First Report of Mermithidae (Enoplea: Mermithida) Parasitizing Adult Stable Flies in Japan.

Mermithidae is a family of nematodes that parasitize a wide range of invertebrates worldwide. Herein, we report nematodes that were unexpectedly found in three of 486 adult stable flies (Stomoxys calcitrans) captured from three farms (F1, F2, and F3) in different regions of Gifu Prefecture, Japan. We aimed to characterize these nematodes both at the morphological and molecular level. Morphological studies revealed that the nematodes were juveniles of Mermithidae. Phylogenetic analysis based on 18S and 28S rDNA indicated that the mermithids from farms F1 and F2 could be categorized into the same cluster as Ovomermis sinensis and Hexamermis sp., whereas the mermithid from farm F3 clustered with Amphimermis sp. Additionally, these mermithids could be categorized within the same clusters as related mermithids detected in Japan that parasitize various arthropod orders. Our findings suggest that these stable flies may have been parasitized by mermithids already present in the region and that genetically distinct species of mermithids occur across Japan. To the best of our knowledge, this is the first report of mermithids parasitizing adult stable flies in Japan.

Splenic sarcoid reaction mimicking metachronous metastasis in patients after distal gastrectomy for gastric cancer: a case report and literature review.

BACKGROUND: The occurrence of sarcoid reactions has been recognized in various cancers. The common location for observing these granulomas is mainly the lymph nodes, but a rare occurrence in the spleen has been reported. Almost all splenic sarcoid reactions associated with gastric cancer have been resected synchronously and diagnosed accidentally, and a rare metachronous occurrence of a sarcoid reaction in the spleen after distal gastrectomy can mimic cancer metastasis. We describe a rare case of a splenic sarcoid reaction recognized in a patient with gastric cancer 6 months after distal gastrectomy. CASE PRESENTATION: An 82-year-old man underwent laparoscopic distal gastrectomy for gastric cancer (T3N0M0, stage IIA). Six months after gastrectomy, CT and 18F-fluorodeoxyglucose (FDG)-PET/CT showed the appearance of a splenic mass. We diagnosed solitary splenic metastasis from gastric cancer and performed laparoscopic-assisted splenectomy. His splenic tumor was diagnosed as a sarcoid reaction by histopathological examination. CONCLUSION: To our knowledge, this is the first report of a splenic sarcoid reaction recognized 6 months after distal gastrectomy for gastric cancer without any chemotherapy. The splenic sarcoid reaction and cancer metastasis to the spleen were undistinguishable from the CT and FDG-PET/CT findings. The present case and literature review showed that cases of splenic sarcoid reactions associated with gastric cancer can also be accompanied by the occurrence of these granulomas in lymph nodes. When the appearance of a solitary mass is observed in the spleen after resection of primary cancer, it is necessary to consider not only cancer metastasis but also sarcoid reactions. Retrospective histopathological confirmation of the existence of sarcoid reactions in lymph nodes from resected specimens might possibly avoid incorrect diagnosis and intervention.

Laparoscopic treatment in a patient with median arcuate ligament syndrome identified at the onset of superior mesenteric artery dissection: a case report.

BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare clinical entity caused mainly by extrinsic compression of the celiac axis by the median arcuate ligament (MAL). Severe celiac artery stenosis can lead to the development of collateral circulation, aneurysms, and, rarely, superior mesenteric artery (SMA) dissection. The treatment of MALS involves the surgical release of the MAL. However, a standard procedure with the use of laparoscopy has not been established, and intraoperative complications can lead to severe vascular injury. CASE PRESENTATION: The patient was a 43-year-old man with MALS identified at the onset of SMA dissection. After treatment for the SMA dissection, he underwent laparoscopic MAL release. Using the technique of laparoscopic gastrectomy within the surgical field, we performed laparoscopic MAL release and ganglionectomy safely with a good view. Immediate symptomatic improvement was acquired, and no recurrence was observed at the 20-month follow-up. CONCLUSION: We reported a rare case of MALS and SMA dissection. A horizontal 3D laparoscopic approach of the celiac axis allows for safe, meticulous, and radical MAL release and ganglionectomy.

