Prosthetic valve infective endocarditis with severe mitral stenosis caused by Cutibacterium acnes: a case report

Background

Infective endocarditis rarely results in mitral stenosis. This report presents a case of prosthetic valve infective endocarditis caused by Cutibacterium acnes infection, which resulted in mitral stenosis and was difficult to diagnose.

Case summary

A 78-year-old Japanese man underwent aortic and mitral bioprosthetic valve replacement six years prior to the initiation of hormone therapy for prostate cancer. Three weeks after hormone therapy initiation, the patient developed exertional dyspnoea that progressively worsened and ultimately led to orthopnoea. Chest radiography revealed pulmonary congestion, and transthoracic echocardiography revealed mitral stenosis that was not present three months previously. The patient progressed to heart failure, and bicuspid valve replacement was performed. The excised aortic and mitral bioprosthetic valves were covered with vegetations, and pathological examination confirmed the presence of C. acnes. Therefore, the cause of mitral stenosis was infective endocarditis.

Discussion

In patient with rapidly progressive prosthetic valve stenosis after valve replacement, infective endocarditis due to C. acnes should be suspected even if blood cultures are negative.

Impact of the Lumbar Arteries on Aneurysm Diameter and Type 2 Endoleak after Endovascular Aneurysm Repair

BACKGROUND

Prophylactic embolization of the inferior mesenteric artery (IMA) during endovascular aneurysm repair (EVAR) is recommended to prevent type 2 endoleak (T2EL). However, the impact of patent lumbar arteries (LAs) on T2ELs and aneurysm diameter has not been elucidated.

METHODS

Fifty-seven consecutive patients who underwent EVAR at our institution between January 2013 and September 2022 and whose IMA had been occluded preoperatively or newly occluded postoperatively were included in the study. Predictive factors for aneurysm sac enlargement, sac shrinkage, and T2EL were investigated.

RESULTS

T2ELs occurred in 22.8% of the patients. The 4-year cumulative incidence rates of sac enlargement and shrinkage were 6.7% and 64.6%, respectively. The number of postoperative patent LAs was identified as a risk factor for T2ELs (95% confidence interval [CI]: 1.54-12.7, P = 0.0065). The number of postoperative patent LAs was found to be a significant predictor of sac enlargement (adjusted hazard ratio [AHR] 3.15, 95% CI: 1.43-6.96, P = 0.0045) and shrinkage (AHR 0.63, 95% CI: 0.43-0.91, P = 0.014).

CONCLUSIONS

The current study demonstrated that the number of postoperative patent LAs had a significant impact on the development of T2ELs and the change in aneurysm diameter in patients in whom the IMA was occluded after EVAR.

Totally endoscopic concomitant aortic and mitral valve surgery in junctional epidermolysis bullosa: a case report

BACKGROUND

Junctional epidermolysis bullosa is a rare skin and mucosal disorder characterized by blister formation in response to minor trauma and extracutaneous manifestations. There have been no reports of cardiac surgery and prognostication in patients with epidermolysis bullosa due to skin and mucosal fragility.

CASE PRESENTATION

A 55-year-old man presented with congenital junctional epidermolysis bullosa, hypertension, and vasospastic angina. He complained of dyspnea on exertion, and transthoracic echocardiography revealed severe aortic valve regurgitation, moderate aortic valve stenosis (tricuspid valve), and severe mitral valve regurgitation. Considering that the skin condition in the right chest wall was relatively healthy, the right thoracotomy approach was preferred and totally endoscopic concomitant mitral valve repair and aortic valve replacement were performed using a sutureless bioprosthetic valve (Perceval™ (Corcym, Group, Milan, Italy)). Polyurethane and silicon dressing foams were used to protect the skin at the site of contact with the bag valve mask, arterial pressure catheter, intravenous catheter, and the tracheal intubation tube. Vertical mattress sutures were used for the skin sutures. The postoperative course was uneventful, and the patient was discharged nine days after the operation. There was no indication for reoperation until three years follow-up period.

CONCLUSIONS

The totally endoscopic concomitant aortic and mitral valve surgery using Perceval™ prosthesis can be performed safely in patients with junctional epidermolysis bullosa by adequate protection of the skin and mucosa.

Contemporary outcomes of mitral valve replacement in octogenarians

AIM OF THE STUDY

We aimed to determine the outcomes of contemporary mitral valve replacement (MVR) in octogenarians, for rational treatment selection in a patient cohort.

METHODS

Between 2007 and 2018, 656 consecutive MVRs were performed. Among these cases, 109 patients were aged 80 years or older, and 547 patients were younger than 80 years. Isolated MVRs were performed in 211 patients, of whom 36 were aged 80 years or older. Perioperative mortality and complications were compared between the two groups, adjusted by propensity score.

