[Off-pump coronary artery bypass for old myocardial infarction associated with jejunotomy for obstructive ileus due to gall bladder stone; report of a case].

In non-cardiac operative cases with inflammatory digestive organ disease, bacterial translocation (BT) often results from non-enteral nutrition postoperatively. If coronary artery bypass grafting (CABG) is performed in the case having old myocardial infarction (OMI) and inflammatory digestive organ disease at first before non-cardiac operation, he seems vulnerable to have severe complications such as multiple organ failure due to systemic inflammatory response syndrome (SIRS) and preexisting BT postoperatively. We performed a off-pump CABG (OPCAB) for OMI associated with jejunotomy for obstructive ileus due to gall bladder stone. No complication was found in the postoperative course. We conclude that combined operation, non-cardiac surgery after OPCAB is worth considering in those cases. And we think OPCAB is better than conventional CABG in such cases, because cardiopulmonary bypass is known to ponder comparable damages to immune system, coagulation system and others.

Functional anatomy of musical perception in musicians.

The present study used functional magnetic resonance to examine the cerebral activity pattern associated with musical perception in musicians and non-musicians. Musicians showed left dominant secondary auditory areas in the temporal cortex and the left posterior dorsolateral prefrontal cortex during a passive music listening task, whereas non-musicians demonstrated right dominant secondary auditory areas during the same task. A significant difference in the degree of activation between musicians and non-musicians was noted in the bilateral planum temporale and the left posterior dorsolateral prefrontal cortex. The degree of activation of the left planum temporale correlated well with the age at which the person had begun musical training. Furthermore, the degree of activation in the left posterior dorsolateral prefrontal cortex and the left planum temporale correlated significantly with absolute pitch ability. The results indicated distinct neural activity in the auditory association areas and the prefrontal cortex of trained musicians. We suggest that such activity is associated with absolute pitch ability and the use-dependent functional reorganization produced by the early commencement of long-term training.

Vagal stimulation prior to atrial rapid pacing protects the atrium from electrical remodeling in anesthetized dogs.

Atrial electrical remodeling is thought to be the cause of the maintenance of atrial fibrillation (AF). Although the initiation and maintenance of AF is partially associated with autonomic nervous tone, vagally mediated AF does not tend to become permanent. Therefore, the effects of preceding vagal stimulation (VS) on the atrial effective refractory period (ERP) under electrical remodeling conditions were investigated in anesthetized dogs. Atrial ERPs were measured at 5 sites before and after a 7-h period of atrial rapid pacing in the control group. In the VS group, the vagus nerve was stimulated for 20 min before a period of atrial rapid pacing. Atrial rapid pacing shortened the ERP at each site in the control group (electrical remodeling). On the other hand, atrial rapid pacing after VS did not shorten the ERP at any site in the VS group. Tetrodotoxin, which was administered into the fatty tissue overlying the right atrial side of the right pulmonary vein junctions, blocked the protective effect of VS against the shortening of the ERP induced by atrial rapid pacing. In contrast, atropine did not interfere with such protective effects. These results suggest that VS prior to atrial rapid pacing protects the atrium from atrial electrical remodeling.

Target volume definition for upper abdominal irradiation using CT scans obtained during inhale and exhale phases.

PURPOSE: To evaluate the clinical utility of a treatment-planning technique involving the use of CT images obtained during both the static exhalation phase and static inhalation phase (two-phase planning). METHODS AND MATERIALS: Ten patients with pancreatic or liver tumors underwent CT scanning under static exhale and inhale conditions, after a period of mild ventilation. By setting image positions differently, we were able to treat the two-phase images as one dataset. Each gross tumor volume (GTV) was contoured separately and the mixed GTV was used for the two-phase treatment planning. Treatment plans were constructed to compare the two-phase plans with the plans constructed using static exhalation images. The shift of the center of the GTV and kidneys and the minimum dose of GTV were then calculated. RESULTS: The shift of the GTV ranged from 2.6 to 27. 3 mm and that of the kidneys from 2.2 to 24 mm. In some patients whose treatment was planned using exhalation planning, the minimum dose of GTV at inhalation was less than 90% of the isocenter dose. CONCLUSION: Two-phase planning is a simple technique that can visualize tumor and organ movement simultaneously using CT. It further defines adequate field margins around the tumor and prevents unexpected radiation exposure to critical organs. Routine use of this technique for upper abdominal irradiation is recommended.

Normal limits of high-resolution signal-averaged ECG parameters of Japanese adult men and women.