[Aspergillus prosthetic aortic valve endocarditis; report of a case].

A 76-year-old woman, who had underwent aortic valve replacement (AVR) 2 months previously, was admitted to our hospital for persistent pyrexia. Her blood culture results were negative. A new heart murmur was noted on day 19 after admission. Esophageal echocardiography indicated the usual prosthetic valve endocarditis (PVE) findings, including a hyperechoic area in the prosthetic valve and deterioration of regurgitation. Medication was unable to prevent heart failure on day 39 after admission. Subsequently, we performed redo AVR and annulus debridement, but she died due to complicated sepsis in the postoperative period. As reports of Aspergillus PVE are scarce, its precise prognosis remains unknown. However, given that the prognoses of infective endocarditis related to Aspergillus species are poor, we believe that Aspergillus PVE can be fatal. Therefore, we suggest that Aspergillus PVE should be diagnosed as soon as possible, and that prompt surgery should be performed to improve the patient prognosis.

[Trans-thoracic esophagectomy with 3-field lymph nodes dissection].

Although open-chest surgery is the mainstay treatment for esophageal cancer, the understanding of the context of the surgery differs in Japan and the rest of the world. Three-field lymph node dissection has been unique to Japan, although some reports on its benefits are emerging elsewhere. In addition to three-field lymph node dissection, various efforts are made during surgical procedures to reduce complications at high-volume Japanese healthcare institutions.

[Early results of surgical repair of ventricular septal rupture].

BACKGROUND AND OBJECTIVE: Ventricular septal rupture (VSR) is a lethal complication of acute myocardial infarction, and its operative results are far from good. SUBJECTS: Six patients who underwent operations for VSR in our department between 2001 and 2008. All these patients received coronary angiography, which showed 1-vessel disease in 4 patients, 2-vessel disease in 1, and 3-vessel disease in 1. The sites of myocardial infarction were the anteroseptal region in 3 patients and the inferoseptal region in 3. RESULTS: Infarct exclusion was conducted in the 3 patients with anteroseptal infarction. Of the 3 patients with inferoseptal infarction, 1 underwent infarct exclusion and 2 Daggett operation. The number of in-hospital deaths was 3 (50%). Residual shunts were observed in 3 out of the 4 patients (75%) who had received infarct exclusion. Two of these 3 patients needed reoperation. The 2 patients with inferoseptal infarction who had undergone Daggett operation presented no residual shunts, and could be easily weaned from the cardiopulmonary bypass. CONCLUSIONS: Because the infarct exclusion method frequently shows residual shunts, its technical modifications are required to improve the operative results. The Daggett method can be considered useful in patients with VSR after inferior myocardial infarction.

Defibrillation efficacy of a subcutaneous array lead: A case report.

We report a case of Brugada syndrome with a high defibrillation threshold (DFT) in whom a subcutaneous array lead was used to lower the DFT in combination with a transvenous right ventricular defibrillation lead. The patient had previously received pacemaker implantation due to sick sinus syndrome. An implantable cardioverter defibrillator (ICD) with a transvenous right ventricular defibrillation lead alone required a high DFT. A subcutaneous array lead improved defibrillation efficacy in combination with a right ventricular lead. These data suggest that a subcutaneous array lead facilitates implantation of an effective ICD lead system in patients requiring a high DFT.

Direct hemoperfusion using polymyxin-B immobilized fiber for septic shock after cardiac surgery.