RESULTS

In-hospital mortality of the entire MVR (<80: 26 [4.8%] vs. ≥80: 6 [5.5%], p = .81) and isolated MVR (<80: 6 [3.4%] vs. ≥80: 1 [2.8%], p > .99) groups were similar. Age >80 years did not influence in-hospital mortality (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.36-3.14, p = .9), stroke (HR, 1.12; 95% CI, 0.19-6.71, p = .9), hemodialysis (HR, 1.44; 95% CI, 0.45-4.66, p = .54), or prolonged ventilation (HR, 1.61; 95% CI, 0.81-3.23, p = .18), but influenced the incidence of reopening for bleeding (HR, 3.97; 95% CI, 1.11-14.19, p = .03). Cox proportional hazard model results showed that age >80 years did not affect cardiac death (HR, 1.45, 95% CI: 0.67-3.12, p = .35), bleeding events (HR, 1.89, 95% CI: 0.84-4.27, p = .13), or stroke (HR, 1.51, 95% CI: 0.54-4.21, p = .44) during the follow-up period.

CONCLUSIONS

The perioperative and follow-up outcomes of MVR in octogenarians were not inferior to those of younger patients. We should not hesitate to conduct MVR on the grounds of old age.

Short- and mid-term outcomes of the frozen elephant-trunk procedure for degenerative aortic arch aneurysm

PURPOSE

The frozen elephant-trunk (FET) procedure is used widely in total aortic arch replacement (TAR) surgery; however, its safety, effectiveness, and long-term outcomes compared with those of the conventional elephant trunk (cET) procedure for degenerative aneurysms are unclear.

METHODS

Between July, 2011 and August, 2019, 126 patients underwent elective total aortic arch replacement at our institution. We compared the short- and mid-term outcomes of 60 patients who underwent the FET procedure (FET group) with those of 66 patients who underwent cET (cET group).

RESULTS

The in-hospital mortality rate tended to be lower in the FET group than in the cET group (p = 0.12). There were two cases of paraplegia (3.3%) in the FET group and in none in the cET group. The all-cause mortality at the 3-year follow-up did not differ significantly between the groups (p = 0.31). The FET group required more unexpected interventions at the surgical site in the mid-term period.

CONCLUSIONS

FET was associated with a shorter operative time and lower surgical mortality than cET. Although the mid-term total aortic arch replacement outcomes of FET were acceptable, careful imaging observation is necessary because reinterventions were required more frequently.

Comparison of porcine versus bovine pericardial bioprosthesis in the mitral position

BACKGROUND

There are no reports of midterm outcomes after mitral valve replacement with a 25-mm bioprosthesis in a large series of patients. This study aimed to examine perioperative and midterm outcomes of bioprosthetic valve choice, porcine or bovine pericardial, in the mitral position, focusing on 25-mm valves.

METHODS

From 2007 to 2018, 467 patients received a mitral bioprosthesis, with or without concomitant procedures. Of these, 111 (23.8%) were porcine, and 356 (76.2%) were bovine pericardial, and 219 patients (46.9%) received a 25-mm valve. A propensity-matched cohort of 192 patients was used for outcome analyses. The influence of the valve type on midterm survival and incidence of cardiac death was assessed. Similarly, subanalysis stratified by valve size was conducted.

RESULTS

In matched patients, there were no differences in midterm survival and incidence of cardiac death between the two groups (log-rank test; p = .268 and p = .097, respectively). There were no differences in midterm survival and incidence of cardiac death between the 25-mm valve and larger valve (log-rank test; p = .563 and p = .597, respectively). The Cox proportional-hazards model revealed that the valve type and 25-mm valve did not affect midterm survival (p = .487 and p = .375, respectively) and incidence of cardiac death (p = .678 and p = .562, respectively).

CONCLUSIONS

The choice of a porcine or bovine pericardial bioprosthesis does not affect midterm survival and cardiac death. The 25-mm valves, whether bovine or porcine, could be an appropriate alternative when the patient's body size is small.

[Surgical Excision of Calcified Amorphous Tumors on Mitral and Aortic Valves:Report of a Case]

Calcified amorphous tumor (CAT) is a nonneoplastic cardiac tumor that can be located in any of the four cardiac chambers, but is predominantly detected on the mitral valve. We report a rare case of CAT originating from the mitral and aortic valves. A 69-year-old woman with end-stage renal disease, hypertension, and diabetes mellitus was referred to our hospital for the evaluation of cardiac masses found incidentally on screening transthoracic echocardiography. She had no symptoms, including fever and neurological deficits, and her blood cultures were negative. Echocardiography revealed mobile masses arising from the mitral and aortic valves. We performed surgical excision and histopathologically diagnosed the masses with cardiac CATs. Mobile and pedunculated CAT frequently causes systemic embolization, and thus, complete surgical excision is recommended in such a case.

Impact of the collateral network on central-repair-first strategy in superior mesenteric artery occlusion with type A acute aortic dissection

OBJECTIVES

Surgery for acute type A aortic dissection with mesenteric malperfusion is challenging. Although the peripheral-reperfusion-first strategy has shown good results, more discussion regarding indicated patients is needed. This study aimed to describe the imaging features and surgical outcomes of mesenteric malperfusion and to clarify which cases should be considered for the peripheral-reperfusion-first strategy.

