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Purpose: To determine whether scanning laser polarimetry with variable corneal compensation (GDx-VCC) or optical coherence tomography (OCT) is helpful for the analysis of the retinal nerve fiber layer (RNFL) thickness in glaucoma subjects with tilted disk., Design: Retrospective case-control study., Methods: We included 21 glaucomatous eyes with tilted disk and 35 glaucomatous eyes without tilted disk. Peripapillary RNFL thickness measurement by GDx-VCC and OCT, and also visual field testing with a Humphrey Field Analyzer program 30-2 (HFA) were performed in all subjects., Results: In the group without tilted disk, the RNFL thickness values obtained with GDx-VCC and OCT analysis had a good correlation with mean deviation (MD), and clearly showed stage-dependent reduction. Conversely, in the group with tilted disk, a discrepancy in the RNFL measurement between GDx-VCC and OCT was observed. The correlation of RNFL measurement to the visual field was further examined at each hemifield (superior and inferior). In the group without tilted disk, the measurements of both instruments at each hemifield were in good correlation with the mean pattern deviation values. However, in the group with tilted disk, the GDx-VCC derived values did not correlate with the visual field defect in both hemifields, whereas OCT was in good association with both mean pattern deviation values. Infrared images acquired with a wavelength of nearly 780 nm revealed a high reflex from the sclera in the tilted disk., Conclusions: Our study has suggested that RNFL analysis by OCT is more suitable for the glaucoma assessment in the tilted disk compared with GDx-VCC.

Purpose: To estimate the risk of retinal detachment in the fellow eye of patients with bilateral high myopia who had retinal detachment associated with macular hole (MH-RD) in one eye., Methods: The present study examined retrospectively 56 patients with bilateral high myopia who had MH-RD. To determine the incidence of involvement of the fellow eye, patients who completed a follow up of 12 months or longer were eligible for the current study., Results: Of 56 patients with MH-RD due to high myopia, 54 had unilateral detachment at presentation and two had bilateral detachment. Of the 54 highly myopic fellow eyes without retinal detachment at presentation, 37 eyes underwent 12 or more months of documented follow up. Mean follow up after initial surgery to the primary eye was 6.5 +/- 4.9 years. During follow up, a macular hole without retinal detachment was noted in one (2.7%) of these 37 eyes. Three other eyes (8.1%) had MH-RD at 1, 2 and 7 years, respectively, after the initial surgery to the primary eye. At the final visit, 12 eyes (32%) had visual acuity of > or =6/9, whereas 12 eyes (32%) had visual acuity of < or =6/60., Conclusions: When patients with bilateral high myopia have MH-RD in one eye, they would be expected to be at increased risk of retinal detachment in the fellow eye.

Background: Methanol is a highly toxic substance used as an industrial solvent and automotive antifreeze. Human consumption of methanol may result in severe visual disturbances. Because optical coherence tomography (OCT) is very useful for evaluating retinal edema and nerve fiber swelling, we used OCT to examine a patient with methanol-induced retinal toxicity., Case: A 37-year-old man who drank industrial alcohol (100 ml/day) for 4 days., Observations: The retinal profiles were evaluated by OCT and fluorescein angiography during the course of treatment. OCT demonstrated peripapillary nerve fiber swelling and accumulation of intraretinal fluid in the acute phase. In the chronic phase, the retinal thickness was diffusely decreased. Steroid pulse therapy was not effective, and his visual acuity was 6/200 OD and 4/100 OS 2 years after the event., Conclusion: OCT was very useful for evaluating the severity of the retinal edema and the temporal changes in the retinal profile.

Purpose: To evaluate visual field defects after radial optic neurotomy (RON) in eyes with central retinal vein occlusion (CRVO)., Methods: Eight patients (eight eyes) underwent RON for macular edema associated with CRVO. Goldmann perimetry was performed on each patient both before and after surgery., Results: Postoperative Goldmann perimetry showed a temporally located wedge-shaped visual field defect consistent with neural damage secondary to RON in seven eyes (88%). After surgery, the visual field decreased from preoperative values by 7% at 3 months (P = 0.30) and by 21% at 12 months (P = 0.0023). Although three patients (38%) were aware of the postoperative visual field defect, only one patient (13%) considered this defect to be a visual disability., Conclusions: After RON, most patients showed a postoperative defect in the temporal visual field consistent with the incision to the optic disk. However, this visual field defect appears to be well tolerated by most patients.

Purpose: To evaluate quantitatively, by means of ultrasound biomicroscopy (UBM), changes in the anterior segment configuration, including the ciliary processes, induced by cataract surgery in eyes with primary angle closure., Design: Retrospective interventional case series., Participants: Thirty-one eyes of 31 patients with primary angle closure or primary angle-closure glaucoma were treated with cataract surgery. Before cataract surgery, 10 eyes had been treated with laser peripheral iridotomy, and 1 with laser peripheral iridoplasty., Methods: Configuration of the anterior chamber was examined by means of UBM before and at 3 months after cataract surgery., Main Outcome Measures: Using UBM, anterior chamber depth (ACD), angle opening distance at points 500 mum from the scleral spur (AOD500), and trabecular-ciliary process distance (TCPD) were measured., Results: Not only ACD and AOD500, but also TCPD, increased significantly after cataract surgery, compared with measurements obtained before surgery (P<0.001). Postoperative AOD500 was correlated significantly with postoperative TCPD (r = 0.72, P<0.001) and with the amount of change of TCPD caused by cataract surgery (Delta TCPD) (r = 0.52, P<0.01)., Conclusions: Cataract surgery attenuated anterior positioning of the ciliary processes in eyes with primary angle closure, concomitant with significant widening of the angle. Cataract surgery resulted in not only complete dissolution of lens volume and pupillary block, but also attenuation of the anterior positioning of the ciliary processes, all of which contributed to postoperative widening of the angle in eyes with primary angle closure.

