BACKGROUND: Although the same treatment strategy has been applied for patients with aortic intramural hematoma (AIH) as typical aortic dissection (AD), the natural history of AIH with medical treatment is not known clearly. The purposes of this study were to test the hypothesis that absence of direct flow communication through intimal tear in AIH has different impact on clinical course compared with typical AD and to clarify the natural history of AIH. METHODS: Total 181 patients of acute aortic pathology (AD / AIH =57 / 124) were enrolled from 5 institutions. Patients received medical treatment without surgical intervention regardless of the affected site in acute stage, and follow-up imaging studies (FUIS) were performed in 105 patients with AIH. Clinical data of these patients were retrospectively analyzed. RESULTS: Fifty-four patients showed involvement of the ascending aorta (AD / AIH =13 / 41) and 127 revealed distal pathology (AD / AIH =44 / 83). Compared to the patients with AD, those with AIH were older regardless of the type and showed higher incidence of pleural effusion and mediastinal hemorrhage. In-hospital mortality of proximal AIH was 7 %, which was significantly lower than that of proximal AD (62 %); mortality of distal AIH was also lower than that of distal AD (1.2 Vs 9 %, p < 0.05). In proximal AIH, FUIS confirmed resorption of AIH in 67 %(24/36) and development of AD in 25 %(9/36). In distal AIH, resorption was confirmed in 78 %(54/69) and development of AD in 16 %(11/69). CONCLUSIONS: Patients with AIH showed excellent clinical course and high rate of resorption with medical treatment regardless of the affected site; typical AD developed only in limited cases. Absence of direct flow communication through intimal tear in AIH might explain more favorable response to medical treatment than typical AD.
Aorta ; Follow-Up Studies* ; Hematoma* ; Hemorrhage ; Hospital Mortality ; Humans ; Incidence ; Mortality ; Natural History ; Pathology ; Pleural Effusion ; Retrospective Studies

Aneurysms of the distal anterior cerebral artery (DACA) are rare and their surgical treatments present some unique difficulties from a technical standpoint. In this report, we presented our experiences of cases with DACA aneurysms, and analyzed the clinical features and prognostic factors affecting the final outcomes. Among 770 cases of intracranial aneurysms operated from 1990 to 1998, 19 cases of DACA aneurysms (2.5%) were studied retrospectively. The characteristic findings were female preponderance (M:F=1:2.8), common multiple aneurysms (57.9%), and frequent intracerebral hemorrhage (ICH) on initial brain CT scan (42.1%). All patients were operated via interhemispheric approach. Intraoperative aneurysmal rupture was developed only in 3 cases (15.8%), and had no relationship with the final outcome Fifteen out of 19 patients (78.9%) showed favorable outcome with a mortality rate of 5.3%. The follow-up data suggest that the initial ICH on brain CT scan portend a poor prognosis.
Adult ; Age Distribution ; Aged ; Cerebral Hemorrhage/mortality/pathology/surgery ; Female ; Human ; Incidence ; Intracranial Aneurysm/mortality/*pathology/*surgery ; Male ; Middle Age ; Sex Distribution ; Treatment Outcome