METHODS

A total of 200 patients underwent emergent aortic repair for acute type A aortic dissection at our institution between October 2011 and July 2019. Superior mesenteric artery occlusion on preoperative contrast-enhanced computed tomography was detected in 12 patients, who were categorized into two groups based on enhancement (n = 7) or non-enhancement (n = 5) of the superior mesenteric artery peripheral branches. Operative outcomes after central repair were compared between groups.

RESULTS

Four patients in the enhanced group had no postoperative abdominal complications, and three patients required superior mesenteric artery bypass grafting with the central-repair-first strategy. However, all patients in the enhanced group survived and did not require intestinal resection. In contrast, four patients (80%) in the non-enhanced group had intestinal necrosis, three patients required intestinal resection, and one patient died from multiple organ failure.

CONCLUSION

The presence or absence of an enhancement of the peripheral superior mesenteric artery by the collateral network could be helpful for decision-making. The central-repair-first strategy may be permitted in patients with enhanced peripheral branches. Conversely, in patients with non-enhanced peripheral branches, a more invasive assessment should be considered before central aortic repair, and peripheral-reperfusion-first strategy may be required.

Impact of Prosthesis-Patient Mismatch After Mitral Valve Replacement: A Propensity Score Analysis

The effect of patient-prosthesis mismatch (PPM) on late outcomes after mitral valve replacement (MVR) remains unclear. We evaluated the impact of PPM after MVR on the late survival using propensity score matching analysis. From 2007 to 2018, 660 consecutive MVRs were performed. Effective orifice areas were obtained from a literature review of in vivo echocardiographic data, and mitral PPM was defined as an effective orifice area index of ≤1.2 cm²/m². Propensity score matching yielded a cohort of 126 patients with PPM and 126 patients without PPM. Mitral PPM was found in 37.8% of the patients. In the whole matched patients, there were no differences in late survival (log-rank test, P = 0.629) between 2 groups. Patients aged ≤70 years and those aged >70 years had no differences in late survival (log-rank test, P = 0.073 and 0.572). The Cox proportional hazards model for the overall survival showed that mitral PPM tended to decrease survival in patients aged ≤70 years (P = 0.084, hazard ratio [HR] 2.647, 95% CI: 0.876-7.994). Mitral PPM did not adversely affect long-term survival. There may be a tendency of adverse impact on late survival in patients aged ≤70 years. Implanting a safe size rather than larger size prosthesis in mitral position may be an appropriate option in older patients.

Calcified amorphous tumor presenting with rapid growth in the ascending aorta

A calcified amorphous tumor (CAT) is a rare, non-neoplastic cardiac mass frequently located in cardiac chambers, especially the mitral valve or annulus. Here, we report an exceedingly rare case of CAT as an atypical mobile mass in the ascending aorta in a 62-year-old man who was on hemodialysis for 11 years. The CAT grew rapidly within 3 months. We resected the mass, and he was discharged with no complications. This report shows that the CAT can grow rapidly, even in the aorta, and provides important information on the progression of this rare disease and its clinical features.

Incidence and influence of prosthesis-patient mismatch after reoperative aortic valve replacement: a retrospective single-center study

Background

Reoperative aortic valve replacement (AVR) is associated with increased mortality compared with initial surgery, and a smaller valve might be implanted during repeat AVR (re-AVR; AVR after prior AVR). We describe the clinical outcomes and incidence of prosthesis-patient mismatches (PPM) after reoperative AVR.

Methods

Among 113 patients who underwent reoperative AVR between 2007 and 2018, 44 underwent re-AVR and 69 underwent a first replacement of a diseased natural valve after any cardiac surgery except AVR (primary AVR). We then compared early and late outcomes, the impact of re-AVR on the effective orifice areas (EOA), and the incidence and influence of PPM on reoperative AVR.

Results

Hospital mortality was 2.7%, and the overall 1-, 3-, and 5-year survival rates were 95, 91 and 86%, respectively. The reference EOA of the newly implanted valve was smaller than that of the previous valve (1.4 ± 0.3 vs. 1.6 ± 0.3 cm², p < 0.01). The mean pressure gradient was greater (15.2 ± 6.4 vs. 12.7 ± 6.2 mmHg, p = 0.04) and indexed EOA was smaller (0.92 ± 0.26 vs. 1.06 ± 0.36 cm²/m², p = 0.04) during re-AVR than primary AVR, whereas the incidence of PPM was similar (38.7% vs. 34.8%, p = 0.87) between the groups.

Conclusions

The clinical outcomes of reoperative AVR were acceptable. Although the reference EOA of new implanted valves was smaller than that of previous valves, re-AVR did not increase the incidence of PPM. These findings might serve as a guide for future decisions regarding the surgical approach to treating degenerated prosthetic valves.

