Combined coronary artery bypass, mitral valve plasty, and abdominal aneurysmectomy in an 80-year-old patient: report of a case

An 80-year-old man suffering from angina on exertion due to stenosis of the left main coronary artery, heart failure due to mitral valve regurgitation, and an abdominal aortic aneurysm (AAA) was successfully operated on with simultaneous surgical procedures. A coronary cineangiography revealed 90% stenosis of the left main coronary artery in segment 5, and 99% and 90% stenosis in segments 2 and 4AV, respectively, of the right coronary artery. Left ventriculography and aortography showed moderate mitral valve regurgitation and the presence of a fusiform-shaped AAA with a maximum diameter of 6 cm. It was thought that insertion of an intraaortic balloon pump (IABP) would prove difficult due to AAA; therefore, simultaneous surgery combining triple coronary artery bypass grafting (CABG), mitral valve plasty, and prosthetic replacement of the AAA was undertaken. The patient's postoperative course was uneventful, and subsequent angiography showed good patency of all coronary bypass grafts and the abdominal prosthesis, along with the disappearance of mitral regurgitation. This patient's clinical course suggests that an extended surgical procedure is effective for the treatment of complicated cardiovascular disease, even in very elderly patients.

Development of an assay for bioactive insulin

A method to detect the biological activity of serum insulin has been developed. This method, called a bioactive insulin assay, determines the ability of serum insulin to stimulate the autophosphorylation of insulin receptors in an intact cell system. For this, intact Chinese hamster ovary cells which overexpress the human insulin receptor are treated with serum and then lysed. Autophosphorylation of the insulin receptors is then measured by a two-site immunofluorometric assay using monoclonal anti-insulin receptor antibodies and europium-labeled anti-phosphotyrosine antibodies. The detection limit of this assay is 1 microU/ml of insulin. Dilution and recovery test inter- and intraassay coefficient variations are permissible. The amount of insulin determined by this assay correlated well with the amount of insulin detected by a traditional immunological assay for insulin (r = 0.94, P < 0.001). In the case of a mutant insulin, the insulin from a Wakayama subject, the biologically active insulin was found to constitute 9% of the immunologically reactive insulin. Since this assay specifically measures the amount of biologically active insulin present in serum, it should be particularly useful in monitoring active insulin in patients with various mutant insulins.

Detection of the PGP9.5 and tyrosine hydroxylase mRNAs for minimal residual neuroblastoma cells in bone marrow and peripheral blood

The "touchdown" polymerase chain reaction (PCR) technique has been applied to analyze expression of the neuron-specific protein, PGP9.5, and tyrosine hydroxylase (TH) genes for detection of minimal residual neuroblastoma cells in bone marrow and peripheral blood. PGP9.5 and TH gene products were not detected in any normal samples (n = 72) examined. However, in patients more than 1 year of age with stage III and IV neuroblastoma PGP9.5 mRNA was detected in six of seven bone marrow samples and in four of eight peripheral blood samples, and TH mRNA in four of seven and three of eight, respectively. The detection sensitivity was up to 10(-6) to 10(-7) micrograms of total cellular RNA for PGP9.5 and 10(-4) micrograms for TH. Among forty bone marrow specimens from nineteen patients with neuroblastoma both PGP9.5 and TH mRNAs were detected in six, and only PGP9.5 mRNA was detected in ten. Since detection of PGP9.5 and TH gene transcripts by the "touchdown" PCR was highly specific and sensitive, it might be most informative at present to carry out both PGP9.5 and TH mRNA assays for minimal residual neuroblastoma cells in blood and bone marrow.

Regulation of albumin mRNA and its promoter-binding nuclear factors under different perioperative nutritional methods in hepatectomized rats

BACKGROUND

Regulation of perioperative albumin synthesis under parenteral (PN) and enteral (EN) nutrition was investigated.

METHODS

Rats were divided into PN and EN groups. Both groups received the same regimen of artificial nutrition for 7 days and then underwent 70% hepatectomy. Serum albumin and mRNA levels of albumin and its promoter-binding nuclear factors (C/EBPalpha, beta, and DBP) were measured.

RESULTS

Serum albumin and albumin mRNA in the PN group were significantly lower than those in the EN group at 72 hours after hepatectomy. Preoperative and postoperative DBP and C/EBPalpha mRNA levels in the EN group were significantly higher than those in the PN group.