PURPOSE: The laparoscopic adrenalectomy (LA) has become the preferred procedure for adrenal tumors due to many advantages; a more rapid and comfortable recovery, shortened hospitalization period, and fewer complications. This study reports on an initial 4 year period of experience with LA and describes various unusual findings encountered during the treatment. METHODS: From February 1997 to November 2000, a total of 20 LA were performed. Of the several LA techniques previously described we prefer the transabdominal approach in the lateral decubitus position utilizing 3 or 4 trocars, and this method was employed in all the cases presented here. RESULTS: All 20 patients had a unilateral tumor. The pathological findings consisted of 11 aldosteronomas, 6 Cushing adenomas, 2 pheochromocytomas and 1 cortical carcinoma. Of the 20 patients, 18 were successfully operated with the laparoscopic procedure and the remaining 2 cases were converted to open adrenalectomy. The reasons for conversion were sudden cardiac arrest of unknown origin in one and intraoperative bleeding due to periadrenal massive fat in the other. During LA, 2 patients with non-catecholamine-secreting cortical adenomas pathologies displayed abnormal EKG findings, which reverted to normal after the operation. The average complete LA operation times was 186 minutes in the first 9 cases and 132 minutes in the next 9 cases. The first oral intake was started within 24 hours in all cases. There were no postoperative complications, operative morbidity or mortality. The average hospital stay was 6.2 days in the first 9 cases and 4.2 days in the next 9 cases. CONCLUSION: LA is a relatively fast and safe method and has become is accepted as the preferred procedure for adrenal tumors but it requires good perioperative preparation. Surgeons and anesthesiologists need to be aware of the possible cardiovascular complications and of the problems inherent in the manipulation of the adrenal gland during LA.
Adenoma ; Adrenal Glands ; Adrenalectomy* ; Death, Sudden, Cardiac ; Electrocardiography ; Hemorrhage ; Hospitalization ; Humans ; Length of Stay ; Mortality ; Pathology ; Pheochromocytoma ; Postoperative Complications ; Surgical Instruments

Medical tangles caused by the death of women and infants in perinatal period are very normal in the forensic appraisal. The author collected and analyzed 49 cases of these tangles from many aspects, such as sex and age of the dead, hospital,information of autopsy, fault of medical action and so on,and discovered the normal causes of death, medical action's effects and the causes of tangle. It would be useful to the forensic appraisal, settlement and prevention of these medical tangles.
Adult ; Asphyxia Neonatorum/mortality* ; Autopsy ; Cause of Death ; Female ; Forensic Pathology ; Humans ; Infant, Newborn ; Male ; Malpractice/legislation & jurisprudence* ; Maternal Mortality ; Postpartum Hemorrhage/mortality* ; Pregnancy ; Respiratory Tract Diseases/mortality* ; Retrospective Studies ; Young Adult

Hypernatremic dehydration is an important cause of intracranial hemorrhage. A possible association of intraventricular hemorrhage (IVH) with hypernatremia and/or high sodium intake has been suggested in preterm infants. To investigate the associations of early fluid and sodium intake or serum sodium concentrations with severe intraventricular hemorrhage (IVH) in extremely low birth weight (ELBW) infants, we reviewed the medical records of 169 inborn ELBW infants. Daily fluid and sodium intake, urine output, weight loss and serum sodium concentration during the first 4 days of life were obtained. Patients were divided into the severe IVH (grade 3/4) and the control (no or grade 1/2 IVH) group. The maximum serum sodium concentration and the incidence of hypernatremia did not differ between the two groups. Related to the fluid balance and sodium intake, the risk for severe IVH was strongly associated with total fluid and sodium intake during the initial four days of life. With respect to the fluids other than transfusion, severe IVH can be discriminated only by sodium intake but not by fluid intake. Large randomized controlled trials are required to clarify the causal relationship between the early sodium intake and severe IVH in ELBW infants.
Birth Weight ; Dehydration ; Drinking ; Heart Ventricles/*pathology ; Hemorrhage/mortality/*pathology ; Humans ; Hypernatremia/*blood ; Infant ; Infant Mortality ; Infant, Extremely Low Birth Weight/*blood ; Infant, Newborn ; Infant, Premature ; Infant, Premature, Diseases/epidemiology ; Retrospective Studies ; Sodium/*blood ; Sodium, Dietary