Background: Although endovascular stent-grafting (SG) has become acceptable for blunt aortic injury (BAI), open surgical repair (OR) does provide reliable, good long-term results. A current surgical strategy for BAI, taking account of associated brain injury, is presented and preferable initial management for BAI is proposed., Methods and Results: The surgical strategy for BAI was established in 2001: SG is performed for patients with obvious brain injuries, but OR is performed for patients without brain injury, and conservative treatment should be used initially for patients with critical non-aortic injuries. Between 2001 and 2004 20 patients with BAI were admitted to hospital: 16 blunt aortic ruptures and 4 blunt aortic dissections. Of them 15 patients underwent surgery (SG, 9; OR, 6) and 5 patients were treated conservatively. One patient died from associated lung injury after SG, all patients treated conservatively died because of associated brain injuries or another rupture of BAI, and 2 elderly patients treated by OR died within 1 year from postoperative respiratory failure., Conclusion: This brain-injury conscious surgical strategy for BAI provided acceptable early results. OR should be chosen for young patients without brain injury, but endovascular SG seems to be a better initial treatment for elderly patients or patients with other comorbidities.

We have analyzed 105 autosomal polymorphic short tandem repeat (STR) loci for nine East and South-eastern Asian populations (two Japanese, five Han Chinese, Thai, and Burmese populations) and a Caucasian population using a multiplex PCR typing system. All the STR loci are genomewide tetranucleotide repeat markers of which the total number of observed alleles and the observed heterozygosity were 756 and 0.743, respectively, for Japanese populations. Phylogenetic analysis for these allele frequency data suggested that the Japanese populations are more closely related with southern Chinese populations than central and/or northern ones. STRUCTURE program analysis revealed the almost clearly divided and accountable population structure at K=2-6, that the two Japanese populations always formed one group separated from the other populations and never belong to different groups at K> or =3. Furthermore, our new allele frequency data for 91 loci were analyzed with those for 52 worldwide populations published by previous studies. Phylogenetic and multidimensional scaling (MDS) analyses indicated that Asian populations with large population size (six Han Chinese, three Japanese, two Southeast Asia) formed one distinct cluster and are closer to each other than other ethnic minorities in east and Southeast Asia. This pattern may be the caviar of comparing populations with greatly differing population sizes when STR loci were analyzed.

It still remains undetermined whether endovascular stent-graft placement (ESGP) is the optimal initial treatment for elective cases of thoracic aortic disease because of unknown long-term results. However, it is also recognized that ESGP contributes to better outcome as an initial treatment for aortic emergency, such as rupture, aortic injury, and complicated acute type B aortic dissection. Despite the fact that most patients are elderly, early mortality rates of ESGP are reportedly around 10% in cases of ruptured degenerative thoracic aortic aneurysm. Postoperative morbidity is also superior in ESGP compared with conventional open repair. Postoperative paraplegia has rarely occurred with ESGP. In cases of blunt aortic injury (BAI), other complications may also be present because of other serious injuries. ESGP has changed the surgical strategy for BAI and partially resolved some of the clinical dilemmas. Early mortality rate is almost zero when a stent graft can be placed before re-rupture. While BAI is a very good indication for ESGP, young patients need careful management and attention because of the unknown long-term outcome. In cases of complicated acute type B aortic dissection, the two main determinants of death, shock from rupture and visceral ischemia, could be managed by ESGP with or without conventional endovascular interventions. Recent reports disclosed less than 10% early mortality with ESGP for complicated acute aortic dissection. Even if the possibility of endotension remains, ESPG seems to be beneficial for these critical patients as the preferable initial treatment. The importance of close follow-up should be stressed to avoid some devastating late complications following ESGP.

We present a case of perforation of the sigmoid colon due to blunt abdominal trauma. Computed tomography showed nominal free air in the inguinal fossa. The distribution of free air may be a clue to the site of an injured intestine. Early detection of intestinal injury is difficult, but repeated computed tomography after several hours may reveal increased free air.

Background: Early defibrillation and cardiopulmonary bypass have been postulated to be a promising intervention against out-of-hospital cardiac arrest (OHCA); however, little is known about the long-term prognosis. The effects of early recovery of circulation (ROC) on neurological recovery and the long-term outcome in patients with OHCA were examined., Methods and Results: Functional recovery and long-term (22.0+/-15.3 months) outcome were examined in 100 patients with definite diagnosis of OHCA. Spontaneous circulation recovered in 79% of the patients (using on-site counter shock in 20% of the patients). Cardiopulmonary bypass was performed in 38 of the OHCA patients. The total survival and favorable neurological recovery rates were 40% and 25%, respectively. The patients with favorable recovery obtained early ROC (28.2+/-16.0 min). Receiver-operating characteristic analysis showed that a period of less than 35 min for ROC was the optimal period for achieving a favorable recovery, with sensitivity of 68% and specificity of 73%. The patients with a prior history of heart failure or reduced left ventricular ejection fraction exhibited more frequent, exacerbated heart failure and ventricular arrhythmias., Conclusions: Early ROC using on-site counter shock or cardiopulmonary bypass might result in better long-term outcome in patients with OHCA of cardiac origin.