BACKGROUND: The factors contributing to the efficacy and outcome of direct hemoperfusion using polymyxin-B immobilized fiber (PMX-DHP) after cardiac surgery were investigated. METHODS AND RESULTS: In 23 patients who received PMX-DHP for shock related to infection after cardiac surgery, there were no differences in the pre- and intraoperative clinical data of survivors (n=14) and non-survivors (n=9). Before the PMX-DHP treatment, the clinical assessment values of the survivors and non-survivors, respectively, showed the following significant differences: sepsis-related organ failure assessment score, 9.46+/-2.84 vs 12.89+/-3.37 (P<0.05); number of failed organs, 1.8+/-0.9 vs 3.1+/-1.1 (P<0.05); partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio, 194+/-118 vs 102+/-29 (P<0.05); and total bilirubin, 2.7+/-2.8 vs 8.7+/-6.5 mg/dl (P<0.05). The systolic blood pressure and catecholamine index in the survivors improved significantly 12 h after PMX-DHP treatment, from 83+/-19 mmHg to 118+/-14 mmHg (P<0.01), and from 20.7+/-11.5 to 14.9+/-8.0 (P<0.05). Conversely, in the non-survivors, only the systolic blood pressure improved significantly, from 74+/-17 mmHg to 118+/-33 mmHg (P<0.001). CONCLUSIONS: Prompt initiation of PMX-DHP with drug treatment during the postoperative course of patients with septic shock caused by systemic inflammatory response syndrome related to infection and who are refractory to vasopressor treatment, can improve the disease state before multiple organ failure develops.

Early initiation of polymyxin B-immobilized fiber therapy effective for septic shock after aortic replacement.

A 76-year-old female underwent ascending aorta and partial arch replacement. She developed septic shock on postoperative day 6. She was administered dopamine, 10 microg x kg(-1) x min(-1); dobutamine, 5 microg x kg(-1) x min(-1); and norepinephrine, 0.3 microg x kg(-1) x min(-1). However, the blood pressure was 74/40 mmHg. Direct hemoperfusion using polymyxin B-immobilized fiber (PMX-DHP) was started; 3 h later, the blood pressure increased to 118/54 mmHg. Norepinephrine was stopped, and dopamine and dobutamine doses were decreased to 5 microg x kg(-1) x min(-1) 3 and 12 h after completing PMX-DHP, respectively. In suspected septic shock, early PMX-DHP simultaneously with drug treatment facilitates hemodynamic improvement.

[Mitral valve replacement for hypertrophic obstructive cardiomyopathy with repeated heart failure; report of a case].

A 62-year-old woman with hypertrophic obstructive cardiomyopathy suffered from repeated heart failure. Preoperative echocardiogrphy demonstrated pressure gradient (PG) of 64 mmHg in left ventricular cavity, mitral regurgitation II, and tricuspid regurgitation II with an ejection fraction of 74%. Cardiac catheterizaition revealed cardiac index of 1.50 l/min/m2. She was recommended mitral valve replacement (MVR) because she was hospitalized several times for heart failure. She underwent MVR, tricuspid annuloplasty, and modified maze operation. Postoperative PG fell till 15 mmHg in echocardiogrphy. Postoperative cardiac catheterization revealed cardiac index of 2.00 l/min/m2. MVR contributed to decrease of PG in intraventricular cavity and increase of cardiac output. Postoperative cardiac status was classified as New York Heart Association (NYHA) class I-II.

Chronic stage left ventricular aneurysm and thrombus after myocardial infarction.

A 60-year-old man had acute myocardial infarction 13 years ago. After percutaneous coronary intervention, the follow-up left ventriculography (8 years ago) showed dyskinesia in the anterolateral and apical segments of the wall. Following this, there was no change in the clinical symptom. After 6 years the patient discontinued aspirin without seeking medical advice. In this year, a thrombus was found in the left ventricle, and thrombectomy was performed. Left ventricular aneurysm has always been a risk for thrombogenesis in any stage, and a periodic follow-up including an echocardiogram and anticoagulation therapy is necessary.

Right atrial separation effect for chronic atrial fibrillation with atrial septal defect: report of four cases.

We operated on 56 adults diagnosed with atrial septal defect (ASD) between 1990 and 2004. Of these, eight had complications of atrial fibrillation (AF) in the preoperative period. After 1998, right atrial separation was performed in four cases. Marked improvement was noted in three out of the four cases. The right atrial separation procedure was a simple, easy, and effective method for the treatment of chronic AF associated with ASD.

