of milk fat globule epidermal growth factor-VIII may be an indicator of poor prognosis in malignant melanoma.

BACKGROUND: Milk fat globule epidermal growth factor-VIII (MFG-E8) is a secreted protein that binds phosphatidylserine and promotes apoptotic cell ingestion by phagocytes, mediating the immune tolerance and maintenance of homeostasis. A recent study has shown that MFG-E8 expression in human melanoma is increased with tumour progression; however, the effect of its expression on patient survival has not yet been clarified. OBJECTIVE: To analyse MFG-E8 expression in melanoma, and to determine whether it can serve as a marker for diagnosis, tumour progression and/or prognosis. METHODS: MFG-E8 expression was examined by immunohistochemistry in 60 primary melanomas, 22 metastatic lesions and 30 benign naevi. The following clinicopathological variables were evaluated: age, gender, histological type, tumour site, Breslow thickness, Clark's level, the presence or absence of ulceration and tumour-infiltrating lymphocytes, and survival periods. Statistical analyses were performed to assess associations and melanoma-specific survival. RESULTS: MFG-E8 expression was significantly higher in primary and metastatic melanoma than in naevus. Furthermore, it increased according to tumour progression and metastasis. Patients with MFG-E8 expression in primary tumours had significantly shorter survival periods than those without MFG-E8 expression. Univariate and multivariate analyses revealed that MFG-E8 expression was a statistically significant and independent prognostic factor. CONCLUSION: MFG-E8 expression may serve as a tumour progression marker and can predict an unfavourable prognosis in patients with melanoma.

[Surgical treatment for acute type A aortic dissection].

The purpose of this study was to assess the factors for clinical outcome of the surgical treatment of acute type A aortic dissection. From April 1996 to March 2006, 44 patients underwent emergency operation for acute type A dissection within 2 weeks from the onset. Resection of the intimal tear was performad with open distal anastomosis. The mean age was 63.4 (range 29-83) years, and 28 were female. As for their preoperative condition, 5 patients were in severe hemodynamic instability including cardiac arrest in 2, apnea in 1, and rupture in 4. Distal resection extended to ascending aorta in 24 patients (54.5%), hemiarch in 7 (15.9%), and total arch in 13 (29.5%). 30-day mortality was 4.5% and the incidence of stroke was 13.6%. Several methods were used including axillary artery cannulation and central repair with adventitial inversion technique. Patients with malperfusions caused by acute type A dissection should undergo immediate aortic reconstruction by adequate circulatory assisting methods.

[Atrial fibrillation after isolated coronary bypass surgery].

Postoperative atrial fibrillation (Af) remains a significant source of morbidity after coronary artery bypass grafting (CABG). Prophylactic therapy with beta-adrenergic blockers or amiodarone hydrochloride is reported to reduce the incidence of Af. We studied the incidence of Af retrospectively and considered the risk factors for it. Ninety-three patients who underwent isolated CABG from April 2003 to March 2004 are included in this study. Postoperative Af was observed in 22 (25%) patients. Ten of them were operated on off-pump procedure, and 14 had any type of beta-adrenergic blockers preoperatively. The mean age of the group of postoperative Af is 69.7 +/- 9.2 years old (older than the non-Af group: 65.5 +/- 10 years old, p = 0.087). And the preoperative left atrial size was larger in the Af group than in the non-Af group (43.4 +/- 6.1 versus 40.6 +/- 5.4mm, p = 0.064) Major embolic complication occurred in only 1 (1.1%) patient of non-Af group. We observed postoperative Af in 25% of patients after CABG. Older age and larger left atrial size may relate to the incidence of Af, and appropriate anticoagulant therapy and medication of beta-blockers are important for the patients who have such risk factors.

[Operative decision for acute type A aortic dissection; ascending aorta or arch replacement].

