Differentiation of multiple visceral artery aneurysm rupture from major bleeding after coronary artery bypass grafting

BACKGROUND

Visceral artery aneurysm is a very rare disease, but it is clinically important because of the high risk of rupture involved. These ruptures must be differentiated from those that occur during hospitalization after extra-abdominal surgery.

METHODS

During hospitalization after off-pump coronary artery bypass grafting, a 77-year-old woman developed hypovolemic symptoms and had decreased hemoglobin. There was no obvious bleeding, but while screening for possible complications after cardiac surgery, abdominal computed tomographic angiography showed multiple visceral artery aneurysms of the gastroduodenal and pancreaticoduodenal arteries along with hemoperitoneum.

RESULTS

The patient underwent coil embolization of the visceral artery aneurysm and was discharged without any complications.

CONCLUSIONS

In patients with coronary artery disease with risk factors for atherosclerosis, if anemia occurs without apparent bleeding after surgery, visceral artery aneurysm should be considered as a differential diagnosis.

Acute biological mitral valve thrombosis after the left atrial venting in a patient with a venoarterial extracorporeal membrane oxygenator

BACKGROUND

Left atrial venting through atrial septotomy in patients with decreased left ventricular (LV) contractility after venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a simple and effective method for treating LV decompression.

MATERIALS & METHODS

We report a case of prosthetic mitral valve thrombosis after left atrial venting in a patient with VA-ECMO.

RESULTS

In patients undergoing mitral valve replacement, left atrial venting reduces the flow through the mitral valve and forms a prosthetic thrombosis.

DISCUSSION

Therefore, excessive left atrial venting should be avoided. Other venting methods that can maintain the flow through the mitral valve should be considered after mitral valve replacement.

A retrospective analysis of 29 isolated sphenoid fungus ball cases from a medical centre in Korea (1999-2012)

BACKGROUND

Isolated sphenoid sinus disease (ISSD) is rare. Fungus ball (FB) is the third most common ISSD. We analysed the characteristics of isolated sphenoid FB based on demographic data, presenting symptoms, preoperative computed tomography (CT), magnetic resonance imaging (MRI), and treatment outcomes.

METHODOLOGY

From 1999 to 2012, 29 patients were identified with isolated sphenoid FB. Demographic data; clinical characteristics; endoscopic, CT, and MRI findings and treatment outcomes were retrospectively analysed.

RESULTS

The most common symptom was headaches, which were localized in various regions of the brain. Other symptoms were uncommon. The most common CT findings were sclerosis, calcification, enlarged sinus and total opacification. On T2-weighted MRI images, we most commonly observed signal void. Endoscopic transnasal paraseptal sphenoidotomy was performed in all patients, and for most, this was performed under local anaesthesia. No recurrence was observed in any patient.

CONCLUSION

Isolated sphenoid FB is predominantly observed in older women, and it is characterised by headaches and sclerosis of the sinus wall observed on CT scans. In cases of isolated sphenoid FB, endoscopic transnasal paraseptal sphenoidotomy can be successfully performed under local anaesthesia, which may facilitate rapid recovery and a low morbidity rate.

A case of successful primary coronary intervention for the total occlusion of left main stem with the aid of abciximab

A 61-yr-old male patient presented with severe chest pain with cardiogenic shock due to an extensive anterolateral myocardial infarction. Two-dimensional echocardiogram showed severe left ventricular systolic dysfunction (ejection fraction=17%). Emergent coronary angiogram obtained immediately after placing temporary pacing electrode revealed total thrombotic occlusion in the left main stem. We performed direct coronary intervention using kissing balloon technique with the aid of Abciximab (ReoPro) infusion. Residual stenosis with thrombus remained even after high pressure balloon dilatations, therefore we placed two stents, one in the ostia of left anterior descending (LAD) and the other in left circumflex artery (LCX). Coronary angiogram after kissing stents showed improved LAD and LCX flows without residual stenosis. Chest pain resolved and blood pressure normalized after coronary intervention. The whole procedure time was 15 min. Follow-up coronary angiogram taken one week later showed patent previous stented arteries, and echocardiography demonstrated 40% of left ventricular ejection fraction. The clinical course for one-year follow-up was uneventful.

