Ethanol Infusion in the Vein of Marshall in a Patient with Persistent Atrial Fibrillation

We report the case of a 64-year-old male with persistent atrial fibrillation (AF) terminated by ethanol infusion into vein of Marshall as add-on therapy. Three-dimensional automated complex fractionated atrial electrogram (CFAE) during AF revealed clustering of CFAE at perimitral isthmus (PMI) and its unipolar mapping showed rotor-like activation, which was suggested to be critical in the perpetuation of AF. AF was organized to atrial tachycardia (AT) by 100% ethanol infusion in the vein of Marshall. Adjunctive radiofrequency ablation at PMI successfully terminated AT and led to bidirectional block of PMI.

Feasibility and accuracy of a new mobile electrocardiography device, ER-2000(®), in the diagnosis of arrhythmia

BACKGROUND

We performed this study to evaluate the feasibility and accuracy of a new mobile electrocardiography (ECG) device, ER-2000(®), in detecting cardiac arrhythmia, by comparing it to a 12-lead ECG used as the gold standard.

METHODS

Mode 1 of ER-2000(®) was recorded using three electrodes with cables attached to the anterior chest wall, and mode 2 was recorded using the side chest channel and finger channel. Standard 12-lead ECG was used to record with a speed of 25 mm/s, simultaneously.

RESULTS

Seventeen patients with complaints of palpitation were enrolled. Twelve-lead ECG revealed normal sinus rhythm in three patients, sinus tachycardia in one, atrial fibrillation (AF) in two, atrial tachycardia (AT) in one, first degree atrioventricular block in one, pacing rhythm in two patients who underwent permanent pacemaker implantation, AF with intermittent ventricular pacing in one, complete right bundle branch block in one, J-wave elevation in one, narrow QRS tachycardia in one, atrial premature beat (APB) in one, ventricular premature beat (VPB) in one, and narrow QRS tachycardia with intermittent aberrant conduction in one. Rhythm diagnosis obtained by the two different modes of ER-2000(®) was correlated with that obtained by the 12-lead ECG in all patients except in one in whom ER-2000(®) showed one APB while 12-lead ECG showed sinus rhythm. R-R interval was accurately recorded despite the detailed morphology of QRS, and T-wave was somewhat modified with the use of ER-2000(®). A pacing blip detected by 12-lead ECG was not detected by ER-2000(®) despite a similar wide QRS duration in the paced QRS.

CONCLUSIONS

A rhythm strip obtained using ER-2000(®) is accurate in diagnosing arrhythmia, despite some differences in the detailed morphology of the QRS and T-wave, and the pacing spike compared to those obtained by the 12-lead ECG.

Unusual polymorphic ventricular tachycardia originating from the pulmonary artery

We report a case about a 27-year-old healthy young male who developed syncope during exercise, which was subsequently identified to be attributable to non-sustained polymorphic ventricular tachycardia (VT). Occurrence of polymorphic VT was neither related to a prolonged QT interval nor a fixed short coupling interval. Standard examinations including echocardiography, coronary angiography, isoproterenol infusion study, and cardiac MRI showed no structural heart disease. On the electrophysiology study, activation mapping revealed that a discrete potential preceded the premature ventricular complex (PVC) triggered polymorphic VT, which was recorded just above the pulmonary valve. After radiofrequency ablation at this area, PVC and polymorphic VT disappeared and did not recur after a 2 month follow up.

Spinal cord injury after conducting transcatheter arterial chemoembolization for costal metastasis of hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) has been used widely to treat patients with unresectable hepatocellular carcinoma. However, this method can induce various adverse events caused by necrosis of the tumor itself or damage to nontumor tissues. In particular, neurologic side effects such as cerebral infarction and paraplegia, although rare, may cause severe sequelae and permanent disability. Detailed information regarding the treatment process and prognosis associated with this procedure is not yet available. We experienced a case of paraplegia that occurred after conducting TACE through the intercostal artery to treat hepatocellular carcinoma that had metastasized to the rib. In this case, TACE was attempted to relieve severe bone pain, which had persisted even after palliative radiotherapy. A sudden impairment of sensory and motor functions after TACE developed in the trunk below the level of the sternum and in both lower extremities. The patient subsequently received steroid pulse therapy along with supportive care and continuous rehabilitation. At the time of discharge the patient had recovered sufficiently to enable him to walk by himself, although some paresthesia and spasticity remained.