A sewing needle completely buried in the myocardium removed under extracorporeal circulation.

A 14-year-old boy had a needle accidentally inserted through his chest wall. Chest X-ray showed a needle-shaped metallic density localized in the cardiac silhouette. An echocardiography indicated the needle had passed through the interventricular septum, and its eye and point had reached the right and left ventricle, respectively. Surgical removal of the needle was performed. The needle could not be observed from the heart surface, and was recognized in a dent 5 mm on the right side from the left anterior descending branch (LAD). The needle was easily removed under extracorporeal circulation, and he was discharged ten days after the operation.

Tricuspid pouch can cause systemic embolization in adulthood.

A 63-year-old-man with significant left hemiplegia was admitted to hospital. He had experienced a transient cerebral ischemic attack 10 years ago. Computed tomography revealed hypodensity along the right lateral ventricle, which corresponded to the left paralysis. Echocardiography and left ventricular angiography revealed an aneurysm of the membranous septum (AMS) without a ventricular septal defect (VSD). Therefore, the embolism was thought to be of cardiac origin, but surgery revealed that it was not caused by AMS. The aneurysm was created when the septal leaflet of tricupid valve formed a giant capsule during the process of natural closure of the VSD. It was a large pouch, 2.0 cm in diameter, adjacent to the septal leaflet. Anomalies of the tricuspid valve, including pouches, can resemble AMS.

Expression of intestinal trefoil factor (TFF-3) in hepatocellular carcinoma.

BACKGROUND: Trefoil peptides (TFF-1, 2, 3) are a family of protease-resistant regulatory factors that play a role in mucosal restitution, angiogenesis, apoptosis, and tumor progression. Intestinal trefoil peptide (TFF-3) expression has been demonstrated in benign hepatobiliary diseases, but there are limited data regarding its expression in HCC. METHODS: Thirty consecutive cases of HCC from 1998 to 2003 were studied. Immunohistochemistry was performed on formalin-fixed paraffin-embedded blocks of HCC using polyclonal antibody to TFF-3. TFF-3 expression was classified as strong, moderate, weak, focal, and negative. Clinical data were obtained per an IRB-approved protocol. RESULTS: Median age was 69 yr (range: 39-83 yr). Twenty- three patients were males and 7 were females. Treatments included hepatic resection (n = 16), chemo-embolization (n = 4), combined modality therapy (n = 5) and no treatment (n = 4). HCC was well differentiated in 12 (40%), moderately differentiated in 13 (43%), and poorly differentiated in 5 (17%) patients. TFF-3 expression was detected in 28/30 (93.3%) patient samples. Sixteen patients (53%) had moderate and 1 (3%) patient had strong TFF-3 expression. Tumor/ normal tissue interface was assessable in 21 cases; 11 cases expressed TFF-3 at the interface. There was a strong correlation between tumor grade and TFF-3 expression, wherein poorly differentiated tumors had moderate/strong TFF-3 expression (p = 0.008). There was no correlation between TFF-3 expression and survival (p = 0.77). Furthermore, there was no correlation among age, disease stage, and survival. CONCLUSION: TFF-3 is commonly expressed in HCC and its expression correlates with tumor grade.

Surgical treatment for complications of acute myocardial infarction.