High-resolution signal-averaged electrocardiography (Hi-Res ECG) has been found useful in measuring ventricular late potentials for identifying patients prone to life-threatening ventricular arrhythmias. Several studies have reported cut-off values (normal limits) of Hi-Res ECG parameters, including sex-specific limits, for adult population. However, there are no such studies reporting such limits in the Japanese population. Hi-Res ECGs were recorded from 482 normal healthy patients (204 men; 278 women) with no cardiac disease and normal electrocardiogram. Three Hi-Res ECG parameters filtered QRS duration (FQRSD), low amplitude signal duration under 40 microV of terminal QRS (LASD), and root mean square voltage in the terminal 40 milliseconds (RMSV) were analyzed. FQRSD was longer in men than in women (P < .0001). RMSV was larger in men than in women (P < .0001). There was no significant difference in LASD between men and women. The upper limit (90th percentile) of FQRSD was 116 milliseconds for women. The upper limit of LASD was 42 milliseconds for both men and women. The lower limit (10th percentile) of the RMSV was 14 microV for both men and women. There was no significant difference in the distributions of the Hi-Res ECG parameters between our study and an earlier study on mostly whites from the United States and Europe. The upper limits (90th percentile) of FQRSD and LASD in the Japanese normal patients were nearly the same as for whites. But, the lower limit (10th percentile) of RMSV in our Japanese normals was significantly smaller than that for whites. Therefore, it may be necessary to use race-specific normal limits for late potential analysis. Criteria for abnormal late potentials (defined as abnormal values in at least 2 of the 3 Hi-Res ECG parameters) were met in 18 of 482 (3.7%) normal healthy patients. Further studies are needed to evaluate the role of these criteria in identifying cardiac patients with life-threatening arrhythmias in the Japanese population.

Treatment for pyothorax-associated lymphoma.

In eight patients with pyothorax-associated lymphoma (PAL), which resulted from artificial pneumothorax for the treatment of pulmonary tuberculosis, seven patients received radiotherapy and five showed no local recurrence. All four patients treated by primary chemotherapy had disease progression. Radiotherapy of 50 Gy with wide margins is recommended to treat PAL.

The autonomic control of the transmural dispersion of ventricular repolarization in anesthetized dogs.

INTRODUCTION: The initiation of ventricular arrhythmias is in part associated with autonomic nervous tone. We investigated the effects of sympathetic and parasympathetic stimulation on the monophasic action potentials (MAPs) of the epicardium (EPi), mid-myocardial (M) region, and endocardium (Endo) in vivo. METHODS AND RESULTS: In 12 mongrel open chest anesthetized dogs, both sides of the cervical vagus nerves and stellate ganglia were crushed with a tight ligature. Right atrial pacing at 600 msec cycle length was begun after the sinus nodal area had been crushed. MAPs from the M region were measured by two needle electrodes that were supported by a W-shaped plastic frame. The epicardial, M region, and endocardial MAP durations at 90% repolarization (MAPD90) were 287+/-7, 315+/-7, and 290+/-8 msec, respectively. The MAPD90 from M cells was longer than that from Epi or Endo. Sympathetic stimulation shortened MAPD90 more in the M region (53+/-4 msec) than that in the Epi (27+/-3 msec) or Endo (26+/-4 msec). The transmural dispersion of repolarization during sympathetic stimulation was shorter than that of the control. Parasympathetic stimulation did not significantly affect any of the MAPD90 values. Simultaneous sympathetic and parasympathetic stimulation produced changes not significantly to those produced by sympathetic stimulation alone. CONCLUSION: Our results suggest that sympathetic activity can reduce transmural dispersion of repolarization under autonomic control in the canine heart under baseline conditions.

[Easy graphical display of beam directions in three-dimensional converging radiation therapy: proposal for a radiation map].

In stereotactic radiosurgery, non-coplanar isocentric beams are employed to concentrate the dose distribution on the planning target volume (PTV). However, the directions of incident beams must be determined with great care by using a digitally reconstructed beam's eye view (BEV) to prevent the irradiation of organs at risk. We present a new method of 2-dimensional graphical representation (radiation map) to facilitate the understanding of 3-dimensional relationships between incident beams and critical organs. After determining the isocenter and beam diameter, beam directions and critical organs are projected onto the imaginary sphere centered on the isocenter. The coordinate of the beam directions and the organs at risk can be expressed by latitude and longitude on the sphere. The contours of the organs at risk are displayed with a margin of the the radius of the radiation beam. Mirror images of the critical organs are also displayed to prevent irradiation by the opposing beams. The radiation map could be produced within 5 minutes using a workstation. Radiation maps, like DVH, will be very useful in the evaluation of radiation treatment planning.