Enhanced phagocytic activity of neutrophils caused by administration of egg white derivatives (EWD) in cats injected with cyclophosphamide (CPA)

To examine in vivo effects of egg white derivatives (EWD), the numbers of peripheral blood cells and neutrophil phagocytosis were evaluated in cats injected intramuscularly with cyclophosphamide (CPA). There were no changes in the number of red blood cells (RBC) or packed cell volume (PCV) values regardless of oral administration of EWD or injection of CPA, but the numbers of platelets, white blood cells (WBC) and neutrophils in cats administered EWD significantly increased (p<0.05 to 0.01) when compared with those in control cats which received saline solution. In addition, the administration of EWD resulted in a significant enhancement in the phagocytic activity of neutrophils (p<0.01) when compared to control cats, suggesting that EWD has a stimulating effect on leukocyte progenitors. The numbers of platelets, WBC and neutrophils, and the phagocytic activity of neutrophils in cats injected with CPA alone were significantly lower (p<0.05 to 0.01) than those in control cats. However, co-administration of EWD to cats injected with CPA resulted in a significant increase in the numbers of platelets, WBC and neutrophils (p<0.05 to 0.01), and in the phagocytic response of neutrophils (p<0.01) when compared to cats injected with CPA alone. Therefore, these results suggest that co-administration of EWD may be effective in reducing some possible side effects in animals treated with immunosuppressive or antitumor agents.

Different cutoff values of Cyfra 21-1 for cavitary and noncavitary lung cancers

STUDY OBJECTIVES

Cell lysis and tumor necrosis release cytokeratin, a tumor marker of lung cancer, into the serum. The serum cytokeratin level can also be elevated in benign cavitary lung diseases. The purpose of this study was to evaluate whether Cyfra 21-1 can differentiate malignant lung diseases from benign diseases with cavitary lesions.

DESIGN

This study is a retrospective review of the case records of patients with lung lesions seen during a 4-year period from January 1993 to May 1996.

SETTING AND PATIENTS

Serum Cyfra 21-1 levels were measured in 306 patients with lung cancer (n = 143) or benign lung disease (n = 163). The patients were grouped according to radiologic evidence of cavitary lung lesions. Lung cancer included both non-small cell (n = 123) and small cell (n = 20) lung cancers, and the benign diseases include tuberculosis (n = 87), abscess (n = 26), pneumonia (n = 4), and others (n = 46).

MEASUREMENTS AND RESULTS

Although Cyfra 21-1 clearly differentiated cavitary lung cancer (15.0, 9.1-29.8 ng/ml, median and interquartile range, n = 39) from benign cavitary disease (P < 0.001), and noncavitary lung cancer from benign noncavitary disease (1.7, 0.9-2.6 ng/ml, n = 108, P < 0.001), it could not differentiate noncavitary lung cancer (5.0, 2.1-12.4 ng/ml, n = 104) from benign cavitary diseases (3.3, 1.4-8.3 ng/ml, n = 55, P = 0.45).

CONCLUSIONS

Serum Cyfra 21-1 is a useful tumor marker for differentiating benign from malignant lung diseases. However, different cutoff values are needed, depending on the presence of cavitary lesions. We recommend cutoff values of 30 ng/ml for cavitary lung diseases and 6 ng/ml for noncavitary lung diseases. If there are no radiologic data, a cutoff value of 15 ng/ml is recommended.

Comparison of Tc-99m sestamibi, serum neuron-specific enolase and lactate dehydrogenase as predictors of response to chemotherapy in small cell lung cancer