Successful retrieval of a fractured and entrapped 0.035-inch terumo wire in the femoral artery using biopsy forceps

A 0.035-inch guide wire fracture and entrapment in a peripheral artery is a very rare complication, but when it does occur it may lead to life-threatening complications, such as perforation, thrombus formation, embolization, and subsequent limb ischemia. We describe our experience of successfully retrieving a fractured 0.035-inch Terumo guide wire in the external iliac artery using a biopsy forcep.

Tool Contact Acceleration Feedback for Telerobotic Surgery

Minimally invasive telerobotic surgical systems enable surgeons to perform complicated procedures without large incisions. Unfortunately, these systems typically do not provide the surgeon with sensory feedback aside from stereoscopic vision. We have, thus, developed VerroTouch, a sensing and actuating device that can be added to Intuitive Surgical's existing da Vinci S Surgical System to provide auditory and vibrotactile feedback of tool contact accelerations. These cues let the surgeon feel and hear contact with rough textures as well as the making and breaking of contact with objects and other tools. To evaluate the merits of this approach, we had 11 surgeons use an augmented da Vinci S to perform three in vitro manipulation tasks under four different feedback conditions: with no acceleration feedback, with audio feedback, with haptic feedback, and with both audio and haptic. Subjects expressed a significant preference for the inclusion of tool contact acceleration feedback, although they disagreed over which sensory modality was best. Other survey responses and qualitative written comments indicate that the feedback may have improved the subject's concentration and situational awareness by strengthening the connection between the surgeon and the surgical instruments. Analysis of quantitative task metrics shows that the feedback neither improves nor impedes the performance of the chosen tasks.

Cause of Chest Pain in a Patient with Previous Myocardial Infarction: Look Outside the Heart for Extracardiac Mass

We report a case of thymic carcinoma that was initially detected by echocardiography in an 80-year-old male who visited the emergency room for chest pain and had a history of myocardial infarction and percutaneous coronary intervention. Transthoracic echocardiography showed a huge extracardiac mass that was located in the anterior mediastinum and was diagnosed as a thymic carcinoma by biopsy.

The current state of robot assisted radical prostatectomy

AIM

The introduction of robotics in the operating room made its first major impact in the arena of prostate cancer. Robot assisted radical prostatectomy (RARP) is the most commonly performed surgery for prostate cancer in the United States.

METHODS

In this review article, we discuss the history of robotic prostatectomy as well as the benefits and drawbacks of the robotic surgical platform. Our University of Pennsylvania technique is described. Patient selection, peri-operative factors, oncological data, and functional outcomes specific to RARP are addressed.

RESULTS

While cost remains a valid criticism to the robotic technique, some of the additional expenditure is offset by improved convalescence, fewer medical complications, and decreased morbidity. Data with follow up approaching 10 years demonstrates equal if not superior outcomes with respect to continence, sexual and oncological factors.

CONCLUSION

The diligent efforts of many have led to the rapid evolution of robot assisted radical prostatectomy. There is a renewed interest in the anatomy, oncological outcomes, and functional consequences of prostatectomy. With technological advances occurring at an accelerating rate, the advances in surgery should be very exciting indeed.

Sublingual grass pollen immunotherapy is associated with increases in sublingual Foxp3-expressing cells and elevated allergen-specific immunoglobulin G4, immunoglobulin A and serum inhibitory activity for immunoglobulin E-facilitated allergen binding to B cells

BACKGROUND

The mechanisms of sublingual immunotherapy (SLIT) are less well understood than those of subcutaneous immunotherapy (SCIT).

OBJECTIVES

To determine the effects of grass-pollen SLIT on oral mucosal immune cells, local regulatory cytokines, serum allergen-specific antibody subclasses and B cell IgE-facilitated allergen binding (IgE-FAB).