Left ventricular assist device exchange: the Toronto General Hospital experience

BACKGROUND

As support times for left ventricular assist devices (LVADs) become longer, several complications requiring device exchange may occur. To our knowledge, this is the first Canadian report regarding implantable LVAD exchange.

METHODS

We retrospectively reviewed the cases of consecutive, unique patients implanted with an LVAD between June 2006 and October 2015 at Toronto General Hospital.

RESULTS

In total, 122 patients were impanted with an LVAD during the study period. Eight patients required LVAD exchange, and 1 patient had 2 replacements (9 of 122, 7.3%). There were 7 HeartMate II (HMII), 1 HVAD and 1 DuraHeart pumps exchanged. Two of these exchanges occurred early at the time of initial implant, whereas 7 occurred late (range 8-623 d). Six exchanges were made owing to pump thrombosis. Of the 3 exchanges made for other causes, 1 HMII exchange was owing to a driveline fracture, 1 DuraHeart patient had early inflow obstruction requiring exchange to HMII at the initial implant, and the third had a suspected inflow obstruction with no evidence of thrombosis at the time of the procedure. The mean support time before exchange was 225 days, and time from exchange to transplant, death or ongoing support was 245 days. Three patients were successfully bridged to transplant, and at the time of data collection 2 were supported awaiting transplant. Three patients died after a mean duration of 394.3 days (range 78-673 d) of support postreplacement. Four cases were successfully performed using a subcostal approach.

CONCLUSION

Pump thrombosis is the most common cause for LVAD exchange, which can be performed with acceptable morbidity and mortality. The subcostal approach may be the preferred procedure for an HMII exchange when indicated.

Impact of the Clinical Frailty Scale on Outcomes After Transcatheter Aortic Valve Replacement

Background:

The semiquantitative Clinical Frailty Scale (CFS) is a simple tool to assess patients’ frailty and has been shown to correlate with mortality in elderly patients even when evaluated by nongeriatricians. The aim of the current study was to determine the prognostic value of CFS in patients who underwent transcatheter aortic valve replacement.

Methods:

We utilized the OCEAN (Optimized Catheter Valvular Intervention) Japanese multicenter registry to review data of 1215 patients who underwent transcatheter aortic valve replacement. Patients were categorized into 5 groups based on the CFS stages: CFS 1-3, CFS 4, CFS 5, CFS 6, and CFS ≥7. We subsequently evaluated the relationship between CFS grading and other indicators of frailty, including body mass index, serum albumin, gait speed, and mean hand grip. We also assessed differences in baseline characteristics, procedural outcomes, and early and midterm mortality among the 5 groups.

Results:

Patient distribution into the 5 CFS groups was as follows: 38.0% (CFS 1-3), 32.9% (CFS4), 15.1% (CFS 5), 10.0% (CFS 6), and 4.0% (CFS ≥7). The CFS grade showed significant correlation with body mass index (Spearman’s ρ=−0.077, P =0.007), albumin (ρ=−0.22, P <0.001), gait speed (ρ=−0.28, P <0.001), and grip strength (ρ=−0.26, P <0.001). Cumulative 1-year mortality increased with increasing CFS stage (7.2%, 8.6%. 15.7%, 16.9%, 44.1%, P <0.001). In a Cox regression multivariate analysis, the CFS (per 1 category increase) was an independent predictive factor of increased late cumulative mortality risk (hazard ratio, 1.28; 95% confidence interval, 1.10–1.49; P <0.001).

Conclusions:

In addition to reflecting the degree of frailty, the CFS was a useful marker for predicting late mortality in an elderly transcatheter aortic valve replacement cohort.

Coronary artery bypass graft surgery vs percutaneous interventions in coronary revascularization: a systematic review

IMPORTANCE

Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups.

OBJECTIVE

To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD).

EVIDENCE REVIEW

A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible.

FINDINGS

Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX ≤22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies.

CONCLUSIONS AND RELEVANCE

Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.

Surgical correction of tetralogy of Fallot in a 61-year-old patient

Tetralogy of Fallot (TOF) is a congenital heart disease that is usually diagnosed and treated during infancy. Only 3% of such patients reach the age of 40 without surgery. We describe a 61-year-old woman with uncorrected TOF that was successfully treated by radical surgery. The patient presented with exertional dyspnea, insomnia, and malaise. Echocardiography and cardiac catheterization indicated a dilated, severely hypertrophic right ventricle, ventricular septal defect, an overriding aorta, and infundibular stenosis in the right ventricular outflow tract. All symptoms disappeared after full surgical correction, which remains the preferred treatment for adult TOF because it confers long-term survival and an improved quality of life.

Angiogenic properties of sustained release platelet-rich plasma: characterization in-vitro and in the ischemic hind limb of the mouse

BACKGROUND

While single growth factor has limitation to induce optimal neovascularization, platelet-rich plasma (PRP) is an autologous reserver of various growth factors. However, little is known about the mechanism of PRP-related neovascularization.The objective of this investigation was to characterize the angiogenic and growth factor content of PRP and to determine, in vitro, its effect on endothelial cell proliferation. Additionally, this experiment sought to determine the effectiveness of different compositions of PRP (solution versus sustained release) on perfusion and neovascularization in a murine model of hind limb ischemia.