Hypernatremic dehydration is an important cause of intracranial hemorrhage. A possible association of intraventricular hemorrhage (IVH) with hypernatremia and/or high sodium intake has been suggested in preterm infants. To investigate the associations of early fluid and sodium intake or serum sodium concentrations with severe intraventricular hemorrhage (IVH) in extremely low birth weight (ELBW) infants, we reviewed the medical records of 169 inborn ELBW infants. Daily fluid and sodium intake, urine output, weight loss and serum sodium concentration during the first 4 days of life were obtained. Patients were divided into the severe IVH (grade 3/4) and the control (no or grade 1/2 IVH) group. The maximum serum sodium concentration and the incidence of hypernatremia did not differ between the two groups. Related to the fluid balance and sodium intake, the risk for severe IVH was strongly associated with total fluid and sodium intake during the initial four days of life. With respect to the fluids other than transfusion, severe IVH can be discriminated only by sodium intake but not by fluid intake. Large randomized controlled trials are required to clarify the causal relationship between the early sodium intake and severe IVH in ELBW infants.
Birth Weight ; Dehydration ; Drinking ; Heart Ventricles/*pathology ; Hemorrhage/mortality/*pathology ; Humans ; Hypernatremia/*blood ; Infant ; Infant Mortality ; Infant, Extremely Low Birth Weight/*blood ; Infant, Newborn ; Infant, Premature ; Infant, Premature, Diseases/epidemiology ; Retrospective Studies ; Sodium/*blood ; Sodium, Dietary

The study aimed to investigate the impact of intraclot recombinant tissue-type plasminogen activator (rt-PA) on perihematomal edema (PHE) development in patients with intracerebral hemorrhage (ICH) treated with minimally invasive surgery (MIS) and the effects of intraclot rt-PA on the 30-day survival. We reviewed the medical records of ICH patients undergoing MIS between October 2011 and July 2013. A volumetric analysis was done to assess the change in PHE and ICH volumes at pre-MIS (T1), post-MIS (T2) and day 10-16 (T3) following diagnostic computed tomographic scans (T0). Forty-three patients aged 52.8±11.1 years with (n=30) or without rt-PA (n=13) were enrolled from our institutional ICH database. The median rt-PA dose was 1.5 (1) mg, with a maximum dose of 4.0 mg. The ratio of clot evacuation was significantly increased by intraclot rt-PA as compared with controls (77.9%±20.4% vs. 64%±15%; P=0.046). From T1 to T2, reduction in PHE volume was strongly associated with the percentage of clot evacuation (ρ=0.34; P=0.027). In addition, PHE volume was positively correlated with residual ICH volume at the same day (ρ ranging from 0.39-0.56, P<0.01). There was no correlation between the cumulative dose of rt-PA and early (T2) PHE volume (ρ=0.24; P=0.12) or delayed (T3) PHE volume (ρ=0.19; P=0.16). The 30-day mortality was zero in this cohort. In the selected cohort of ICH patients treated with MIS, intraclot rt-PA accelerated clot removal and had no effects on PHE formation. MIS aspiration and low dose of rt-PA seemed to be feasible to reduce the 30-day mortality in patients with severe ICH. A large, randomized study addressing dose titration and long-term outcome is needed.
Adult ; Aged ; Brain Edema ; drug therapy ; mortality ; pathology ; surgery ; Cerebral Hemorrhage ; drug therapy ; mortality ; pathology ; surgery ; Female ; Humans ; Male ; Middle Aged ; Minimally Invasive Surgical Procedures ; Tissue Plasminogen Activator ; administration & dosage ; Tomography, X-Ray Computed ; Treatment Outcome

OBJECTIVETo investigate the clinical epidemiology change trend of upper gastrointestinal bleeding (UGIB) over the past 15 years.

METHODSConsecutive patients who was diagnosed as continuous UGIB in the endoscopy center of The First Affiliated Hospital of Sun-Yat University during the period from 1 January 1997 to 31 December 1998 and the period from 1 January 2012 to 31 December 2013 were enrolled in this study. Their gender, age, etiology, ulcer classification, endoscopic treatment and hospitalization mortality were compared between two periods.