Operative technique of acute type A aortic dissection remains controversial. We adopted the strategy to replace the aortic arch only when the entry of the dissection was found in the aortic arch, or atherosclerotic arch aneurysm existed. The purpose of the current study was to elucidate the feasibility of the ascending aorta and hemiarch replacement and to follow the fate of the patent false lumen distal to the anastomosis after surgery. Nineteen patients operated from 2000 to 2004 were included in this study. Ascending or hemiarch replacement were performed in 15/19 (78.9%) patients. The early mortality rate was 10.5% (2/19). The causes of death included major brain infarction and rupture of the descending aortic aneurysm 25 +/- 23 days after surgery. Thrombosed distal false lumen of the thoracic aorta was observed in 60% (9/15) of patients of De Bakey type I dissection. Thus our strategy for acute type A aortic dissection including entry closure and the ascending or hemiarch replacement is a reasonable option especially for the elderly patients in acute phase. Our results also indicated that the thrombosis of the false lumen distal to the anastomosis can be expected and the enlargement of the distal aorta is minimal.

WFS1 (Wolfram syndrome 1) gene product: predominant subcellular localization to endoplasmic reticulum in cultured cells and neuronal expression in rat brain.

Wolfram (DIDMOAD) syndrome is an autosomal recessive neurodegenerative disorder accompanied by insulin-dependent diabetes mellitus and progressive optic atrophy. Recent positional cloning led to identification of the WFS1 (Wolfram syndrome 1) gene, a member of a novel gene family of unknown function. In this study, we generated a specific antibody against the C-terminus of the WFS1 protein and investigated its subcellular localization in cultured cells. We also studied its distribution in the rat brain. Biochemical studies indicated the WFS1 protein to be an integral, endoglycosidase H-sensitive membrane glycoprotein that localizes primarily in the endoplasmic reticulum (ER). Consistent with this, immunofluorescence cell staining of overexpressed WFS1 showed a characteristic reticular pattern over the cytoplasm and overlapped with the ER marker staining. No co-localization of WFS1 with mitochondria argues against an earlier clinical hypothesis that Wolfram syndrome is a mitochondria-mediated disorder. In the rat brain, at both the protein and mRNA level, WFS1 was found to be present predominantly in selected neurons in the hippocampus CA1, amygdaloid areas, olfactory tubercle and superficial layer of the allocortex. These expression sites, i.e. components of the limbic system or structures closely associated with this system, may be involved in the psychiatric, behavioral and emotional abnormalities characteristic of this syndrome. ER localization of WFS1 suggests that this protein plays an as yet undefined role in membrane trafficking, protein processing and/or regulation of ER calcium homeostasis. These studies represent a first step toward the characterization of WFS1 protein, which presumably functions to maintain certain populations of neuronal and endocrine cells.

Successful reoperation for diffuse supravalvular aortic stenosis.

We reoperated for diffuse supravalvular aortic stenosis using a modified technique of patch plasty described by Brom. A 36-year-old woman admitted to our hospital with a peak systolic pressure gradient of 92 mmHg across the ascending aorta had previously undergone Doty's operation at another hospital. Aortography showed an ascending aorta diffusely stenotic from the sinotubular junction to the aortic arch. We transected the ascending aorta just above the stenotic portion and incised the proximal wall to the sinus of Valsalva. Three patches were sewn to each sinus to expand them and the ascending aorta. The pressure gradient decreased postoperatively to 11 mmHg, and we conclude that this technique sufficiently relieves diffuse supravalvular aortic stenosis.

Mitral valve replacement in a patient with idiopathic thrombocytopenic purpura.

Reports of a cardiac operation in a patient with idiopathic thrombocytopenic purpura are scarce. Here we present a case of successful mitral valve replacement in a patient with idiopathic thrombocytopenic purpura. Preoperative treatment with high-dosage gamma-globulin successfully increased the platelet count from 50,000/microliter to 80,000/microliter. Twenty units of platelet-rich plasma were administered during and after the operation. No other blood products were used. The postoperative convalescence was uneventful. Perioperative management for patients with idiopathic thrombocytopenic purpura undergoing open-heart surgery is discussed.

[Surgical results of postinfarction ventricular septal perforation: operative planning using "endocardial patch repair with infarct exclusion"].

Between 1983 and 1996, twenty-two consecutive patients underwent surgical repair for postinfarction ventricular perforation (VSP). Overall hospital mortality was 31.8% in the reviewed group. 15 patients were operated upon within two weeks of onset of VSP and hospital mortality was 27.3% in this group. The earlier operation might provide more favorable results in the surgery of VSP. When the preoperative coronary angiography revealed multivessel disease, concomitant myocardial revascularization was performed. In recent 2 cases, we employed the new technique introduced by Komeda and David for the reconstruction of the left ventricule using a single pericardial patch. We found this new technique had many advantages over traditional "Daggett's method". Better operative results could be expected with this technique.