The purpose of this study was to investigate a suitable protocol of contrast-enhanced computed tomography (CECT) in cases with a cardiopulmonary support system. Contrast-enhanced computed tomography with intra-arterial injection (IAI) of contrast medium (CM) via a perfusion cannula showed sufficient contrast enhancement in 2 cases of cardiac decompensation (CD). Contrast-enhanced computed tomography with intravenous injection of CM showed insufficient and delayed contrast enhancement of the aorta in 2 cases of CD and 3 cases of pulseless electrical activity. We encourage administration of CM by means of IAI.

Two high-risk patients underwent an endovascular stent-grafting for thoracoabdominal aortic aneurysms (TAAA) following bypass-grafting to the visceral arteries. The first patient was a 73-year-old woman with severe ischemic heart disease (IHD) and chronic respiratory failure. The second patient was a 59-year-old woman with myelodysplastic syndromes (MDSs) and hepatic cell carcinoma (HCC). In general, TAAA is not considered to be indicated for endovascular stent-grafting because of the need to revascularize the visceral vessels. However, in some selected cases, such as the two cases presented herein, endovascular stent-grafting combined with bypass-grafting of the visceral arteries can be a feasible and a less-invasive alternative to conventional surgery.

Purpose: To review the efficacy of a combination of triamcinolone acetonide (TA) injection and pars plana vitrectomy (PPV) for the treatment of macular edema associated with branch retinal vein occlusion (BRVO)., Methods: Seventeen eyes with macular edema associated with BRVO underwent PPV with an intraoperative injection of TA (10 mg) into the vitreous cavity. Residual or recurrent macular edema was treated with postoperative sub-Tenon capsule injections of TA (20 mg)., Results: With PPV and an intraoperative injection of TA, 82% of eyes showed rapid reduction of macular edema; foveal thickness decreased from 507 +/- 115 microm preoperatively to 261 +/- 123 microm 2 months after surgery (P = 0.0041). However, 59% of eyes showed recurrence of macular edema during the follow-up period. Twelve eyes with residual or recurrent macular edema received sub-Tenon capsule injections of TA; of these eyes, 9 showed substantial reduction of macular edema. Foveal thickness decreased from 381 +/- 102 microm to 256 +/- 56 microm (P = 0.0076) 2 weeks after postoperative injections of TA. At the final visit, visual acuity (logMAR) improved from 0.74 +/- 0.40 preoperatively to 0.40 +/- 0.34 (P = 0.010)., Conclusion: An intraoperative injection of TA in combination with PPV has the potential to facilitate the absorption of macular edema associated with BRVO. In addition, residual or recurrent macular edema can be treated with additional sub-Tenon capsule injections of TA.

Background: Neovascular glaucoma (NVG) occurring after branch retinal artery occlusion (BRAO) might not be as rare as previously thought. We report a case of unilateral NVG after BRAO., Case: A 72-year-old man with chronic heart failure suffered from BRAO in the left eye. Funduscopic examination showed retinal edema and many cotton wool spots in the superotemporal retina., Observations: Five weeks later, he had increased blurring of vision due to a second BRAO in the inferotemporal retina of the left eye. Three days later, he felt pain and had severe visual loss in the left eye. In the presence of angle neovascularization, intraocular pressure (IOP) in the left eye rose to 35 mmHg. Immediate focal photocoagulation to the affected retina diminished the neovascularization and lowered the IOP., Conclusion: It is possible for NVG to occur as a complication of BRAO.

Background: We investigated the influence of dialysis on late aortic events in end-stage renal failure patients who had undergone replacement of the thoracic aorta., Methods: Between 1990 and 2003, 28 dialysis patients underwent thoracic aortic aneurysm repair. The cause was non-dissection in 17 patients and dissection in 11 patients. Six patients needed emergency operations. After the initial operation, 10 patients in the dialysis group had a patent false channel distal to the operative area, and 7 patients in the dialysis group had untreated separate aneurysms. These lesions were defined as residual aneurysms. We performed a retrospective case-control analysis of survival and late aortic events (enlargement of the remaining thoracic aorta, sudden death and reoperation) in dialysis patients versus carefully matched non-dialysis patients. Matching criteria included age, sex, cause, operative procedures, operative date, and operative status (elective or emergency)., Results: Survival rates at 1 and 5 years for dialysis patients versus non-dialysis patients were 63 +/- 9% vs. 85 +/- 7% and 41 +/- 11% versus 64 +/- 13%, respectively (p = 0.02). Four of nine late deaths in the dialysis group were due to rupture of residual aneurysm. Freedom from late aortic events for dialysis patients versus non-dialysis patients was 91+/- 6% versus 92 +/- 5% and 25 +/- 14% versus 68 +/- 12% at 1 and 5 years, respectively (p = 0.0073)., Conclusions: There is a high incidence of late aortic events in dialysis patients undergoing thoracic aortic aneurysm repair. This finding indicates the need for close follow-up examination of dialysis patients who have undergone surgical treatment of thoracic aortic disease.