OBJECTIVE: We report the results of surgical repair for postinfarction left ventricular free wall rupture (LVFR) and ventricular septal perforation (VSP) complicating acute myocardial infarction. METHODS: We experienced 14 LVFRs and 10 VSPs from January 1991 to December 2002. The mean age of patients with LVFR was 74+/-8.1 years. There were 6 oozing cardiac ruptures and 8 blowout cardiac ruptures. An intraaortic balloon pump (IABP) was inserted in 8 patients, and percutaneous cardiopulmonary support (PCPS) was inserted in 5 patients. The mean age of patients with VSP was 72+/-5.1 years. The rupture was located within the anterior septum in 8 patients and within the posterior septum in 2 patients. All patients required IABP, and one of them needed PCPS. We employed a sutureless technique in 8 patients, direct closure in 5 patients, and infarct exclusion in 1 patient with LVFR. Infarct exclusion was conducted in 9 patients, and the da Silva technique was used in 1 patient with VSP. RESULTS: The patient survival rate of LVFR was 36% (blowout 13%; oozing 67%). Residual shunt occurred in 4 patients with VSP postoperatively. The overall survival rate for VSP was 70%. CONCLUSION: The operative prognosis of blowout cardiac rupture was poor. Good results were obtained with the infarct exclusion technique for patients with VSP. Although some patients had postoperative residual shunts, the infarct exclusion technique was generally a safe and excellent procedure.

Frequent trefoil factor 3 (TFF3) overexpression and promoter hypomethylation in mouse and human hepatocellular carcinomas.

Expression profiling analysis revealed ectopic high expression of mouse TFF3 in non-tumor liver tissues from the hepatocellular carcinoma (HCC) susceptible PWK/Rbrc strain. TFF3 is a member of the trefoil factor family peptides, which are small secreted proteins regulating mucosal regeneration and repair, and which are overexpressed during inflammatory processes and cancer progression. We, therefore, analyzed the TFF3 expression extensively in mouse and human HCCs. Expression of the mouse TFF3 gene was significantly increased in 6 out of 7 HCCs from a PWK spontaneous tumor model and in all 7 HCCs from an SV40T antigen-induced transgenic MT-D2C57BL/6 model. In humans, 8 of 20 HCCs (40%) had overexpression of TFF3 in both mRNA level and protein level. We then analyzed DNA methylation patterns of the TFF3 promoter region to evaluate expression regulation of promoter methylation. In mouse HCCs, we demonstrated that two CpGs, at positions -992 and +109, were hypomethylated in 13 of 14 mouse HCCs. In human HCCs, hypomethylation at CpG -260 was associated with TFF3 overexpression (p=0.04). These results indicate that TFF3 overexpression may be a critical process in mouse and human hepatocellular carcinogenesis, and the specific promoter CpG hypomethylation may be one of the regulation mechanisms of TFF3 overexpression in HCCs.

Perioperative features of coronary artery bypass grafting in patients aged 75 years or older.

OBJECTIVES: Coronary artery bypass grafting (CABG) is well established as an effective operation to overcome ischemic heart disease; however, the number of aged patients with a high operative risk undergoing this procedure has increased in recent years. This retrospective study evaluates our experience of performing CABG in a consecutive series of patients aged 75 years or older. METHODS: To assess the hospital mortality and morbidity associated with this procedure, we retrospectively analyzed 49 patients aged 75 years or older (Elderly Group) who underwent CABG and compared the results with those of 88 patients aged 65-74 years (Control Group) who underwent CABG during the same period. Patients were examined for cerebrovascular diseases, and those with significant stenosis underwent pulsatile cardiopulmonary bypass. To avoid pulmonary complications, patients were extubated early. RESULTS: The Control Group had a significantly higher incidence of arterial grafts than the Elderly Group (0.8 +/- 0.5 versus 0.3 +/- 0.5; p < 0.0001). The Elderly Group had a significantly higher incidence of postoperative complications than the Control Group, with supraventricular arrhythmia in 57.1% versus 28.4%, (p = 0.0009), delirium in 36.7% versus 11.4%, (p = 0.0004), pneumonia in 6.1% versus 0%, (p = 0.0439), and intubation duration of 88.3 +/- 212.5 hours versus 37.2 +/- 92 hours (p = 0.0296), respectively. However, there was no significant difference in hospital mortality between the two groups, being 8.2% versus, 2.3%, in the Elderly group and Control Group, respectively (p = 0.1867). CONCLUSION: These findings indicated that when elderly patients were appropriately managed, CABG could be performed with an acceptably low risk to mortality.