Non-Hodgkin's lymphoma presenting with adrenal insufficiency and hypothyroidism: an autopsy case report.

A 55-year-old male presented with an initial manifestation of primary adrenal insufficiency, hypothyroidism. Computed tomography scans showed enlarged bilateral adrenal glands and thyroid. A pathological diagnosis of diffuse large cell, B cell lymphoma was made by a needle biopsy of the adrenal gland. He was treated with combination chemotherapy and adrenal and thyroid hormone replacement. The lymphoma subsequently involved the central nervous system. He died of pneumonia 8 months after the presentation of the first symptom. The postmortem examination demonstrated a complete regression of lymphoma in the bilateral adrenal glands and thyroid. This is an extremely rare case of coexistent lymphoma of the adrenal glands and the thyroid presenting with adrenal failure and hypothyroidism.

High dose rate brachytherapy for carcinoma of the cervix: risk factors for late rectal complications.

PURPOSE: To determine the incidence of late rectal complications in patients treated with high dose rate brachytherapy for FIGO Stage IIB, IIIB carcinoma of the uterine cervix, and to evaluate the treatment factors associated with an increased probability of treatment complications. METHODS AND MATERIALS: Records of 100 patients with FIGO IIB and IIIB cervical carcinoma treated with definitive irradiation using high dose rate intracavitary brachytherapy (HDR-ICR) between 1977 and 1994 were retrospectively reviewed. For each HDR-ICR session, 6-Gy isodose volume was reconstructed retrospectively and the relationship between probability of late rectal complications and several treatment factors, including a specific point dose and parameters representing isodose volume, were examined. Statistical analyses were performed to determine the treatment factors predictive of late rectal complications. RESULTS: Of patients treated for both stages, 33% and 38% had experienced moderate to severe (Grade 2-4) complications at 3 and 5 years, respectively. Mean value of depth (D) of 6-Gy isodose volume in HDR-ICR in patients with and without complication were 51 mm and 46 mm, respectively (p = 0.0070). A significant difference was noted in complication rate between patients with D > 51 mm and D < or = 51 mm (p = 0.0023). Cumulative Point S (2 cm dorsal from the midpoint of the ovoid sources) dose (p = 0.044), and single or total point S dose by HDR-ICR (p = 0.019, each) were significantly higher in patients who developed complication, whereas these factors did not significantly affect the probability of pelvic control. Multivariate analysis revealed that D was the independent predictor for the endpoint of actuarial complication rate (p = 0.047). No significant difference was noted in the product of L, D, and W value (L x D x W) between patients with less than Grade 2 rectal complication and those with Grade 2-4. CONCLUSION: Depth of 6-Gy isodose volume determined three dimensionally (3D) has the predictive value of late rectal complications. This suggests that the shape of the high dose area in HDR-ICR influences the incidence of late rectal complications regardless of its volume.

Squamous cell carcinoma of the maxillary sinus treated with radiation therapy and conservative surgery.

BACKGROUND: For patients with squamous cell carcinoma of the maxillary sinus, combined modality treatment is usually employed, involving radiation and en bloc radical surgery. In this study, local control was analyzed retrospectively in patients who underwent less aggressive piecemeal surgery. METHODS: Of the 37 patients irradiated between 1973 and 1992, 62% were classified as having T4 lesions. Thirty-two patients underwent surgery and radiation therapy; conventional fractionation radiation therapy was used in most cases. Thirty of these patients underwent piecemeal debulking of their tumors and simultaneous radiation therapy. RESULTS: Local recurrence free survival at 5 years was 59%, and orbital exenteration was performed on only 1 patient. T classification, the number of operations, and the presence of macroscopic residual disease each had a statistically significant impact on local recurrence. For the patients with macroscopic residual disease, more than 58 gray administered in conventional fractionation appeared to be necessary to improve local control. CONCLUSIONS: Combined with radiation therapy, conservative surgery with piecemeal debulking was an effective method of treatment for the patients in this study.

Local control of piriform sinus cancer treated by radiation therapy alone.