Adrenergic neurotransmitters and calcium ionophore-induced situs inversus viscerum in Xenopus laevis embryos.

Xenopus laevis embryos at the blastula-early tail bud stage were exposed to norepinephrine or octopamine dissolved in culture saline until they reached the larval stage. The left-right asymmetry of the heart and gut was then examined. We found that these adrenergic neurotransmitters induced situs inversus in the heart and/or gut in up to 35% of tested neurula embryos. Norepinephrine-induced situs inversus was blocked by the alpha-1 adrenergic antagonist prazosin. Furthermore, A23187, a calcium ionophore, also increased the incidence of situs inversus up to 54% when late-neurula embryos were exposed to the solution. A23187 treatment initiated before neural groove formation was less effective. The incidence of situs inversus induced by these reagents decreased towards the control level (2.2%, 25 untreated embryos out of 1127 embryos in total) in embryos past the stage of neural tube closure. In the present experiments we obtained 22 gut-only situs inversus embryos having an inverted gut and a normal heart. In contrast, such embryos were not observed among the 1127 untreated embryos. An adrenergic signal mediated by an increase in intracellular free calcium may be involved in the asymmetrical visceral morphogenesis of Xenopus embryos.

In vivo assessment of nonlinear myocardial deformation using finite element analysis and three-dimensional echocardiographic reconstruction.

In vitro data have shown that the myocardium exhibits nonlinear passive stress-strain relationship and a non-linear pressure-volume relationship. A finite element (FE) analysis and optimization algorithm was used on three-dimensional reconstructed left ventricular (LV) geometry using echocardiographic images, along with hemodynamic measurements, in seven closed-chest dogs to show a nonlinear stress-strain relationship in vivo. Our analysis included the computation of Poisson's ratio from the measured volumetric strain of the myocardium and a simulated pericardial pressure load ("equivalent pericardial pressure") applied to the epicardial surface of the reconstructed LV. LV geometry was reconstructed in three or four incremental time steps in diastasis and the myocardium was assumed to be homogeneous, isotropic, and linearly elastic during these short intervals in this initial study. Simultaneous LV chamber pressure and equivalent pericardial pressure were incorporated into the algorithm to predict actual LV expansion. Computations were performed iteratively at each interval to compute the optimized elastic modulus. By performing the FE analysis and optimization at each interval (a step-wise linear analysis approach), a linear relationship between the myocardial elastic modulus and LV chamber pressure was derived (r = .87 to .98). Such a linear relationship is equivalent to an exponential myocardial stress-strain relationship in vivo. Detailed measurement of nonhomogeneous regional deformation are becoming possible with the advent of sophisticated imaging techniques. The methodology described in this study, with appropriate modifications in the FE analysis and optimization algorithms, can be applied to assess the complex three-dimensional pressure-deformation characteristics in vivo.

Alterations in coagulation and fibrinolysis after surgery for aortic aneurysm.

We investigated the alterations in the coagulation and fibrinolysis systems after aortic aneurysm surgery under cardiopulmonary bypass (CPB) while using newly developed "molecular markers". Fibrinogen and antithrombin III (AT-III) decreased after surgery but returned to normal values within three days. The thrombin-antithrombin III complex (TAT) and plasmin-alpha-2-plasmin inhibitor complex (PIC) both showed increased values even preoperatively, which indicated that coagulation and fibrinolysis were activated in some patients with an aortic aneurysm. Both markers maintained a high level for at least 14 days after surgery. The fibrin degradation product (FDP) also showed an increased value before and after surgery. These results apparently showed that coagulation/fibrinolysis had already been activated in some patients and maintained such a state for at least 14 days after surgery. The relation of activated system and postoperative organ dysfunction as well as the means to suppress such activation are also discussed.

Preoperative disseminated intravascular coagulation (DIC) associated with aortic aneurysm--does it need to be corrected before surgery?