METHODS

Biopsies from the sublingual mucosa of up to 14 SLIT-treated atopics, nine placebo-treated atopics and eight normal controls were examined for myeloid dendritic cells (mDCs) (CD1c), plasmacytoid dendritic cells (CD303), mast cells (AA1), T cells (CD3) and Foxp3 using immunofluorescence microscopy. IL-10 and TGF-beta mRNA expression were identified by in situ hybridization. Allergen-specific IgG and IgA subclasses and serum inhibitory activity for binding of allergen-IgE complexes to B cells (IgE-FAB) were measured before, during and on the completion of SLIT.

RESULTS

Foxp3(+) cells were increased in the oral epithelium of SLIT- vs. placebo-treated atopics (P=0.04). Greater numbers of subepithelial mDCs were present in placebo-treated, but not in SLIT-treated, atopics compared with normal controls (P=0.05). There were fewer subepithelial mast cells and greater epithelial T cells in SLIT- compared with placebo-treated atopics (P=0.1 for both). IgG(1) and IgG(4) were increased following SLIT (P<0.001). Peak seasonal IgA(1) and IgA(2) were increased during SLIT (P<0.05). There was a time-dependent increase in serum inhibitory activity for IgE-FAB in SLIT-treated atopics.

CONCLUSIONS

SLIT with grass pollen extract is associated with increased Foxp3(+) cells in the sublingual epithelium and systemic humoral changes as observed previously for SCIT.

Phenylephrine hypertrophy, Ca2+-ATPase (SERCA2), and Ca2+ signaling in neonatal rat cardiac myocytes

We endeavored to use a basic and well-controlled experimental system to characterize the extent and time sequence of sarco(endo)plasmic reticulum Ca(2+)-ATPase (SERCA) involvement in the development of cardiac hypertrophy, including transcription, protein expression, Ca(2+) transport, and cytoplasmic Ca(2+) signaling. To this end, hypertrophy of neonatal rat cardiac myocytes in culture was obtained after adrenergic activation with phenylephrine (PE). Micrographic assessment of myocyte size, rise of [(14)C]phenylalanine incorporation and total protein expression, and increased transcription of atrial natriuretic factor demonstrated unambiguously the occurrence of hypertrophy. An early and prominent feature of hypertrophy was a reduction of the SERCA2 transcript, as determined by RT-PCR with reference to a stable marker such as glyceraldehyde-3-phosphate dehydrogenase. Reduction of Ca(2+)-ATPase protein levels and Ca(2+) transport activity to approximately 50% of control values followed with some delay, evidently as a consequence of a primary effect on transcription. Cytosolic Ca(2+) signaling kinetics, measured with a Ca(2+)-sensitive dye after electrical stimuli, were significantly altered in hypertrophic myocytes. However, the effect of PE hypertrophy on cytosolic Ca(2+) signaling kinetics was less prominent than observed in myocytes subjected to drastic SERCA2 downregulation with small interfering RNA or inhibition with thapsigargin (10 nM). We conclude that SERCA2 undergoes significant downregulation after hypertrophic stimuli, possibly due to lack of SERCA gene involvement by the hypertrophy transcriptional program. The consequence of SERCA2 downregulation on Ca(2+) signaling is partially compensated by alternate Ca(2+) transport mechanisms. These alterations may contribute to a gradual onset of functional failure in long-term hypertrophy.

Ecological modeling for water quality management of Kwangyang Bay, Korea

This study estimated the appropriate pollutant load reduction from point sources in Kwangyang Bay, Korea, using an eco-hydrodynamic model. The total chemical oxygen demand (COD), nitrogen (TN), and phosphorus (TP) loads from rivers and ditches that provide input to the bay were approximately 2.8x10(4), 2.5x10(4), and 5.9x10(2) kg day-1, respectively. Wastewater discharge from industrial complexes was the greatest contributor to pollutant loads in the inner part of the bay. COD values in the inner part of the bay were greater than 3.0 mg l-1, and exceeded Korean seawater quality grade III limits. A residual current was simulated, using a hydrodynamic model, to have a slightly complicated pattern in the inner part of the bay, ranging from 0.001 to 8 cm s-1. In the outer part of the bay, the simulated current flowed out to the South Sea with a southward flow at a maximum of 15 cm s-1. The results of the ecological model simulation of COD levels showed high concentrations, exceeding 4 mg l-1, in the southwest of the Myodo, an area of wastewater discharge, and lower levels, approaching less than 1 mg l-1, closer to the outer part of the bay. Engineering countermeasures to reduce the organic and inorganic material loads from point sources by more than 45% were required to keep the COD levels below 2 mg l-1.