METHODS

Different growth factors were measured by enzyme-linked immunosorbent assay (ELISA). In vivo study, we used gelatin hydrogel as a sustained release carrier for growth factors in PRP. We induced hind limb ischemia by excising right femoral artery in wild type C57BL6 mice. After surgery, mice were randomly assigned to four experimental groups; control (C), 100 muL of sustained release form of platelet-poor plasma (PPP), 100 muL of solution form of PRP (PRP-sol), 100 muL of sustained release form of PRP (PRP-sr); each formulation was administered via an intramuscular injection to the ischemic hind limb. Endpoint evaluations were blood perfusion by laser Doppler perfusion image, vascular density by anti Von Willebrand factor (vWF), and mature vessel density by anti smooth muscle actin (SMA) antibody. Green fluorescent protein (GFP+) transgenic mice were generated by transplantation of bone marrow derived mononuclear cells to wild type C57BL6 mice, and finally CD34+ cell in the ischemic site of transgenic mice was detected by staining with anti-CD34 antibody.

RESULTS

In vitro study showed that PRP containing different growth factors induces endothelial cell proliferation and capillary tube formation. In vivo study demonstrated that sustained release of PRP increased perfusion of ischemic tissue as measured by laser Doppler perfusion imaging (LDPI) (57 +/- 12, 56 +/- 9, 72 +/- 7, 98 +/- 4 for groups C, PPP, PRP-sol, and PRP-sr, respectively; P < .05); capillary density (151 +/- 16, 158 +/- 12, 189 +/- 39, 276 +/- 39 for groups C, PPP, PRP-sol, and PRP-sr, respectively, P < .05) and mature vessel density (28 +/- 2, 31 +/- 3, 52 +/- 10, 85 +/- 13 for groups C, PPP, PRP-sol, and PRP-sr, respectively, P < .05) . Sustained release PRP also increases CD34+ cells in the ischemic site of transgenic mice (6 +/- 3 vs 18 +/- 5/mm(2) for groups control and PRP-sr respectively, P < .05).

CONCLUSION

Sustained release of PRP containing potent angiogenic growth factors restores blood perfusion presumably by stimulating angiogenesis, arteriogenesis, as well as vasculogenesis in the mouse hind limb ischemia.

CLINICAL RELEVANCE

PRP is a natural reserver of various growth factors that can be collected autologously and is costeffective. Thus for clinical use, no special considerations concerning antibody formation and infection risk are needed.Some clinical devices to automatically prepare PRP are available at present. PRP are consistently being used clinically inthe department of orthopedics and plastic surgery (oral, maxillary facial) for a long time. On the basis of researchevidence, some publications have reported positive results in either bone or soft tissue healing. However, some researchconcludes that there is no or little benefit from PRP. This is likely due to faster degradation of growth factors in PRP sincesome authors suggest using sustained release form of PRP to deliver optimal effect of PRP. Gelatin hydrogel is also beingused clinically as a slow, sustained release of carrier for growth factors in our center recently.

3He spin-dependent cross sections and sum rules

We present a measurement of the spin-dependent cross sections for the 3He over -->(e over -->,e')X reaction in the quasielastic and resonance regions at a four-momentum transfer 0.1< or =Q2< or =0.9 GeV2. The spin-structure functions have been extracted and used to evaluate the nuclear Burkhardt-Cottingham and extended Gerasimov-Drell-Hearn sum rules for the first time. The data are also compared to an impulse approximation calculation and an exact three-body Faddeev calculation in the quasielastic region.

Ossifying fibroma of the mandible with primary hyperparathyroidism due to non-familial parathyroid adenoma

Ossifying fibroma is an uncommon benign osteogenic neoplasm arising from cells of the periodontal ligament, typically with a slowly progressive enlargement of the affected bone. The neoplasm sometimes presents with hyperparathyroidism, most of which cases are due to familial parathyroid tumours. We report a rare case of ossifying fibroma of the mandible which showed very rapid growth and presented with primary hyperparathyroidism due to non-familial parathyroid adenoma. Despite improvement of parathyroid dysfunction after removal of the parathyroid adenoma, the tumour continued to grow very aggressively. The case required partial mandibular resection for complete resection of the tumour, and fixation of the remaining mandible with a titanium plate.

Traumatic pericardial rupture involved with complication by blunt chest trauma

A 65-year-old man who had sustained a blunt chest trauma in a traffic accident demonstrated a mass in the left hilum by chest radiography. Emergency surgery demonstrated a rupture of the left-side pericardium with herniation of the heart into the left pleural cavity along with a right ventricular rupture. The tear in the right ventricle was sutured using 4-0 polypropylene with felt and the pericardial rupture was repaired with an expanded polytetrafluoroethylene sheet. A 31-year-old man who had been crushed against a tree while skiing 5 years and 6 months earlier was diagnosed as having severe tricuspid valve regurgitation and tricuspid valve replacement was performed. Large left pericardial defect was found and repaired with an equine pericardial patch. In both cases, a bridging of phrenic nerve was found in the pericardial defect that was regarded as a traumatic rupture.