Local control rate by radical radiation therapy was analyzed in 33 patients with a piriform sinus cancer. Twenty-five patients (76%) were in stage T3 + T4. Local recurrence-free survival at 3 years was 49% in T1 + T2 and 25% in T3 + T4 (p = 0.01). In T1 + T2 lesions, a biologically effective dose for an acute reaction over 80 Gy and total treatment time less than 70 days appeared to improve local control. In T3 + T4 lesions, good radiation response assessed by the regaining of laryngeal mobility affected local control favorably. An esophageal involvement and destruction of the laryngeal cartilage as well as soft tissue extension precluded the possibility of local control by radiation therapy alone. In addition to the T-stage, other tumor factors should also be considered for predicting local control with radiation therapy.

A case of acute myocardial infarction with reentrant sustained ventricular tachycardia developing in the prehospital phase.

A case of development of monomorphic sustained ventricular tachycardia in the prehospital phase of acute myocardial infarction is reported. By performing pacing from the right ventricular outflow tract during ventricular tachycardia, constant fusion and progressive fusion were documented without constant and progressive fusion from the right ventricular apex pacing, and it was terminated by pacing from the right ventricular outflow tract. Thus, reentry was considered to be the mechanism of this ventricular tachycardia occurring in the prehospital phase. Direct angioplasty successfully recanalized the totally occluded coronary artery, but late potential was present probably because of late reperfusion. In an electrophysiologic study in the chronic phase, slow conduction areas were found at the interventricular septum and the exit of this ventricular tachycardia was at the mid-septum of the right ventricle. A review of the literature failed to reveal any report of a similar case.

Primary carcinoma of the gallbladder: role of external beam radiation therapy in patients with locally advanced tumor.

BACKGROUND/AIM: Several reports have demonstrated that occasional long-term survival might be obtained with external beam radiation therapy in patients with gallbladder cancer. However, there are few reports which evaluate the local effect of irradiation. The aim of our study was to investigate the local effect of radiation therapy. and to evaluate its role for locally advanced gallbladder cancer. PATIENTS AND METHODS: Twenty-two patients with locally advanced gallbladder cancer were treated with high-dose external beam radiation therapy. Tumor resection was performed in 5 patients, palliative surgery in 5, and the remaining 12 patients were treated by radiation therapy alone. RESULTS: Overall survival was 36% at 1 year, 18% at 3 years and 14% at 5 years. All but 2 patients developed local recurrence and died of disease at 1 to 99 months after radiation therapy. Among 17 patients who had not undergone tumor resection, partial response was obtained in 4 patients and no response in 13. Survival times in patients who achieved partial response were 14, 26, 47 and 99 months, whereas those of no response were 1 to 12 months with a mean of 4.8 months. Survival between these 2 groups (partial vs. no response) showed significant difference (p = 0.0008, logrank test). CONCLUSION: It is concluded that high-dose external beam radiation therapy could improve survival in some patients with unresectable gallbladder cancer.

[Whole mediastinal irradiation with or without entire hemithoracic irradiation for invasive thymoma].

We retrospectively reviewed the case histories of 45 patients with invasive thymoma who underwent postoperative or definitive radiotherapy. Patients in stage II or stage III were classified according to the treatment volume as follows: a) those who received irradiation confined to the primary tumor site with a generous margin (involved field group, n = 17) and b)those who received prophylactic whole mediastinal irradiation with or without entire hemithoracic irradiation (prophylactic group, n = 21). Seven recurrences were observed among the involved field group, while all patients in the prophylactic group were relapse-free and alive after a median follow-up interval of 50 months. Major side effects were observed in two patients who received entire hemithoracic irradiation. One developed severe pneumonitis resulting in lung fibrosis that required hospitalization, while the other developed nephrotic syndrome of unknown cause. We conclude that whole mediastinal irradiation with or without entire hemithoracic irradiation can be used as a treatment of choice for postoperative invasive thymoma.

A case of septal Wolff-Parkinson-White syndrome associated with newly developed delta waves due to disappearance of impedance mismatch.

A 65-year-old woman who had shown no delta waves or atrioventricular block when seen in February 1989, suddenly developed advanced atrioventricular block in April 1990. The first electrophysiologic study revealed that atrioventricular block was caused by His ventricular block, and only weak retrograde conduction was documented. A DDD-type permanent pacemaker was implanted. One month after implantation, delta waves developed. The second electrophysiologic study, performed in February 1993, disclosed that a Kent bundle with bidirectional conduction capacity was located at the posterior septum and that the normal conduction system remained blocked at the His ventricular site. The etiology of the newly developed delta waves seems to be the disappearance of impedance mismatch at the ventricular insertion site of the Kent bundle.