Neuron-specific enolase (NSE) and lactate dehydrogenase (LDH) are tumor markers of small cell lung cancer (SCLC) which were reported to predict outcome of patients with SCLC. We previously reported that dipyridamole-modulated Tc-99m sestamibi (dipyridamole-MIBI) single photon emission computed tomography (SPECT) could predict the response to chemotherapy in SCLC patients. The purpose of this study was to compare dipyridamole-MIBI and pretreatment serum levels of NSE and LDH for the prediction of response to chemotherapy in SCLC. Twenty-eight SCLC patients underwent dipyridamole-MIBI SPECT 3 to 7 days before starting chemotherapy (80 mg/m2 etoposide and 80 mg/m2 cisplatin every 3 or 4 weeks for at lease two cycles). Serum levels of NSE and LDH were also measured at the same day of the imaging. Tomographic images before and after 0.84 mg/kg dipyridamole infusion were acquired 1 hour after injection of 370 (10 mCi) and 1,110 (30 mCi) MBq MIBI, respectively. The response to chemotherapy was grouped as specified as complete (CR), partial response (PR), no change (NC), and progressive disease (PD), according to the change in tumor size on chest roentgenography and CT. Patients showing CR and PR were classified as responders, and those who showed NC and PD were considered nonresponders. Among the 28 patients, 15 were responders (2 CR, 13 PR) and 13 were nonresponders (11 NC, 2 PD). The change of tumor-to-normal lung ratio (T:NL) after infusion of dipyridamole was significantly higher in responders as compared with nonresponders (0.38 +/- 0.64 vs. -0.38 +/- 0.50, respectively, p = 0.002). However, pretreatment serum NSE and LDH levels did not correlate with the response to chemotherapy. Increase of T:NL after dipyridamole infusion was a strong negative predictor of chemotherapeutic response in SCLC patients, while NSE and LDH could not predict it.

Predictive factors for the second restenosis after coronary interventions

One of the major limitations in coronary intervention is restenosis. This study was aimed to identify clinical, angiographic, and procedural factors that may be related to the second restenosis (SR). We studied 101 patients who underwent more than two follow-up coronary angiograms after two coronary interventions between January 1996 and December 1998 in Chonnam University Hospital (out of 4,092 total coronary interventions in 3,030 patients during the same period). The patients were divided into two groups according to the evidence of SR. Fifty-two patients (group A: 57+/-10 years, M:F = 44:8) who had SR and the other 49 patients (group B: 54+/-9 years, M:F = 44:5) without SR were analyzed. Clinical features, angiographic characteristics, coronary interventional procedures, and other risk factors were compared between two groups by univariate analysis and multivariate stepwise logistic regression analysis was performed for the predictive factors for SR. The clinical variables of age, sex, clinical diagnosis, and risk factors were not different between two groups. The lesion severer than B(2) by AHA/ACC classification were associated with SR (P<0.05). Recurrent angina as an indication for follow-up angiography was associated with SR (P<0.01). Predictive factors associated with SR were patient's subjective symptom and lesion severer than type B(2) according to AHA/ACC classification.

The role of glutathione in the acute nephrotoxicity of sodium dichromate

Ascorbate treatment 30 min prior to sodium dichromate (20 or 30 mg/kg, s.c.) shows higher potency than that of glutathione (GSH) in protecting against both the metabolic disturbance and nephrotoxicity induced by dichromate. However, ascorbate treatment after 2 h of dichromate intoxication had no effect on dichromate-induced blood urea nitrogen (BUN) elevation 3 days after intoxication. In contrast, dichromate-induced glucosuria, which reached maximum levels at 3 days after treatment, was significantly decreased by GSH or N-acetyl cysteine (NAC) treatment, even if its administration was after 24 h of dichromate intoxication. Pretreatment with GSH depletors such as diethyl maleate (DEM) and buthionine sulfoximine (BSO) had no effect on dichromate-induced nephrotoxicity. GSH levels in the liver and kidney were not affected at 3 h after dichromate treatment. However, dichromate significantly increased tissue GSH levels with a marked increase in liver per kidney GSH ratio at 24 h after treatment, if food was withheld subsequent to dichromate treatment, indicating that GSH biosynthesis resulted from the accelerated protein breakdown. These results suggest that GSH-mediated dichromate reduction is not a kinetically favorable pathway in vivo; however, GSH plays an important role in protection against dichromate-induced nephrotoxicity. In addition, the cellular metabolism of dichromate in the early period after treatment is important in the pathogenesis of its nephrotoxicity.