Measurement of the generalized forward spin polarizabilities of the neutron

The generalized forward spin polarizabilities gamma(0) and delta(LT) of the neutron have been extracted for the first time in a Q2 range from 0.1 to 0.9 GeV2. Since gamma(0) is sensitive to nucleon resonances and delta(LT) is insensitive to the Delta resonance, it is expected that the pair of forward spin polarizabilities should provide benchmark tests of the current understanding of the chiral dynamics of QCD. The new results on delta(LT) show significant disagreement with chiral perturbation theory calculations, while the data for gamma(0) at low Q2 are in good agreement with a next-to-leading-order relativistic baryon chiral perturbation theory calculation. The data show good agreement with the phenomenological MAID model.

Measurement of the generalized polarizabilities of the proton in virtual Compton scattering at Q2=0.92 and 1.76 GeV2

We report a virtual Compton scattering study of the proton at low c.m. energies. We have determined the structure functions P(LL)-P(TT)/epsilon and P(LT), and the electric and magnetic generalized polarizabilities (GPs) alpha(E)(Q2) and beta(M)(Q2) at momentum transfer Q(2)=0.92 and 1.76 GeV2. The electric GP shows a strong falloff with Q2, and its global behavior does not follow a simple dipole form. The magnetic GP shows a rise and then a falloff; this can be interpreted as the dominance of a long-distance diamagnetic pion cloud at low Q2, compensated at higher Q2 by a paramagnetic contribution from piN intermediate states.

Q2 evolution of the neutron spin structure moments using a 3He target

We have measured the spin structure functions g(1) and g(2) of 3He in a double-spin experiment by inclusively scattering polarized electrons at energies ranging from 0.862 to 5.058 GeV off a polarized 3He target at a 15.5 degrees scattering angle. Excitation energies covered the resonance and the onset of the deep inelastic regions. We have determined for the first time the Q2 evolution of Gamma(1)(Q2)= integral (1)(0)g(1)(x,Q2)dx, Gamma(2)(Q2)= integral (1)(0)g(2)(x,Q2)dx, and d(2)(Q2)= integral (1)(0)x(2)[2g(1)(x,Q2)+3g(2)(x,Q2)]dx for the neutron in the range 0.1< or =Q2< or =0.9 GeV2 with good precision. Gamma(1)(Q2) displays a smooth variation from high to low Q2. The Burkhardt-Cottingham sum rule holds within uncertainties and d(2) is nonzero over the measured range.

Syphilitic cervical lymphadenopathy

Syphilis is well known as a great mimic, however it is not recognized as a cause of cervical lymphadenopathy. We report a case of a 21-year-old man who presented with marked unilateral cervical lymphadenopathy. He had no evidence of oropharyngeal chancres, skin or genital lesions. Computed tomography (CT) and magnetic resonance (MR) images showed multiple cervical lymphadenopathy, and serologic tests for syphilis were positive. Syphilis should still be a factor for consideration in the differential diagnosis of cervical lymphadenopathy.

Q2 evolution of the generalized Gerasimov-Drell-Hearn integral for the neutron using a 3He target

We present data on the inclusive scattering of polarized electrons from a polarized 3He target at energies from 0.862 to 5.06 GeV, obtained at a scattering angle of 15.5 degrees. Our data include measurements from the quasielastic peak, through the nucleon resonance region, and beyond, and were used to determine the virtual photon cross-section difference sigma(1/2)-sigma(3/2). We extract the extended Gerasimov-Drell-Hearn integral for the neutron in the range of four-momentum transfer squared Q2 of 0.1-0.9 GeV2.

Color Doppler sonography in monitoring after free jejunum transplantation

The authors assessed the usefulness of color Doppler imaging in the monitoring of vascular circulation after free jejunum transplantation. Seven male patients were examined daily with color Doppler sonography for the first postoperative week between 1999 and 2000. All sonographic examinations were performed with an SSD5500 ultrasound scanner. Arterial and venous signals were documented reliably in all patients. The flashing red spots around the serosal wall revealed the patency of the anastomosed artery and vein. No failures of the graft occurred. The presence of the color Doppler signals was considered sufficient to define vascular patency. The real-time monographic (B-mode) examination revealed the thickness and the plicae circulares of the jejunum wall. These monographic (B-mode) images supported the viability of the transplanted jejuna. The authors found color Doppler sonography to be a reliable and effective form of monitoring after free jejunum transplantation.