CONCLUSION

Serum albumin was well maintained by EN after hepatectomy owing to an early recovery of albumin mRNA level and its nuclear factor mRNA levels (C/EBPalpha and DBP). Compared with PN, EN is a more advantageous from of perioperative nutrition as pertains to albumin synthesis.

Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery

OBJECTIVE

Our experience with omental flap transposition in the treatment of deep sternal wound infections is reviewed here with an emphasis on efficacy, risk factors for in-hospital mortality rates, and long-term results.

SUMMARY BACKGROUND DATA

Even with improvements in muscle and omental flap transposition, the timing of closure and the surgical strategy are controversial.

METHODS

Forty-four consecutive patients with deep sternal wound infections were treated using the omental flap transposition from 1985 through 1994. The strategies included debridement with delayed omental flap transposition or single-stage management, which consisted of debridement of the sternal wound and omental flap transposition. Methicillin-resistant Staphylococcus aureus was cultured from more than 50% of the wounds. A logistic regression analysis was used to identify the predictors of in-hospital death after omental flap transposition.

RESULTS

There were seven (16%) in-hospital deaths. Univariate analysis demonstrated that hemodialysis and ventilatory support at the time of omental flap transposition were significantly associated with in-hospital mortality rates (p = 0.0023 and p = 0.0075, respectively). Thirty-seven patients whose wounds healed well were discharged from the hospital. Two patients with cultures positive for methicillin-resistant Staphylococcus aureus had recurrent sternal infections. Patients without positive methicillin-resistant Staphylococcus aureus cultures had good long-term results after reconstructive surgery.

CONCLUSIONS

Transposition of an omental flap is a reliable option in the treatment of deep sternal wound infections, unless the patients require ventilatory support or hemodialysis at the time of transposition.

Effect of the Kobe earthquake on stress and glycemic control in patients with diabetes mellitus

OBJECTIVE

To examine the effects of the Kobe, Japan, earthquake, a life-threatening event, on stress and glycemic control in diabetic patients.

PATIENTS AND METHODS

Hemoglobin A1c levels before and after the earthquake were evaluated in diabetic patients in Kobe (N = 157; magnitude, 7.2) and in Osaka, Japan, as a control (N = 277; magnitude, 4.2), where little damage to houses and traffic facilities occurred. Glycosylated hemoglobin levels were also compared with those of 2 years before and 1 year after the earthquake. The General Health Questionnaire (GHQ) and a self-administered questionnaire regarding damage to houses and relatives killed or injured were used to assess psychological and mental stresses on earthquake survivors.

RESULTS

Glycemic control was aggravated in diabetic patients after the earthquake in Kobe but not in Osaka. THe GHQ scores were significantly higher in the patients in Kobe than those in Osaka. Increased hemoglobin A1c concentrations and high scores on the GHQ were especially evident in diabetic patients with severe damage to houses and/or with relatives killed or injured.

CONCLUSION

These results suggest an association between chronic, life-threatening stress and the worsening of metabolic control in patients with diabetes mellitus.

Simple right atrial procedure for chronic atrial fibrillation with atrial septal defect and aortic valvular regurgitation in an elderly patient

A right atrial separation procedure was performed to eliminate atrial fibrillation (AF) during concomitant repair of an atrial septal defect and aortic valve regurgitation in an elderly patient. This procedure consisted of a Y-shaped incision in the right atrium, followed by cryoablation of the tricuspid annulus and the atrial septum. Only excision of the left atrial auricular appendage was performed in the left atrium. Although this procedure was devised to eliminate chronic AF associated with a solitary atrial septal defect, it was effective to eliminate chronic AF associated with atrial septal defect and aortic valve regurgitation in an elderly patient.

The blood-gas partition coefficient of xenon may be lower than generally accepted

The blood-gas partition coefficients of xenon, reported more than 25 yr ago in the literature, vary considerably from 0.13 to 0.20. Consequently, we have determined this variable by directly injecting xenon-saturated blood into a gas chromatograph-mass spectrometer. This technique yielded a blood-gas partition coefficient for xenon of 0.115 (95% confidence interval 0.107-0.123). The solubility in water measured identically was 0.096, consistent with the reported value of 0.085. These data and a detailed review of the literature strongly suggest that the blood-gas partition coefficient of xenon may be lower than the generally accepted value of 0.14.