Purpose: To investigate the frequency of residual angle closure after resolution of pupillary blocking by laser peripheral iridotomy and the effects of subsequent cataract surgery to resolve angle closure completely., Design: Retrospective, consecutive, interventional study., Participants: Among 70 eyes treated with laser iridotomy, 13 with residual angle closure were treated with cataract surgery., Methods: The provocative test of angle closure by prone position in a dark room for 1 hour was performed; increases in tension of > or =8 mmHg, 6 or 7 mmHg, and < or =5 mmHg were considered to be positive, suspected positive, and negative, respectively. Configuration of the anterior chamber was examined using ultrasound biomicroscopy (UBM)., Main Outcome Measures: Intraocular pressure (IOP), response to the dark room prone position test, and morphologic analysis by UBM were evaluated before and 3 months after cataract surgery., Results: Residual angle closure after iridotomy was seen in 27 (38.6%) of 70 eyes; this was confirmed functionally by the dark room prone position test and morphologically by UBM. Eyes with IOP of > or =20 mmHg or with a glaucomatous visual field defect before iridotomy had a significantly higher incidence of residual angle closure after iridotomy than eyes without these findings (P<0.05). In all the eyes with residual angle closure after iridotomy, the response to the prone position test became negative after cataract surgery, with significant lowering of IOP (P<0.01)., Conclusions: Residual angle closure after iridotomy was common, especially in eyes with primary angle closure and poorly controlled IOP or glaucomatous optic neuropathy. Cataract surgery was effective to resolve completely the residual angle closure after iridotomy and lower IOP.

Purpose: Exudative retinal detachment in acute Vogt-Koyanagi-Harada syndrome often is associated with subfoveal yellowish round structures. This report describes the incidence and clinical characteristics of these structures., Design: Interventional case series., Methods: We reviewed the fundus photographs and medical records of 35 eyes of 19 Japanese patients with bilateral diffuse choroiditis at the onset of acute Vogt-Koyanagi-Harada syndrome., Results: All eyes showed subretinal fluid in the posterior pole. In addition, yellowish round structures were seen in 15 eyes (43%). Most of the yellowish structures were subfoveal in location and ranged in size from less than 1 disk diameter to 3 disk diameters. In 6 eyes with these structures, optical coherence tomography showed liquid accumulation in the retina or thin walls, which seemed to separate the cystoid spaces from the subretinal fluid. Late-phase fluorescein angiography showed pooling of dye within these structures as well as within the subretinal fluid. Immediately after corticosteroid administration was initiated, these structures began to be less obvious, and they disappeared completely within several days; there was a concomitant reduction in the subretinal fluid. At the initial visit, visual acuity in eyes with these yellowish structures was slightly less than that in eyes without them, but no differences in visual acuity were found during the period of follow-up., Conclusion: Subfoveal yellowish round structures may be a common feature in acute Vogt-Koyanagi-Harada syndrome. However, they appear to have only a minor (if any) effect on visual prognosis.

Objective: The risk of stroke caused by dislodgment of loose atheromatous plaque or mural emboli is increased by cross-clamping of the aorta. Some patients undergo descending thoracic aortic aneurysm repair with proximal aortic cross-clamping between the left common carotid artery and the left subclavian artery. The objective of this study was to determine the influence of proximal aortic cross-clamping in arteriosclerotic aneurysm or dissecting aneurysm repair., Methods: Between May 1984 and May 2003, 81 patients underwent elective surgery for distal arch or descending aortic aneurysm repair with proximal aortic cross-clamping between the left common carotid artery and the left subclavian artery. To evaluate the influence of the proximal aortic cross-clamping, patients were divided into two groups: patients who had undergone arteriosclerotic aneurysm repair (group I, n=25) and patients who had undergone dissecting aneurysm repair (group II, n=56)., Results: Eight (9.9%) of the 81 patients had a stroke. Six strokes occurred in operations for arteriosclerotic aneurysm repair group I and two strokes occurred in operations for dissecting aneurysm repair group II (24 vs 3.6%; p=0.009). In-hospital mortality rates were 12% in group I and 8.9% in group II (p=0.70). Major postoperative complications included renal failure requiring hemodialysis (in 4.2% of the patients in group I and in 8.3% of the patients in group II, p=0.99) and pulmonary complication (in 20% of the patients in group I and in 16% of the patients in group II, p=0.67)., Conclusion: Cross-clamping between head vessels should be avoided if at all possible when operating on patients who have arteriosclerotic descending thoracic aneurysms.

Background: We have performed descending thoracic aortic aneurysm repairs with partial cardiopulmonary bypass, including heparin-coated circuits. The aim of this study was to evaluate (i) the impact of partial cardiopulmonary bypass on distal organ function and surgical outcomes; and (ii) the effectiveness of using heparin-coated circuits for preventing bleeding complications., Methods: From July 1980 to June 2004, 309 patients underwent descending thoracic aortic aneurysm repairs using partial cardiopulmonary bypass. Their mean age was 61 years (range 19-81 years). One hundred of the 309 patients underwent repair of descending thoracic aortic aneurysm with heparin-coated circuits. Blood data for renal and hepatic function were collected on the day before the operation and postoperative days., Results: The in-hospital mortality was 15%. Distal organ dysfunction included spinal cord dysfunction in 2 patients (0.7%) and renal failure necessitating hemodialysis in 15 patients (5%, 15/297: excluded 12 dialysis patients). Multivariate analyses showed that preoperative hemodialysis and emergency operation were risk factors for operative mortality and that emergency operation was a risk factor for requiring hemodialysis. Renal and hepatic function normalized by 2 weeks after surgery. There were no significant differences between the heparin-coated group and nonheparin-coated group in amounts of packed red cells, fresh frozen plasma, and platelets transfused during the procedures., Conclusions: Our data showed that partial cardiopulmonary bypass is a safe and effective method for distal perfusion. Using this technique, descending thoracic aortic aneurysm repair can be performed with acceptable mortality and morbidity. However, the superiority of heparin-coated circuits over nonheparin-coated ones was not proved.