Laparoscopic radical prostatectomy: review and assessment of an emerging technique

BACKGROUND

Several recent reports have affirmed the feasibility of the laparoscopic approach for radical prostatectomy. In this review, we discuss the morbidities associated with this technique and compare outcomes and convalescence with standard open radical prostatectomy.

METHODS

We reviewed all currently published data on laparoscopic radical prostatectomy and our series of 45 robotic-assisted radical prostatectomies and compared them to several landmark series of open retropubic and perineal radical prostatectomies.

RESULTS

Although the initial series reported long operating times, these times have been significantly reduced in more recent series. Data on blood loss, convalescence, impotence, and incontinence rates have also been promising.

CONCLUSIONS

Although follow-up has been short thus far, laparoscopic radical prostatectomy has been shown to be similar to open radical prostatectomy in several areas.

Hematopoietic effect of ginsenoside Rg3 in ICR mouse primary cultures and its application to a biological response modifier

Ginsenoside Rg3, which is obtained as a by-product during the steaming of red ginseng, at 300 microg/ml enhanced the proliferation of the total spleen and bone marrow (BM) cells in both the cyclophosphamide (CYC)-treated and non-CYC-treated groups.

Nitrification of high strength ammonia wastewater and nitrite accumulation characteristics

Biological nitrogen removal via the nitrite pathway in wastewater treatment is very important in saving the cost of aeration and as an electron donor for denitrification. Wastewater nitrification and nitrite accumulation were carried out in a biofilm airlift reactor with autotrophic nitrifying biofilm. The biofilm reactor showed almost complete nitrification and most of the oxidized ammonium was present as nitrite at the ammonium load of 1.5 to 3.5 kg N/m3 x d. Nitrite accumulation was stably achieved by the selective inhibition of nitrite oxidizers with free ammonia and dissolved oxygen limitation. Stable 100% conversion to nitrite could also be achieved even under the absence of free ammonia inhibition on nitrite oxidizers. Batch ammonium oxidation and nitrite oxidation with nitrite accumulating nitrifying biofilm showed that nitrite oxidation was completely inhibited when free ammonia is higher than 0.2 mg N/L. However, nitrite oxidation activity was recovered as soon as the free ammonia concentration was below the threshold level when dissolved oxygen concentration was not the limiting factor. Fluorescence in situ hybridization analysis of cryosectioned nitrite accumulating nitrifying biofilm showed that the beta-subclass of Proteobacteria, where ammonia oxidizers belong, was distributed outside the biofilm whereas the alpha-subclass of Proteobacteria, where nitrite oxidizers belong, was found mainly in the inner part of the biofilm. It is likely that dissolved oxygen deficiency or limitation in the inner part of the nitrifying biofilm, where nitrite oxidizers exist, is responsible for the complete shut down of the nitrite oxidizers activity under the absence of free ammonia inhibition.

Intraoperative mild hypothermia does not increase the plasma concentration of stress hormones during neurosurgery

PURPOSE

To determine how mild hypothermia (34 degrees C) affects the hemodynamic and the stress hormonal responses intraoperatively and during extubation in patients undergoing cerebral aneurysm surgery.

METHODS

After induction, anesthesia was maintained with 1.2% isoflurane and 50% nitrous oxide. For the normothermia and the hypothermia groups, the body temperature was maintained at 36.9 +/- 0.3 degrees C and 34.2 +/- 0.2 degrees C respectively up to the recovery room. Hemodynamic changes were recorded continuously. Stress hormones comprising epinephrine, norepinephrine, ADH, ACTH, and cortisol were measured at the awake control, intraoperative, and extubation periods.

RESULTS

Vital signs of the intraoperative and postextubation time periods were not significantly different between the normothermia and hypothermia groups except for a statistically lower pulse rate intraoperatively in the hypothermia group (P <0.05). In the control awake state, all five hormonal concentrations were similar between the two groups. Intraoperatively, all of the hormonal levels tended to be lower in the hypothermia group compared to the normothermia group, but only the epinephrine level decreased sufficiently to reach statistical significance (P <0.05). During extubation, all stress hormone concentrations, except norepinephrine, were lower in the hypothermia group (epinephrine: P <0.05; ADH: P <0.05; ACTH: P <0.05; cortisol: P <0.05).