Relationship between end-tidal and arterial carbon dioxide partial pressure using a cuffed oropharyngeal airway and a tracheal tube

We have compared the differences between end-tidal PE'CO2 and arterial PaCO2 carbon dioxide partial pressures during general anaesthesia using either a cuffed oropharyngeal airway (COPA) or a tracheal tube (TT) in spontaneously breathing adult patients. After induction of anaesthesia, a COPA was inserted in 20 patients who were allowed to breathe spontaneously. When steady state was reached, PE'CO2 and PaCO2 were recorded. The COPA was removed, the trachea intubated with a TT and spontaneous ventilation allowed to resume. After a stable PE'CO2 was reestablished, PaCO2 was measured again and PE'CO2 recorded. Mean difference between PaCO2 and PE'CO2 with the COPA was 0.72 (SD 0.45) kPa and with the TT 0.64 (0.40) kPa (ns; paired t test). Our results suggest that Pe'CO2 is a clinically acceptable indicator of PaCO2 in adults breathing spontaneously via a COPA.

[Left atrial isolation for chronic atrial fibrillation associated with aortic arch dissection and aortic valve disease in a 70-year-old man]

A 70-year-old male with aortic regurgitation, chronic atrial fibrillation (Af) and chronic aortic dissection of the aortic arch was treated simultaneously. We found a limited dissection in front of aortic arch during operation. We performed total arch replacement using a branched prosthesis and aortic valve replacement in addition to a modified left atrial isolation for chronic Af under the aid of extracorporeal circulation, and selective cerebral perfusion. Left atrial isolation is a simpler procedure than maze procedure and left side maze procedure for eliminating Af. This simple procedure makes possible a simultaneous extended operation for complicated aortic and cardiac disease even in an elderly patient.

Vecuronium-induced neuromuscular block during xenon or sevoflurane anaesthesia in humans

Twitch response using accelerometry and plasma concentrations, of vecuronium and its metabolite were studied in 27 surgical patients during xenon or sevoflurance anaesthesia after administration of vecuronium 0.05 mg kg-1. Anaesthesia was maintained using oxygen-xenon (MAC = 71%) or oxygen-sevoflurane (MAC = 2%) at an end-tidal concentration equal to 0.8 MAC (i.e. 57% xenon and 1.6% sevoflurane). Mean time from administration of vecuronium to 25% recovery of the first twitch of the train-of-four response was significantly shorter in the xenon group than in the sevoflurane group (12.9 (SD 2.5) min vs 19.4 (6.0) min, respectively). Plasma concentrations of vecuronium at 25% recovery were significantly higher during xenon than during sevoflurane anaesthesia (187 (49) ng ml-1 vs 136 (40) ng ml-1, respectively), while those of 3-desacetylvecuronium were similar in both groups.

Elevated plasma nitrate in patients with crush syndrome caused by the Kobe earthquake

We investigated the nitric oxide profile in the plasma of ten healthy controls and 29 patients hurt by the Kobe Earthquake. The levels of nitrite (NO2-) and nitrate (NO3-) were measured simultaneously by high-performance liquid chromatography (HPLC) with UV detection using the Griess reaction after the reduction of nitrate to nitrite. Arginine consumed in food or diet-derived nitrite had no effect on the plasma nitrite and nitrate contents of the healthy volunteers. Plasma nitrate was elevated in the crush syndrome patients; whereas neither nitrite nor nitrate was increased in patients with normal renal function. This finding suggests increased nitric oxide synthesis, decreased excretion of nitric oxide in the crush syndrome or both.

Flow velocity of central retinal artery and retrobulbar vessels during cardiovascular operations

OBJECTIVE

Both blood flow monitoring and pressure monitoring are necessary to avoid inadequate cerebral perfusion during cardiovascular operations. Inasmuch as transcranial Doppler ultrasonography does not provide a consistently good signal, especially during cardiopulmonary bypass, we examined the blood flow through the central retinal artery, which has proved to reflect an obstruction of the carotid artery.

METHOD

Twenty-eight consecutive cases were examined with a 5 or 7.5 MHz conventional echocardiographic probe. Correlation between the maximal velocity at the central retinal artery and systolic blood pressure was examined. The blood flow of the central retinal artery and retrobulbar vessels was examined during selective or retrograde cerebral perfusion or intraaortic balloon pumping.