There are few published reports on endovascular stent grafting for thoracic aneurysms in Jehovah's Witnesses. Between 2001 and 2003, we performed endovascular stent grafting for a thoracic aneurysm in three patients of the Jehovah's Witness faith. Two patients had a thoracic aortic aneurysm and one had a chronic type-B dissection. The stent graft was constructed from a self-expanding Z-stent and thin-walled woven polyester fabric. None of the patients required perioperative blood transfusion, there was no postoperative endoleak, and all recovered uneventfully and were discharged from hospital. Thus, stent-graft repair of thoracic aneurysms in Jehovah's Witnesses is feasible and can be achieved without the need for blood transfusion.

Background: We conducted this study to clarify whether the incidence of organ failure after endovascular stent-graft repair of thoracic aneurysm (TAA) and thoracoabdominal aneurysm (TAAA) is much higher than that after surgical repair., Methods: The diseases for surgical repair (surgical group) were TAA in 29 patients and TAAA in 19 patients. Fourteen patients underwent stent-graft repair for TAA and TAAA (stent group). Incidences of preoperative complications in the two groups were compared. Postoperative organ failures, changes in SOFA score and numbers of SIRS criteria were assessed over a period of 7 postoperative days., Results: Although the incidence of preoperative complications in the stent group was significantly higher than that in the surgical group, postoperative organ failure in the surgical group was more frequent than that in the stent group. SOFA score in the stent group during the first 3 postoperative days was significantly smaller than that in the surgical group. However, the number of SIRS criteria in the stent group was significantly higher than that in the surgical group on the first postoperative day., Conclusions: Endovascular stent-graft repair for arotic aneurysm may be less invasive, leading to a reduction in the incidence of postoperative organ failure in high-risk patients.

Purpose: To use progenitor cells isolated from the neural retina for transplantation studies in mice with retinal degeneration., Methods: Retinal progenitor cells from postnatal day 1 green fluorescent protein-transgenic mice were isolated and characterized. These cells can be expanded greatly in culture and express markers characteristic of neural progenitor cells and/or retinal development., Results: After they were grafted to the degenerating retina of mature mice, a subset of the retinal progenitor cells developed into mature neurons, including presumptive photoreceptors expressing recoverin, rhodopsin, or cone opsin. In rho-/- hosts, there was rescue of cells in the outer nuclear layer (ONL), along with widespread integration of donor cells into the inner retina, and recipient mice showed improved light-mediated behavior compared with control animals., Conclusions: These findings have implications for the treatment of retinal degeneration, in which neuronal replacement and photoreceptor rescue are major therapeutic goals.

Background: The mortality of patients with descending thoracic aortic rupture who are treated by conventional surgery is high. Our current strategy for the management of descending thoracic aortic rupture is to treat seriously ill patients with endovascular stent-grafting using handmade grafts, and to treat other patients with traditional open repair. The aim of this study was to assess the early results of our strategy., Methods: Twenty-nine consecutive patients with descending thoracic aortic rupture were referred to Sapporo Medical University Hospital from June 2001 to January 2004. Eighteen of these 29 patients were selected for endovascular stent-grafting because of polytrauma (n = 7), comorbidities (n = 6), advanced age (n = 2), past history of left thoracotomy (n = 2), and patient's preference (n = 1). The remaining 11 patients underwent traditional graft replacement of the diseased aorta. Their outcomes and follow-up data were collected and analyzed retrospectively., Results: The in-hospital mortality rate was 14% (4/29). The mortality rate for surgical patients and stent-grafting patients was 9% (1/11) and 17% (3/18), respectively. The survival rate of patients at 2 years was 63% +/- 10%. In the follow-up period, 2 of the 18 patients who underwent endovascular stent-grafting required open repair, and 1 patient underwent a redo endovascular stent-grafting procedure because of stent failure. One of these 3 patients died of an intraoperative retrograde type A aortic dissection., Conclusions: The early results of endovascular stent-grafting for the treatment of high-risk patients with descending thoracic aortic rupture are promising. Early results of open repair can also be improved by the selection of stabilized patients. However, the requirement of reintervention indicates that detailed follow-up examinations in patients who have undergone endovascular stent-grafting with handmade stent-grafts should be performed.