RESULTSIn periods from 1997 to 1998 and 2012 to 2013, the detection rate of UGIB was 9.99%(928/9 287) and 4.49%(1 092/24 318)(χ=360.089, P=0.000); the percentage of male patients was 73.28%(680/928) and 72.44% (791/1 092) (χ=0.179, P=0.672), and the onset age was (47.3±16.4) years and (51.4±18.2) years (t=9.214, P=0.002) respectively. From 1997 to 1998, the first etiology of UGIB was peptic ulcer bleeding, accounting for 65.2%(605/928)[duodenal ulcer 47.8%(444/928), gastric ulcer 8.3%(77/928), stomal ulcer 2.3%(21/928), compound ulcer 6.8%(63/928)],the second was cancer bleeding(7.0%,65/928), and the third was esophageal and gastric varices bleeding (6.4%,59/928). From 2012 to 2013, peptic ulcer still was the first cause of UGIB, but the ratio obviously decreased to 52.7%(575/1092)(χ=32.467, P=0.000)[duodenal ulcer 31.9%(348/1092), gastric ulcer 9.4%(103/1092), stomal ulcer 2.8%(30/1092), compound ulcer 8.6%(94/1092)]. The decreased ratio of duodenal ulcer bleeding was the main reason (χ=53.724, P=0.000). Esophageal and gastric varices bleeding became the second cause (15.1%,165/1 092, χ=38.976, P=0.000), and cancer was the third cause (9.2%,101/1 092, χ=3.352, P=0.067). The largest increasing amplitude of the onset age was peptic ulcer bleeding [(46.2±16.7) years vs. (51.9±18.9) years, t=-5.548, P=0.000), and the greatest contribution to the amplitude was duodenal ulcer bleeding [(43.4±15.9) years vs. (48.4±19.4) years, t=-3.935, P=0.000], while the onset age of esophageal and gastric varices bleeding [(49.8±14.1) years vs. (48.8±13.9) years, t=0.458, P=0.648] and cancer [(58.4±13.4) years vs. (58.9±16.7) years, t=-0.196, P=0.845] did not change significantly. Compared with the period from 1997 to 1998, the detection rate of high risk peptic ulcer rebleeding (Forrest stage I(a, I(b, II(a and II(b) increased (χ=39.958, P=0.000) in the period from 2012 to 2013. From 1997 to 1998, 54 patients underwent endoscopic treatment, and the achievement ratio of hemostasis was 79.6% (43/54). From 2012 to 2013, 261 patients underwent endoscopic treatment and the achievement ratio of hemostasis was 96.9%(253/261), which was significantly higher (χ=23.287, P=0.000). Compared to the period from 1997 to 1998, more patients with variceal bleeding or non-variceal bleeding received endoscopic treatment in time (39.0% vs. 70.3%, χ=51.930, P=0.000; 3.6% vs. 15.6%, χ=62.292, P=0.000, respectively), and higher ratio of patients staging Forrest stage I(a to II(b also received endoscopic treatment in the period from 2012 to 2013 [27.4%(26/95) vs. 68.5%(111/162), χ=40.739, P=0.000]. More qualified endoscopic hemostatic techniques were used, containing thermocoagulation (0 vs. 15.2%, χ=79.518, P=0.000), hemostatic clip (0 vs. 55.9%, χ=20.879, P=0.000), hemostatic clip combined with thermocoagulation (4.3% vs. 16.4%, χ=5.154, P=0.023), while less single injection was used (87.1% vs. 6.2%, χ=10.420, P=0.001), and single spraying for hemostasis was completely abandoned in the period from 2012 to 2013. The ratio of inpatients undergoing reoperation decreased obviously in the period from 2012 to 2013 [9.3%(86/928) vs. 6.0%(65/1092), χ=7.970, P=0.005], while no significant difference was found in mortality during hospitalization between two periods.

CONCLUSIONCompared with the period from 1997 to1998, the mean onset age of UGIB increased, and the ratio of peptic ulcer bleeding decreased due to the reduction of duodenal ulcer bleeding, the detection rate of high risk peptic ulcer rebleeding increased, the cure rate of endoscopic treatment for UGIB increased, more reasonable and immediate hemostatic methods were used, but overall mortality did not change obviously in the period from 2012 to 2013.