RESULTS

Blood flow could be clearly visualized but disappeared below a certain pressure in every case. With data from 478 measuring points, systolic blood pressure correlated with maximal velocity (r = 0.6902, p < 0.0001). The blood pressure-axis intercept, known as "critical closing pressure," was 35.8 +/- 14.8 mm Hg, varying among individuals and bilateral eyes. Pulsatility index increased after cardiopulmonary bypass (1.095 +/- 0.245 to 1.525 +/- 0.268, p < 0.0001). Patency of the circle of Willis was confirmed by the blood flow during anastomosis of the ipsilateral artery. During retrograde cerebral perfusion, blood flow was detectable at the retrobulbar vessels. During intraaortic balloon pumping, the central retinal artery flow was augmented on inflation of the balloon.

CONCLUSION

Orbital vessel monitoring provides the critical closing pressure of the central retinal artery and confirms patency of the circle of Willis. The eye can be "an acoustic window" into intracranial blood flow during cardiovascular surgery.

Modulation of circadian expression of D-site binding protein by the schedule of parenteral nutrition in rat liver

The aim of this study was to investigate the changes in the circadian rhythm of the expression of liver-specific genes caused by different schedules of parenteral nutrition (PN). Rats received PN continuously throughout the day or intermittently during the night or day for 7 days. They were examined for gene expression of D-site binding protein (DBP), albumin, and cytochrome P450 cholesterol 7alpha-hydroxylase (CYP7) in the liver. The nocturnal PN group showed circadian expression of DBP messenger RNA (mRNA) and protein with a peak at 10 PM, in the same manner as the control rats receiving normal chow feeding. However, the diurnal PN group showed inverted expression of DBP mRNA and protein with a peak at 10 AM. CYP7 mRNA levels exhibited good synchronization with the levels of DBP mRNA in all groups, whereas albumin mRNA levels did not show such synchronization. Gel mobility-shift assay disclosed that the binding activity of the nuclear extracts to the CYP7 gene promoter was changed by the PN schedule in accordance with the expression of CYP7 mRNA. The PN schedule modulates the circadian rhythm of DBP expression and may have an effect on hepatic bile acid formation through transcriptional regulation of the CYP7 gene.

Abdominal aorta and visceral arteries visualized by transgastric echocardiography: technical considerations

Despite the necessity of information regarding the abdominal aorta and visceral arteries during cardiovascular surgery, there has been no intraoperative modality available. We examined the feasibility and limitations of transesophageal echocardiography (TEE) for this purpose. In 21 consecutive patients, the celiac artery (CEA), superior mesenteric artery (SMA), and left and right renal arteries (LRA, RRA) were examined with TEE, and could be visualized in 21 cases (100%), 20 cases (95.2%), 14 cases (66.7%) and 14 cases (66.7%), respectively. Several attempts were needed for successfully visualizing the LRA and the RRA in 2 and 1 case(s), respectively. Three specific manipulations of the probe were helpful for visualizing these vessels: 1) an appropriate counterclockwise rotation and an upward flexion of the probe when the transducer entered the stomach; 2) a stiffening of the flexible portion of the probe at the position of upward flexion by fixing the handle of the TEE probe when the transducer was advanced; and 3) a lateral flexion of the probe to provide a rotation of the image in either the clockwise or counterclockwise direction and to optimize the assessment of the blood flow velocity in the branch artery. Inferior visualization of the renal arteries was a limitation of this method. Two solutions for this problem were 1) repeated attempts at visualization and 2) an examination of the blood flow in the renal parenchyma with color Doppler imaging. Because of possible damage to the gastric wall, it is recommended that this maneuver be conducted by an experienced sonographer.

Emergence times from xenon anaesthesia are independent of the duration of anaesthesia

Xenon (MAC = 71%) has an extremely low blood:gas partition coefficient (0.14). Therefore, we predicted that the rate of emergence from xenon anaesthesia would not be affected greatly by duration of anaesthesia. We studied 54 ASA I-II patients undergoing lower abdominal surgery who received equal MAC anaesthesia with 60% xenon, 60% nitrous oxide with 0.5% isoflurane or 60% nitrous oxide with 0.7% sevoflurane (n = 18 per group), each supplemented with extradural mepivacaine anaesthesia. Duration of anaesthesia was 58-380 min. At the end of operation, all inhalation anaesthetics were discontinued and patients were allowed to wake up while breathing oxygen spontaneously. A blinded investigator recorded the time until patients opened their eyes on command (T1), were judged ready for tracheal extubation (T2), could correctly state their name, date of birth and name of the hospital (T3), and could count backwards from 10 to 1 in less than 15 s (T4). Emergence times after xenon and nitrous oxide-sevoflurane anaesthesia did not correlate with duration of anaesthesia, whereas those from nitrous oxide-isoflurane had positive correlations. Mean emergence times from xenon anaesthesia were: T1, 3.3 (SD 1.0) min; T2, 3.6 (1.0) min; T3, 5.0 (1.1) min; and T4, 6.2 (1.7) min. These values were approximately 50% of those after nitrous oxide-sevoflurane anaesthesia (T1, 5.6 (1.4) min; T4, 10.5 (2.0) min). We conclude that xenon provided fast emergence from anaesthesia, regardless of the duration of anaesthesia.