Background: The purpose of this study was to determine whether the artery of Adamkiewicz (ARM) can be detected by magnetic resonance angiography and to determine the usefulness of preoperative magnetic resonance angiography evaluation of the ARM., Methods: Between April 2000 and December 2003, 120 patients underwent magnetic resonance angiography for detection of the ARM. The morphology of the anterior spinal artery at the ARM junction, as revealed by magnetic resonance angiography, in 99 patients in whom ARM was preoperatively detected was classified into the following three types: noncontinuation of the anterior spinal artery above the ARM junction (type A), continuation of the anterior spinal artery above and below the ARM junction (type B), and noncontinuation of the anterior spinal artery below the ARM junction (type C)., Results: The ARMs were detected in 99 (83%) of 120 patients, and from a total of 110 ARMs 105 (95%) originated from intercostal arteries branching from the left side and 94 (86%) originated between Th9 and Th11. Two ARMs were found in 11 (11%) of 99 patients in whom ARMs were detected. In 107 patients, who underwent magnetic resonance angiography to reveal the morphology of the anterior spinal artery at the ARM junction, the patterns of the anterior spinal artery were type A in 59 patients (55%), type B in 21 patients (20%), type C in 3 patients (3%) and not classified in 24 patients (22%). No spinal cord injury occurred in patients in whom the ARM had been preoperatively detected., Conclusions: Preoperative detection of the ARM is possible by magnetic resonance angiography and is very useful for reducing the incidence of ischemic injury of the spinal cord.

Background: In spite of recent improvements in treatment for acute aortic dissection, mesenteric ischemia secondary to aortic dissection is still challenging. We propose a simple screening method to detect mesenteric ischemia secondary to acute aortic dissection., Methods: From 1991 to 2002, 245 patients with acute aortic dissection were admitted to our hospital. Nine (3.7%) of those were complicated with mesenteric ischemia. The clinical records of those 9 patients were retrospectively analyzed. The ratios of the diameter of the superior mesenteric vein (SMV) to that of the superior mesenteric artery (SMA) were calculated in patients with mesenteric ischemia (group M) and in patients without mesenteric ischemia (group C). Blood test data, including results of arterial blood gas analysis, in the 2 groups were also compared., Results: The SMV/SMA ratios in groups M and C were 1.16 +/- 0.33 and 1.78 +/- 0.29, respectively (P=.003). A cutoff value of the SMV/SMA ratio was 1.5 (sensitivity, 88.9%; specificity, 88.9%) with an odds ratio of 64.0. Although there were differences between the 2 groups in glutamate oxaloacetate transaminase, lactate dehydrogenase, creatine phosphate kinase, pH, and lactate values, the measurement of lactate was especially useful (P=.002)., Conclusions: The combination of the SMV/SMA ratio and lactate concentration is a useful screening method to detect mesenteric ischemia secondary to acute aortic dissection.

Background: Ventricular unloading decreases cardiac ventricular mass. This loss of ventricular mass can be due to either atrophy (a reversible process) or apoptosis (an irreversible process) of the cardiac myocytes. We investigated the effect of ventricular unloading on atrophy and apoptosis of cardiac myocytes, using working and nonworking transplant heart models in rats., Materials and Methods: ACI rats underwent heterotopic heart transplantation with two different techniques to create working and nonworking cardiac grafts. Cardiac grafts were harvested at different time points after transplantation. TUNEL, caspase-3 assay, and electron microscopy were used to assess the degree of apoptosis while cellular atrophy was estimated by calculation of the cytoplasmic index (CI = mean sectional cytoplasmic area/nucleus)., Results: Ventricular mass reduction was more pronounced in nonworking than in working hearts (P < 0.05). Apoptotic index and caspase-3 activities increased in both groups, peaking at 3 days after transplantation, but were not significantly different between the two models. The cytoplasmic index was significantly lower in nonworking than in working grafts (P < 0.05)., Conclusions: These data suggest that cellular atrophy is the primary mechanism that accounts for myocardial weight reduction following ventricular unloading. The inference is that ventricular unloading by ventricular assist devices may not cause permanent loss of cardiac myocytes, thus allowing for functional recovery.

A 35-year-old man sustained a steering wheel injury in a motor vehicle accident. Initial electrocardiography showed ST-segment elevation. Coronary angiography revealed a dissection of the right coronary artery and perfusion delay in the left anterior descending artery. Coronary stents were inserted into the left anterior descending artery. One month later, coronary angiography and intravascular ultrasonography showed that the dissection of the right coronary artery was still present. Coronary stents were inserted from the aorto-ostial lesion to the mid portion of the right coronary artery. Six months later, coronary angiography and intravascular ultrasonography revealed diffuse neointimal hyperplasia inside all of the stents, and the aorto-ostial stent had severe stenosis with perfusion delay. Severe neointimal hyperplasia was found inside the stents used for repair of the coronary artery dissection.

Surgical results were compared between 18 patients (group A) who underwent preoperative anatomic characterization of the Adamkiewicz artery by magnetic resonance angiography (MRA) and 38 patients (group B) without such imaging. In group A, intercostal or lumbar arteries related to the aneurysm were reattached to the graft only when they represented the origin of the Adamkiewicz artery. In group B, reconstruction from the Th 7 intercostal and the L2 lumbar arteries was performed whenever possible. In-hospital mortality was 16.7% in group A and 15.8% in group B. Total aortic clamp time and operating time were only 84 and 437 min in group A, compared with 134 and 589 min in group B. Three patients showed postoperative paraplegia in group B. No spinal cord injury occurred in patients whose artery had been detected preoperatively. Preoperative anatomic delineation of the Adamkiewicz artery by MRA can reduce risk of ischemic injury to the spinal cord and decrease operating time required for repair of thoracoabdominal aortic aneurysms.