CONCLUSIONS

Our data suggest that intraoperative mild hypothermia neither significantly affects the blood pressure response nor increases the concentrations of stress hormones intraoperatively. Furthermore, mild hypothermia significantly decreased the plasma concentrations of stress hormones during the extubation period.

Long-term effects of ureteroscopic laser lithotripsy on glomerular filtration rate in the face of mild to moderate renal insufficiency

BACKGROUND AND PURPOSE

Ureteroscopic laser treatment of calculi in the upper urinary tract was examined in regard to its effect on renal function in the setting of mild renal insufficiency. Percutaneous nephrolithotomy (PCNL) and SWL have been previously shown not to adversely affect the glomerular filtration rate (GFR) in renal insufficiency, but to our knowledge, the effect of ureteroscopic laser lithotripsy on GFR has not been previously reported.

PATIENTS AND METHODS

A retrospective review of all cases of ureteroscopic laser lithotripsy at our institution was performed. A total of 18 patients with a baseline serum creatinine of > or = 1.5 mg/dL were found. The mean follow-up after treatment was 18.0 months (range 4-39 months). The change in the reciprocal of serum creatinine was used as an indicator of change in the GFR. Deterioration of 20% was considered significant.

RESULTS

The overall mean change in treated patients was a 5.9% improvement. Patients with a preoperative creatinine of < 2.0 mg/dL improved 7.6% and those with creatinine of > or = 2.0 mg/dL increased 3.9%. Other factors such as the size of the stone, location of the stone, and total joules used during treatment were not significant.

CONCLUSION

This examination suggests that ureteroscopic laser lithotripsy has no ill effects on renal function in the face of mild to moderate renal insufficiency.

Flail aortic valve and acute aortic regurgitation due to spontaneous localized intimal tear of ascending aorta

This report describes the transesophageal echocardiographic findings of acute severe aortic regurgitation resulting from localized transverse intimal tear of ascending thoracic aorta which could not be suspected as a cause of flail aortic valve preoperatively. In patients with chest pain and acute aortic regurgitation associated with flail aortic valve, localized intimal tear of aorta should be considered as a possible cause of flail aortic valve.

Experience with endoluminal ultrasonography in the urinary tract

Ultrasonography has been an invaluable tool in the field of urology for its noninvasiveness, safety, and relatively low cost. However, examination of the ureter with ultrasound is difficult because of the distance of the transducer from the ureter and because of intervening structures such as nonconductive bowel gas. As smaller probes have become available, attempts have been made to apply them to endoluminal use. Endoluminal ultrasonography has been employed in urology to examine the proper placement of injected collagen, diagnose urethral diverticula, diagnose and stage upper tract transitional-cell carcinoma, locate crossing vessels to guide endopyelotomy, diagnose submucosal calculi, and examine the severity and length of ureteral strictures.

Muc1 mucins on the cell surface are adhesion sites for Pseudomonas aeruginosa

Recently, we cloned and characterized a full-length cDNA of the hamster Muc1 gene, the expression of which appears to be associated with secretory cell differentiation (Park HR, Hyun SW, and Kim KC. Am J Respir Cell Mol Biol 15: 237-244, 1996). The role of Muc1 mucins in the airway, however, is unknown. In this study, we investigated whether cell surface mucins are adhesion sites for Pseudomonas aeruginosa. Chinese hamster ovary (CHO) cells not normally expressing Muc1 mucin were stably transfected with the hamster Muc1 cDNA, and binding to P. aeruginosa was examined. Our results showed that 1) stably transfected CHO cells expressed both Muc1 mRNA and Muc1 mucins based on Northern and Western blot analyses, 2) Muc1 mucins present on the cell surface were degraded by neutrophil elastase, and 3) expression of Muc1 mucins on the cell surface resulted in a significant increase in adhesion of P. aeruginosa that was completely abolished by either proteolytic cleavage with neutrophil elastase or deletion of the extracellular domain by mutation. We conclude that Muc1 mucins expressed on the surface of CHO cells serve as adhesion sites for P. aeruginosa, suggesting a possible role for these glycoproteins in the early stage of airway infection and providing a model system for studying epithelial cell responses to bacterial adhesion that leads to airway inflammation in general and cystic fibrosis in particular.