[Prostate cancer]

Up to stage B1 or prostate cancer with N0-1 positive lymph node may be curable by monotherapy of either radical prostatectomy or irradiation. Localized but more advanced stages (B2 and C), however, are difficult to cure. To further improve the prognosis in these stages, a new treatment modality is proposed; pelvic lymphadenectomy, followed by irradiation with neoadjuvant and adjuvant endocrine therapy. An average 2-year followup is favorable. Further studies is awaited to make conclusion.

A novel method for counting spontaneous motor activity in the rat

Motor activity is a good index for studying the effects of pharmacological agents. Previous investigations have measured spontaneous motor activity by counting the number of times that an animal interrupts a magnetic field or photocell beam. Quite recently, a novel activity-monitoring system, Supermex, was developed. In this system, a sensor detects the radiated body heat of an animal. The Supermex method enables an investigator to perform multi-channel measurement at low cost. Any size home cage may be used, as long as its geometry cannot block the beam's contact with the animal. Operation is very simple and sensitivity adjustment is not required after the sensor-mount position and height from the cage floor are fixed. In the present study we first used the Supermex system to examine the effects of intracerebroventricular (i.c.v.) administration of a known stimulant, thyrotropin-releasing hormone (TRH). Our results confirmed the suitability of this system for testing spontaneous motor activity. We further studied the effects of pituitary adenylate cyclase-activating polypeptide (PACAP) and its related peptide, vasoactive intestinal polypeptide (VIP), on spontaneous motor activity.

Comparison of inhalation inductions with xenon and sevoflurane

BACKGROUND

Xenon is an odorless gas with low blood-gas solubility coefficient and without occupational and environmental hazards. This investigation was performed to evaluate the speed of induction, and respiratory and cardiovascular reactions to inhalation induction with xenon compared to an equianesthetic concentration of sevoflurane.

METHOD

Twenty-four adult ASA 1-2 patients premedicated with 0.05 mg/kg of midazolam were instructed to take vital capacity breaths of 1 minimum alveolar concentration (MAC) of either xenon or sevoflurane until they lost consciousness. Induction time, total ventilatory volume, tidal volume, respiratory rate, minute ventilation, end-tidal MAC fraction, cardiovascular parameters and oxygen saturation were recorded. The patients were interviewed on the following day to evaluate their acceptability rating of the inhalation inductions.

RESULTS

Compared to equianesthetic sevoflurane, xenon produced a faster induction of anesthesia (147 +/- 59 versus 71 +/- 21 s, respectively) with smaller decreases in respiratory rate, tidal volume and minute ventilation. Both agents showed comparable cardiovascular stability and oxygen saturation during induction. One patient in the sevoflurane group had breath-holding and movements of extremities and another had only breath-holding. No patients in the xenon group experienced any complications.

CONCLUSION

Xenon produced a faster induction of anesthesia without any complications than sevoflurane. Xenon had smaller decreases in tidal volume and respiratory rate during induction than sevoflurane. Xenon might offer an alternative to sevoflurane for an inhalation induction.

Xanthogranulomatous pyelonephritis

A 76-year-old woman presented with spiking fever and right back pain. Ultrasonography (US) revealed that her right kidney was enlarged. Computed tomography (CT) showed the parenchyma was replaced by non-enhancing masses but the overall kidney shape was maintained. These findings were compatible with those of xanthogranulomatous pyelonephritis (XP). The nonenhancing masses on CT coincided with the multiple butter yellow nodules of the resected kidney and microscopically these lesions were proved to be abscesses with xanthoma cells. In this case, the US and CT findings reflected the pathological feature of XP and thus these techniques are thought to be useful for the diagnosis of XP.