Purpose: Acute type-A aortic dissection with a clotted false lumen is often managed conservatively; however, we found that surgery has a better outcome., Methods: Enhanced computed tomography (CT) showed a clotted false lumen in the ascending aorta in 38 (33.3%) of 114 patients with acute type-A aortic dissection. After the exclusion of 8 patients whose condition was too critical for comparison, 13 patients who were hemodynamically stable and did not have pericardial effusion, organ ischemia, or a dilated ascending aorta greater than 50 mm in diameter, were managed conservatively (group C) and 17 were managed surgically (group S). We compared the early and late results of both groups., Results: The early mortality rates were 23.1% in group C and 0% in group S ( P = 0.037). The early deaths in group C were caused by redissection in the acute phase. The actuarial survival rates and dissection-related event-free rates 5 years after onset in groups C and S were 64.1% and 80.8% ( P = 0.131) and 46.2% and 92.9% ( P = 0.002), respectively., Conclusion: The early mortality rate and dissection-related event-free rate were better after surgery than after conservative treatment. The indications for conservative management should be limited because redissection is usually fatal.

Purpose: We evaluated the surgical results of minilaparotomy abdominal aortic aneurysm (AAA) repair in comparison with those of standard open repair and retroperitoneal approach repair., Methods: Between February 2000 and January 2003, 30 patients with AAA underwent minimal incision laparotomy repair (MINI) through an abdominal incision 7-12 cm long. Their clinical characteristics and in-hospital outcome were then compared with those of patients who had undergone repair of AAA by a standard open technique (OPEN) or retroperitoneal approach technique (RETRO)., Results: There were significant differences between the MINI, OPEN, and RETRO groups in the time until the patient was able to resume eating (2.4 +/- 1.0 vs 4.4 +/- 2.4* vs 2.8 +/- 1.9 postoperative days [PODs], respectively; *P < 0.05), the time until ambulation outside the room (2.1 +/- 0.7 vs 3.5 +/- 1.3* vs 2.5 +/- 1.9 PODs, respectively; *P < 0.05), and the operation times (188 +/- 43* vs 256 +/- 77 vs 238 +/- 59 min, respectively; *P < 0.05)., Conclusion: Minilaparotomy repair is a feasible technique, which combines the benefits of a small incision with those of conventional open repair. With the exception of patients with an iliac artery aneurysm extending to the external or internal iliac artery, MINI repair should be considered for the elective treatment of patients with aortic disease.

Both paradoxical intracranial embolism, an intracranial arterial embolism caused by venous embolic material that has passed through a right-to-left shunt, and pulmonary arterial embolism are life-threatening complications of joint arthroplasty. We report a case of severe paradoxical intracranial embolism and pulmonary embolism that occurred during hip hemiarthroplasty.

Purpose: To investigate whether conditioned medium from embryonic rat retinas can induce differentiation of adult rat hippocampus-derived neural stem cells (AHSCs) into neurons and glia in vitro., Methods: AHSCs were cultured in 3 types of media: standard culture medium, conditioned medium from embryonic rat retina, and standard culture medium with retinoic acid. Neuronal and glial differentiation of the cultured cells was assessed by cell growth analysis, flow cytometric analysis, immunofluorescent staining, and RT-PCR analysis., Results: Cells cultured in the standard medium showed very little neuronal and glial differentiation. The cells cultured in the conditioned medium and the medium with retinoic acid showed neuronal morphology and growth inhibition. They also expressed mature neuronal markers and glial markers. In addition, the cells cultured in the conditioned medium expressed Thy-1, HPC-1, and calbindin, which were not found in the previous studies with postnatal retinas in vivo. Those cultured in the medium with retinoic acid expressed HPC-1 and calbindin, but not Thy-1., Conclusions: Conditioned medium from embryonic rat retina contains factors that induce neuronal and glial cell differentiation of AHSCs, and promote up-regulation of some types of retinal cell markers., (Copyright 2003 S. Karger AG, Basel)

Ointments of the skin depigmentation agent hydroquinone (HQ) have been prepared by extemporaneous nonsterile compounding in our hospital. The HQ ointments were highly effective in the treatment of various types of skin pigmentations; however, various problems have emerged including chromatic aberration of the ointments, a relatively large variability of efficacy, and mild topical side effects including irritation. In this paper, the cytotoxicity of HQ was assessed in vitro using rat skin fibroblasts as the concentration with 50% survival after 24 h exposure to be 16.5 microM. The intradermal concentrations at 2 h after application of the HQ ointments was also estimated to be 358 mM and 51.7 mM in stratum corneum and viable tissue (viable epidermis+dermis), respectively, by an in vitro rat skin permeation study with rat full-thickness abdominal skin and Franz-type diffusion cells. It was demonstrated that the intradermal concentration of HQ was much higher than that eliciting cytotoxicity, suggesting that the topical side effects after application of HQ ointment were due to the cytotoxicity of HQ.

Purpose: To evaluate changes in the retinal nerve fiber layer following traumatic optic neuropathy., Design: Observational case report., Methods: A patient presented with visual loss after an accident. Scanning laser polarimetry was performed., Results: Thickness of the retinal nerve fiber layer increased immediately after the trauma but then progressively decreased. Severe loss was observed at day 90 and then ceased. Enlargement of the optic disk cup was also observed., Conclusions: This is the first report documenting early transient increase followed by progressive loss of the retinal nerve fiber layer in traumatic optic neuropathy.

Penetrating cardiac injuries commonly occur secondary to gunshot or stab wounds. This is a report an unusual case of a patient who sustained a penetrating cardiac injury due to a nail from a terrorism-related, nail-bomb explosion. Associated problems included pericardial tamponade, penetrating cardiac injuries, acute, traumatic, myocardial infarction, and a penetrating lung injury. Prompt diagnosis and aggressive surgical intervention resulted in full recovery of the patient.