Disseminated intravascular coagulation (DIC) is one of the complications accompanying aortic aneurysm. We herein report four patients with aortic aneurysm who had DIC preoperatively. In all four cases, DIC was corrected immediately after surgery; however, in two cases, DIC could not be corrected preoperatively. This prompted us to reconsider the importance of correcting DIC before surgery. Of the four cases reported in this paper, DIC existed even at the time of surgery in two cases, in spite of meticulous treatment with heparin and/or protease inhibitor; however, the DIC could be removed postoperatively even in these two cases. Surgeons should not waste time with intensive DIC treatment preoperatively. If the DIC cannot be corrected within more than 2 weeks of meticulous treatment, surgeons should then perform surgery on the patient. In addition, it is also essential to ensure that the DIC is due to the aneurysm itself and that no other disease processes have been overlooked.

[Clinical results of selective cerebral perfusion during reconstruction of the transverse aortic arch].

Selective cerebral perfusion (SPC) has become a reliable method for brain protection during reconstruction of the transverse aortic arch. However, arterial cannulation technique for the branches of the aortic arch varies among groups, and the necessity of perfusion for the left subclavian artery is controversial. To avoid atheroembolism to the brain and malperfusion of the vertebral arterial system, we carefully selected the arterial cannulation technique according to the result of preoperative ultrasonographic and angiographic evaluation of the branches of the aortic arch, and decided the necessity of perfusion for the left subclavian artery according to the dominance of the two vertebral arteries and the result of pressure monitoring of all three branches. In this report, we analyzed our clinical results of selective cerebral perfusion on 22 consecutive patients, which was performed between April 1992 and December 1993. There were 14 atherosclerotic aneurysms and 8 aortic dissections. The flow rate for SCP was controlled by a single blood pump separate from that for systemic perfusion, with the mean value being 13.1 ml/kg/min. Mean of minimum left superficial temporal arterial pressure was 51 mmHg, mean duration of SCP was 134 minutes, and mean of the lowest esophageal temperature was 17.9 degrees C. Blood pH was regulated with alpha-stat strategy. Arterial cannula for SCP was inserted directly into the vessels through a stab wound in most cases. In three of four patients in whom dissection extended to the branches, a balloon catheter was introduced through the lumen of the aortic arch.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of dissecting aortic aneurysm and presence of anti-Jr(a) antibody].

A 66-year-old woman was diagnosed as a DeBakey type II dissecting aortic aneurysm with angiography and CT. Antibody screening revealed circulating anti-Jr(a) antibody. Preoperatively, erythropoietin was administered twice a week. Over 24 days, a total of 1200 ml of her blood was removed and stored for autologous transfusion. The dissecting ascending aorta was replaced with the aid of cardiopulmonary bypass. The post operative course was uneventful. By using erythropoietin, pre-donated autologous blood, cell saver, aprotinin and transfusion of fresh autologous blood, it was possible to perform cardiovascular surgery on this patient who had an abnormal antibody. This patient is the first case of repair or dissecting aortic aneurysm with anti-Jr(a) antibody in Japan.

[Acute dissection of the interatrial septum after re-replacement of the mitral valve--a case report].

A 64-year-old man who had received a Carpentier-Edward mitral valve replacement seven years earlier was seen with dyspnea on exertion. After re-replacement of the mitral valve with SJM prosthesis, the patient developed acute left-sided heart failure on the third postoperative day. Transesophageal echocardiography revealed abnormal lumen posterior to the left atrium with regurgitant flow from the left ventricle. Right and left atriotomy revealed dissection of the interatrial septum and after removal of the prosthesis, communication between the left ventricle and the dissected lumen was recognized. After closing the communicating orifice, SJM prosthesis was again sutured on the mitral annulus with sub-annular pledgets to reinforce the annular attachment. Excessive debridement of the annular tissue was thought to be a causative factor to develop the dissection of the interatrial septum after mitral valve replacement.

[Hyperbaric oxygen therapy in the Hokkaido University Hospital].

We surveyed the hyperbaric oxygen therapy during the past seven years in the Hokkaido University Hospital. The mean number of patients was 27 per year. The average number of the therapy was 328 per year. There were neither complications nor accidents attributable to the hyperbaric oxygen therapy. Three representative diseased states hypoxic brain damage, sudden deafness and occlusion of retinal arteries, showed remarkable recovery by this therapeutic modality. A safety standard has been revised in 1991. We have been operating the hyperbaric oxygen therapy according to the revised standard. The inter-departmental approach in this therapeutic modality is mandatory in order to achieve effective outcome.