Nephrotoxicity of sodium dichromate depending on the route of administration

A comparison of the effects of intraperitoneal and subcutaneous routes of administration of sodium dichromate on nephrotoxicity in rats was studied. Dichromate when injected subcutaneously (SC group) produced a higher degree of nephrotoxicity than when administered intraperitoneally (IP group). It caused severe progressive proteinuria followed by polyuria and glucosuria, reaching maximum levels at 3 days after treatment in the SC group, whereas it produced mild proteinuria without glucosuria in the IP group. The dose-dependent increases in blood urea nitrogen (BUN) and creatinine concentrations, shown in the SC group, were not observed in the IP group. However, between the two groups, there were no great differences in either the urinary excretion rate of chromium or the electrophoretic patterns of urinary protein in the day 1 urine specimens. Pretreatment of phenobarbital (PB) had no remarkable effect on the dichromate-induced nephrotoxicity. In contrast, it potentiated dichromate-induced hepatotoxicity, the indices of which were the elevation in serum alanine aminotransferase (ALT) activity and hepatic lipid peroxide formation. These results suggest that the dependence of dichromate-induced nephrotoxicity on the route of administration is related to the chemical forms of chromium reaching the kidney, and the necrotizing property of dichromate results from its metabolic fate in vivo.

Effect of sodium dichromate on carbohydrate metabolism

Subcutaneous injection of sodium dichromate into male Sprague-Dawley rats immediately produced a variety of metabolic changes in a dose-dependent manner. Serum lactate and glucose were significantly increased after dichromate treatment, reaching maximum levels at 15 and 30 min, respectively. Then, the toxicity progressively diminished. In contrast, a steady increase in blood urea nitrogen (BUN) concentration was caused by dichromate, reaching maximum levels at 60 min after the administration; elevated BUN levels were sustained for several hours thereafter. Unlike KCN (5 mg/kg, ip) and As2O3 (5 mg/kg, ip), dichromate rapidly decreased serum insulin within 15 min after intoxication in doses of 20 and 40 mg/kg; hypoinsulinemia lasted 60 min. However, insulin levels returned to the normal range at 120 min after treatment. Dichromate-induced metabolic disturbance was also observed in the 24 hr-fasted rats, the response of which was similar to normal rats except for later hyperglycemia. In both cases, the duration time was short (30 to 60 min). Adrenalectomy and insulin pretreatment had no effect on dichromate-induced hyperglycemia. These results suggest that dichromate-induced metabolic disturbance results from the concomitant effects of a sudden decrease in serum insulin level and its direct inhibitory effect on carbohydrate metabolism. In addition, the characteristic biphasic pattern of metabolic disturbance might be related to metabolic fate of dichromate in vivo.

Acute toxic effect of sodium dichromate on metabolism

The effect of sodium dichromate on cellular metabolism was investigated. Intraperitoneal injection of sodium dichromate into the rat (20 or 40 mg/kg) caused significant increases in serum lactate, pyruvate, and creatinine concentrations within 15 min after intoxication. Severe hyperglycemia occurred thereafter, as a result of increased hepatic glycogenolysis, which was seen in the first 2 h after dichromate. However, liver glycogen was resynthesized in 24 h-fasted rats after glucose refeeding. Dichromate decreased serum total amino acids, with a consequent increase in blood urea nitrogen (BUN) concentration. Unlike HgCl2 (2 mg/kg, i.p.), As2O3 (5 mg/kg, i.p.), and KCN (5 mg/kg, i.p.), dichromate showed the largest metabolic disturbance only in the early period after treatment. In addition, dichromate produced cyanosis, which appeared during the period of the accelerated glycolysis and breakdown of creatinine phosphate. Regardless of chemical species, only the hexavalent chromium compounds had an effect on the cellular metabolism. Trivalent chromium compounds had no effect at all. These results suggest that dichromate possesses a characteristic dual action on cellular metabolism, which might be related to its metabolic fate.

Role of chloride ion as an allosteric activator of angiotensin-converting enzyme

The nature of chloride ion as an activator of angiotensin-converting enzyme was studied by a series of kinetic experiments with hog plasma enzyme preparation. The enzyme required the presence of chloride ion for its full catalytic activity, but its requirement of monovalent anion was not absolute. The KA value for the enzyme-chloride binding was estimated to be about 150 mM in all cases regardless of the peptide substrates employed. In the presence of chloride ion, the activity of the enzyme was increased, but its optimum pH was shifted gradually to the alkaline region up to pH 8.2 depending on the concentration of chloride ion. In addition, in the presence of chloride ion, the apparent Km values were reduced markedly while the Vmax values were not much altered; for example, for the hydrolysis of angiotensin I decapeptide, the Km value decreased by a factor of 50 while only an 18% increase in Vmax was observed when the enzyme was saturated with chloride ion. The result suggests that chloride ion acts as a conformational modifier inducing the affinity of synergistic binding of substrate.