Adult ; Age of Onset ; Aged ; Electrocoagulation ; methods ; trends ; Endoscopy, Digestive System ; trends ; Esophageal and Gastric Varices ; pathology ; therapy ; Esophagus ; pathology ; Female ; Gastrointestinal Hemorrhage ; classification ; epidemiology ; etiology ; mortality ; Gastrointestinal Neoplasms ; pathology ; Hemostasis, Endoscopic ; methods ; trends ; Hemostatic Techniques ; trends ; Hemostatics ; therapeutic use ; Humans ; Male ; Middle Aged ; Peptic Ulcer ; pathology ; therapy ; Peptic Ulcer Hemorrhage ; pathology ; therapy ; Reoperation ; trends ; Stomach Ulcer ; pathology ; therapy ; Surgical Instruments ; trends ; Ulcer ; epidemiology ; therapy

PURPOSE: The laparoscopic adrenalectomy (LA) has become the preferred procedure for adrenal tumors since it has many advantages; a more rapid and comfortable recovery, shorted hospitalization, and fewer complications. The purpose of this study was to report the initial 4 years experiences of LA and describe the unusual findings encountered during the operations. METHODS: From February 1997 to November 2000, a total of 20 LA were performed. Several techniques of LA have been described already. We prefer the transabdominal approach in the lateral decubitus position using 3 or 4 trocars. RESULTS: 20 patients had all unilateral tumor. The pathological findings were 11 aldosteronomas, 6 Cushing adenomas, 2 pheochromocytomas and 1 cortical carcinoma. 18 cases of 20 patients were successfully operated by laparoscopic procedure and 2 cases were converted to open adrenalectomy. The reasons of conversion were sudden cardiac arrest due to unknown origin and intraoperative bleeding due to periadrenal massive fat. During the laparoscopic operation, 2 patients showed abnormal EKG findings. The pathologies of those patients were non-catecholamine-secreting cortical adenomas. After operation, they have been completely normal in EKG. The average operating time for the complete laparoscopic adrenalectomies was 186 minutes in the first 9 cases and 132 minutes in the next 9 cases. The first oral intake was started within 24 hours in all cases. There was no postoperative complication and no operative morbidity or mortality. The average hospital stay was 6.2 days in the first 9 cases and 4.2 days in the next 9 cases. CONCLUSION: The LA is relatively fast and safe method and is accepted as the preferred procedure for the adrenal tumors but it should be well prepared perioperatively. Surgeons and anesthesiologists should be aware of those possible cardiovascular complications and of the problems inherent in the manipulation of the adrenal gland during LA.
Adenoma ; Adrenal Glands ; Adrenalectomy* ; Death, Sudden, Cardiac ; Electrocardiography ; Hemorrhage ; Hospitalization ; Humans ; Length of Stay ; Methods ; Mortality ; Pathology ; Pheochromocytoma ; Postoperative Complications ; Surgeons ; Surgical Instruments

We have recently identified a new clinical syndrome in patients receiving warfarin for anticoagulation therapy. This syndrome has been named warfarin-related nephropathy (WRN), and patients with chronic kidney disease (CKD) appear to be particularly susceptible. WRN is defined as an acute increase in international normalized ratio (INR) to > 3.0, followed by evidence of acute kidney injury (AKI) within 1 week of the INR increase. AKI was defined as a sustained increase in serum creatinine of greater than or equal to 0.3 mg/dL. The AKI cannot be explained by any other factors, and the kidney biopsy demonstrates extensive glomerular hemorrhage with tubular obstruction by red blood cells (RBCs). Beyond AKI, WRN is a significant risk factor for mortality within the first 2 months of diagnosis and it accelerates the progression of CKD. We demonstrated that 5/6 nephrectomy in rats is a suitable experimental model to study WRN. Animals treated with warfarin showed an increase in serum creatinine and morphologic findings in the kidney similar to those in humans with WRN. Our recent evidence suggests that novel oral anticoagulants may induce AKI. Diagnosis of WRN may be challenging for a renal pathologist. A few cases with suspected WRN and pathologic considerations are described.
Acute Kidney Injury* ; Animals ; Anticoagulants* ; Biopsy ; Creatinine ; Diagnosis ; Erythrocytes ; Hemorrhage ; Humans ; International Normalized Ratio ; Kidney ; Models, Theoretical ; Mortality ; Nephrectomy ; Pathology* ; Rats ; Renal Insufficiency, Chronic ; Risk Factors ; Warfarin