The effects of morphine on blood-brain barrier disruption caused by intracarotid injection of hyperosmolar mannitol in rats

This study was performed to evaluate whether morphine could alter the degree of disruption of the blood-brain barrier (BBB) caused by hyperosmolar mannitol. Under isoflurane anesthesia, rats in a control group were infused with 25% mannitol into the internal carotid artery before measuring the transfer coefficient (Ki) of (14)C-alpha-aminoisobutyric acid. Infusion of morphine 3 mg/kg in the small-dose morphine group and 10 mg/kg in the large-dose morphine group was completed, 10 min before administering mannitol. There were no statistical differences in systemic blood pressures between these three groups of animals. In the control group, the Ki of the ipsilateral cortex where mannitol was injected, increased to 4.6 times that of the contralateral cortex (19.5 +/- 8.5 vs 4.2 +/- 1.2 microL. g(-1). min(-1), P < 0.002). The Ki of the ipsilateral cortex of the small-dose morphine group was 13.5 +/- 7.6 microL. g(-1). min(-1). The Ki of the ipsilateral cortex of the large-dose morphine group was 9.2 +/- 4.5 microL. g(-1). min(-1) and was smaller than that of control animals (P < 0.05). There was no significant difference in the Ki of the contralateral cortex among the three groups. In conclusion, morphine attenuated BBB disruption induced by hyperosmolar solution without significant effects on systemic blood pressure.

IMPLICATIONS

Our study suggests that morphine may be effective in reducing the blood-brain barrier disruption by hyperosmolar mannitol without significant effects on systemic blood pressure.

Identification and characterization of high molecular-mass mucin-like glycoproteins in the plasma membrane of airway epithelial cells

A previous lectin binding study demonstrated the presence of high molecular-mass mucin-like glycoproteins (HMGP) on the surface of hamster tracheal surface epithelial (HTSE) secretory cells (Proc. Natl. Acad. Sci. USA 1987;84:9304). In the present study, we intended to isolate and characterize these HMGP from the plasma membrane of the primary HTSE cells and then to determine whether or not these membrane HMGP are Muc-1 mucins, a type of mucins originally discovered on the surface of some carcinomas. A subcellular fraction enriched with the plasma membrane was obtained using a sucrose density gradient centrifugation. This fraction contained high molecular-mass glycoconjugates which were excluded from Sepharose CL-4B gel. Biochemical characterization of these glycoconjugates revealed the following characteristics: (1) susceptibility to both pronase and mild alkaline treatments, but totally resistant to proteoglycan-digesting enzymes; (2) partitioning in the detergent phase of Triton X-114 and resistance to digestion by phosphatidylinositol phospholipase C or D; (3) a buoyant density of 1.5 g/ml based on CsCl density gradient centrifugation; (4) polydispersity in terms of both size and charge density; and (5) lack of immunoreactivity with an anti-Muc-1 mucin antibody. We conclude that the plasma membrane of HTSE cells at confluence contains HMGP, which seem to be the integral membrane proteins but different from Muc-1 mucins, and that these membrane HMGP appear to share some similarities with secreted mucins in terms of size and charge.

Transesophageal echocardiographic identification of left upper pulmonary venous obstruction caused by compression by spontaneous pseudoaneurysm of the descending thoracic aorta

Pseudoaneurysm of the aorta usually occurs as a complication of nonpenetrating trauma or deceleration injuries. Spontaneous pseudoaneurysm of the aorta is, however, extremely rare. Pulmonary veins can be affected in this situation because of the anatomic proximity. However, it is often overlooked during clinical examination, during routine echocardiography, and even at invasive angiography. This report describes the importance of transesophageal echocardiography in the detection of pulmonary vein compression, which is not suspected during other noninvasive and invasive diagnostic tests, in a patient with spontaneous pseudoaneurysm of the descending thoracic aorta.