Columnar-cell carcinoma of the thyroid

A case of columnar-cell carcinoma of the thyroid gland occurring in a 77-year-old female is described. Tracheal deviation and calcified anterior neck lesion were showed in X-ray examination. A computed tomography (CT) scan revealed a soft tissue density mass with calcification of the right thyroid lobe and isthmus. A (99m)Tc scintiscan showed a 'cold' nodule, whereas a (201)Tl scintiscan showed a 'hot' in the right thyroid lobe and isthmus. Subtotal thyroidectomy and dissection of paratracheal adipose tissue were performed after fine needle aspiration cytology (FNA) of the thyroid mass had been done. On the FNA smears, there were many papillary fragments, which contained pseudostratified columnar cells. Histopathologically, the tumor had three different types of neoplasm including papillary carcinoma of usual feature, columnar-cell carcinoma and follicular carcinoma. Transitional changes were observed between columnar-cell carcinoma and follicular carcinoma. The patient has been followed up for 3 years, with no evidence of recurrence or metastasis.

Dynamics of the 16O(e, e'p) reaction at high missing energies

We measured the cross section and response functions for the quasielastic 16O(e,e'p) reaction for missing energies 25< or =E(m)< or =120 MeV at missing momenta P(m)< or =340 MeV/c. For 25<E(m)<50 MeV and P(m) approximately 60 MeV/c, the reaction is dominated by a single 1s(1/2) proton knockout. At larger P(m), the single-particle aspects are increasingly masked by more complicated processes. Calculations which include pion exchange currents, isobar currents, and short-range correlations account for the shape and the transversity, but for only half of the magnitude of the measured cross section.

Dynamical relativistic effects in quasielastic 1p-shell proton knockout from 16O

We have measured the cross section for quasielastic 1p-shell proton knockout in the 16O(e,e(')p) reaction at omega = 0.439 GeV and Q2 = 0.8 (GeV/c)(2) for missing momentum P(miss)</=355 MeV/c. We have extracted the response functions R(L+TT), R(T), R(LT), and the left-right asymmetry, A(LT), for the 1p(1/2) and the 1p(3/2) states. The data are well described by relativistic distorted wave impulse approximation calculations. At large P(miss), the structure observed in A(LT) indicates the existence of dynamical relativistic effects.

Morphometric study of the medial aspect of the human maxillary sinus with special reference to the nasal fontanelle

OBJECTIVE

The purpose of this study was to clarify configurations of the nasal fontanelle (NF) from the morphometrical point of view, especially variations of its four margins (anterior, posterior, superior, and inferior), for clinical application.

METHODS

We used 136 sides of hemi-sectioned heads that were obtained from 119 donated Japanese cadavers (66 men and 53 women with an average age of 77.6+/-12.0). After mucosal examination, the specimens were boiled with a small amount of powdered soap and treated with protease. The residual mucous membrane was then gently removed. These specimens were originally made for our previous study describing variations of the uncinate process (Isobe M, Murakami G, Kataura A. Variations of the uncinate process of the lateral nasal wall with clinical implications, Clin. Anat. 1998;11:295-303). Different series of measurements were conducted based on surgical approaches and angles of observation.

RESULTS

The superior margin of the NF is difficult to identify because the ethmoidal infundibulum, which leads the anterior end of the margin upward, often interrupts the superior margin. Because the inferior and posterior margins are modified by thin paper-like bony structures and because the anterior margin is disturbed by variations of the lacrimal bone and/or the inferior turbinate, they are also difficult to identify. Knowing these variables, we evaluated the NF morphometrically. The NF was located 12.6+/-4.3 mm posterior to the anterior nasal spine and 6.6+/-2.2 mm anterior to the sphenopalatine foramen. The size of the NF was 17.9+/-3.2 mm (anteroposterior axis) x 11.5+/-3.0 mm (inferosuperior axis). The lowest orbital floor was located 10 mm below the superior margin of the anterior NF (-10 mm), and the distance was therefore measured as -3.7+/-2.4 mm on average. Viewed from the maxillary sinus, the location of the NF varied along the anteroposterior axis, whereas it was located consistently at the most superior portion of the medial aspect of the sinus wall.

CONCLUSION

During endoscopic sinus surgery for tumor resection in the maxillary sinus, a large and primary window should be prepared in the posterior NF, including partial removal of the uncinate process. Preparation of an additional window in the inferior meatus is preferable to enlargement of the primary window. Approaching the anterior NF should be avoided, if possible, due to its complicated configuration as well as its proximity to the orbital floor.

A new enzymatic assay for selectively measuring conjugated bilirubin concentration in serum with use of bilirubin oxidase

A new enzymatic assay for selectively measuring conjugated bilirubin concentration in serum with use of bilirubin oxidase (BOD) has been developed. At pH 5.5 BOD can oxidize only conjugated bilirubin in the presence of reagents such as sodium fluoride and N-acetylcysteine which can decrease BOD reactivity to unconjugated bilirubin and bilirubin covalently bound to albumin (delta bilirubin). The resulting decrease in absorbance at 450 nm is linearly related to the concentration of conjugated bilirubin in serum. The BOD in this new assay was confirmed to oxidize conjugated bilirubin, and neither unconjugated nor delta bilirubin, based on both its reactivity to unconjugated bilirubin and HPLC results. This assay was found to give satisfactory results, such as in terms of the range of measurement, the reproducibility of the results, the lack of interference with coexisting substances in serum and the stability of the reagent solutions, in practical applications. The serum conjugated bilirubin concentrations determined using this assay correlate well with those determined by the HPLC analysis. This assay can be used for accurate monitoring of changes in the conjugated bilirubin concentration in patient sera. These findings suggest that the conjugated bilirubin assay is useful for fractional determination of bilirubin in icteric sera.