The use of covered stents in an infected field is controversial. It is generally recommended that infected aneurysms be treated using autografts or allografts. We report a case of infected brachial pseudoaneurysms that developed after medical debridement of a methicillin-resistant Staphylococcus aureus (MRSA)-infected wound of the right arm and emergency brachial artery bypass-grafting using the saphenous vein, which was successfully treated by endovascular stent-grafting followed by antibiotic administration. The present case suggests that endovascular stent-grafting prevents rupture and occlusion of infected aneurysms and enables the continued administration of antibiotics.

A series of clinical studies on the cytochrome P450 2C19 (CYP2C19) genotype and the pharmacokinetics and pharmacodynamics of three proton pump inhibitors (PPIs), omeprazole, lansoprazole and rabeprazole, have been conducted to establish the individualized pharmacotherapy based on the CYP2C19 genotyping, and in the present study, the CYP2C19 genotype-dependency was more pronounced for omeprazole than the other two. Herein, to validate further the difference among 3 PPIs in CYP2C19 genotype-dependency on the phenotype, a comparative in vitro study was conducted using the human liver microsomes and newly developed anti-human CYP antibodies. The residual concentrations of omeprazole and lansoprazole in 5 lots of human liver microsomes were dependent on the CYP2C19 activities, however, for rabeprazole, there was no correlation. The hydroxylation of omeprazole was more inhibited by anti-CYP2C19 antibody than lansoprazole, whereas anti-CYP3A4 antibody showed similar inhibition. In conclusion, the relative contribution of CYP2C19 on total metabolism of 3 PPIs elucidated herein coincided with the CYP2C19 genotype-dependent pharmacokinetics.

We report a case of late mediastinal false aneurysm originating from disruption of the suture line between synthetic vascular grafts for aortic root and total aortic arch replacements. This aneurysm developed without any infection in a patient with Marfan's syndrome. To our knowledge, this event has never been reported before. The only possible cause of this disruption was that the monofilament suture was broken by continuous friction between the pointed anastomotic line and the sternum since the operation. The treatment options for this unusual event after extended synthetic graft replacement are discussed.

One hundred eighty two patients with thoracic aortic aneurysms or dissections who required total arch replacement (TAR) were operated on with separated graft technique and selective cerebral perfusion (SCP) between 1991 and 2000. These patients were divided into 4 groups according to the pathology as follows: group 1; acute type A dissection, group 2; chronic type A dissection, group 3; distal arch aneurysm and group 4; proximal arch aneurysm. For SCP, both the innominate artery and the left common carotid artery were cannulated when the patient was cooled to a rectal temperature of 22 degrees C. Hospital mortalities were 27% in group 1, 14% in group 2, 19% in group 3, and 8% in group 4. Independent predictors of hospital mortality were shock, visceral, and leg ischemia in group 1, and circulatory arrest time of the lower half body to be more than 1 hour and cardiopulmonary bypass time to be more than 5 hours in group 3. Permanent neurological complication occurred in 3% in group 1 and 8% in group 3. Hospital mortality was affected by the type of aneurysms and dissections. It is necessary to give careful consideration to the indication of TAR with SCP, especially in acute type A dissection and distal arch aneurysm.

A successful surgical treatment (vitrectomy) for bilateral bullous retinal detachment in a patient with Vogt-Koyanagi-Harada (VKH) disease is reported. A 78-year-old woman had severe reduction of visual acuity in both eyes because of an extremely bullous nonrhegmatogenous retinal detachment accompanied by VKH disease. We performed lens extraction and vitrectomy on both eyes combined with systemic and topical corticosteroid therapy. The retina was reattached immediately after the surgery and her visual acuity promptly improved in both eyes. She had no recurrence of retinal detachment even after tapering the dose of corticosteroid. We suggest that vitrectomy may be an effective therapeutic option in the treatment for severe bullous retinal detachment associated with VKH disease.

Objectives: To report the satisfactory recovery of a woman with acute aortic dissection who underwent cardiopulmonary resuscitation out of hospital and to show that there are still chances of recovery for patients with prehospital cardiopulmonary arrest even due to acute aortic dissection., Design: Case report., Setting: An adult critical care unit of a university hospital., Patients: A 71-yr-old woman who had a cardiopulmonary arrest out of hospital. Cardiopulmonary resuscitation was performed before arriving at the emergency room of our hospital., Interventions: Cardiopulmonary resuscitation, echocardiography, computed tomography, aortography, coronary angiography, ascending aortic graft replacement, and brain hypothermia., Measurement and Main Results: Restoration of spontaneous circulation was gained 45 mins after onset of cardiopulmonary arrest. Echocardiographic and computed tomographic images revealed cardiac tamponade caused by type A acute aortic dissection. Since involuntary movements of the extremities in response to noxious stimulation were observed at 30 mins after restoration of spontaneous circulation, we performed an ascending aortic graft replacement and postoperative mild brain hypothermia. The patient recovered satisfactorily 1 month after the operation., Conclusion: The results of this case indicate that there are still chances of recovery for patients with prehospital cardiopulmonary arrest, even due to acute aortic dissection. We propose that an appearance of involuntary movements of the extremities in response to noxious stimulation is one key point that should be considered when deciding whether to perform an emergency operation for this kind of patient.