Prognostic factors and treatment outcome in non-Hodgkin's lymphoma of Waldeyer's ring

Prognostic factors and treatment outcome of 71 patients with non-Hodgkin's lymphoma of Waldeyer's ring were analyzed retrospectively. In univariate analyses, unfavorable prognosis was associated with primary disease in the base of the tongue, stage III-IV diseases, B-symptoms, high-grade histology, T-cell phenotype, elevated serum LDH levels, decreased peripheral blood lymphocyte counts, and negative response on delayed type hypersensitivity skin reactions. Multivariate analysis showed that stage III-IV and T-cell phenotype were significant independent risk factors for death. In stage I-II lymphomas, patients with unilateral large or bilateral cervical lymph node involvement had a poorer prognosis. In stage I-II lymphomas with intermediate or high-grade histology, patients who had received radiotherapy with MTCOP-P chemotherapy (pirarubicin, cyclophosphamide, vincristine, methotrexate with leucovorin rescue, peplomycin, and predonisolone) showed significantly better 5-year disease-free survival rate compared with patients treated with radiotherapy alone.

Interaction and immunological effect of very late antigen-4, 5, and fibronectin in tonsillar lymphocytes and their relation to age

We examined the expressions of alpha-subunits of very late antigen (VLA)-4 (alpha4) and VLA-5 (alpha5) on tonsillar lymphocytes and the interaction between these integrin receptors and their ligand, fibronectin (FN). Immunohistological and flow cytometric analyses showed that alpha4 and alpha5 were expressed in the lymphoid follicle and were positive on about 10% each of T cells and on 55% and 35% of B cells. When tonsillar B cells were separated by a discontinuous Percoll gradient, the number of alpha4- and 5-positive cells decreased as the cell density went down, while the number of activated cells went up. After in vitro activation of tonsillar B cells by Staphylococcus aureus Cowan I strain (SAC), the expression of alpha5 and the adhesiveness to FN decreased. The increased proliferation of B cells was observed when tonsillar B cells were cultured with immobilized FN. The expressions of alpha-subunits of VLA-4 and VLA-5 on tonsillar T and B lymphocytes increased with age. These results suggest that: i) B cell activation may cause decreased expressions of VLA-4 and -5, which gives a costimulatory effect on B cell activation itself again in cooperation with FN, ii) Increased expressions of VLA-4 and -5 on tonsillar lymphocytes with age may be related to regional immune response of the palatine tonsils.

Expressions of very late antigen-6 and vitronectin receptor, and their interactions to laminin and vitronectin during tonsillar B-cell activation

This study examined the expressions of a-subunits of very late antigen-6 (VLA-6; alpha 6) and vitronectin receptor (VNR; alpha V) on tonsillar B cells and interactions between those integrins and their respective ligands, laminin (LM) and vitronectin (VN). alpha 6 and alpha V were expressed on about 30 to 40% of tonsillar B cells. When purified tonsillar B cells were separated by a discontinuous Percoll gradient, the number of alpha 6- and alpha V-positive cells decreased as the cell density went down, while the number of activated cells went up. After in vitro activation of tonsillar B cells by Staphylococcus aureus Cowan I strain (SAC), the expressions of alpha 6 and alpha V and their adhesiveness to LM or VN decreased significantly. Increased proliferation of B cells was observed when tonsillar B cells were cultured with immobilized LM or VN. The results of immunohistological staining showed VLA-6, VNR, LM and VN in the follicular area. These results suggest that the expressions of VLA-6 and VNR on tonsillar B cells may be decreased during B cell activation, and the interaction between VLA-6, VNR, and LM, VN may give a costimulatory effect on B cell activation in the follicular area of the tonsil.

Clinical analyses of focus tonsil and related diseases in Japan

Clinical analyses were performed in groups of patients with several diseases that are regarded as diseases of focus tonsils. These patients underwent tonsillectomy from 1981 to 1993 in our department. They included 289 cases of pustulosis palmaris et plantaris (PPP), 35 cases of psoriasis vulgaris (PV), 100 cases of sternocostoclavicular hyperosteosis (SCCH), and 18 cases of rheumatoid arthritis (RA). Tonsillectomy was found to significantly alleviate clinical symptoms of the above diseases as follows: 88.1% of the PPP cases, 48.6% of the PV cases, 80.9% of the SCCH cases, and 66.7% of the RA cases. Age distribution of the patients, relation between the effect of tonsillectomy and age, sex and other factors were also analyzed.