We herein report a rare case of an inflammatory pseudotumor arising from the mitral valve. A 58-year-old man who was undergoing maintenance dialysis was referred to us due to the presence of a tumor mass attached to the mitral valve. It was asymptomatic and had been coincidentally found by echocardiography. The tumor mass was a sphere measuring about 1 cm in size, and it arose from the posterior mitral leaflet. A myxoma of the left atrium was suspected, and the tumor mass was resected along with part of the posterior leaflet by means of a right minithoracotomy (MICS). The tumor was postoperatively diagnosed to be an inflammatory pseudotumor based on the findings of a histopathological examination. During the follow-up period of 1 year and 2 months after surgery, there was no recurrence. An inflammatory pseudotumor is a tumorous lesion characterized by the infiltration of inflammatory cells and the growth of myofibroblasts. This tumor occurs most frequently in the lung, and the greatest number of intracardiac cases have been reported in small children. There are few reports of inflammatory pseudotumors occurring in adults, and only 4 cases originating in the mitral valve has so far been reported, which means that such tumors are extremely rare. For this reason, we reported the findings of this case, while adding a bibliographical survey.

Aplastic anemia is a syndrome characterized by pancytopenia, and performing an open heart operation for patients with this syndrome may be associated with an increased surgical risk for both bleeding and post-surgical infection. We report a case of mitral regurgitation complicated with aplastic anemia that underwent a mitral valve repair via a right lateral minithoracotomy. The patient was a 70-year-old woman who presented with shortness of breath on exertion. She was found to have aplastic anemia based on pancytopenia (WBC 2,150/µl, Hgb 8.8 g/dl, PLT 5.0×10⁴/µl) and the results of a bone marrow biopsy. Echocardiography showed severe mitral valve insufficiency at the same time, and the patient was referred for surgery. To deal with the decrease in white blood cells and platelets, prior to surgery, a granulocyte colony-stimulating factor was administered, 30 units of platelet concentrate were transfused during the operation, and mitral valve repair via a right lateral minithoracotomy was performed. After surgery, there were no complications due to infection or bleeding, and the subsequent course was favorable. Several studies have reported the advantages in right minithoracotomy of less intraoperative bleeding and a lower infection rate compared with full sternotomy. In cases of this kind, in which there is a tendency toward bleeding and ease of infection, we believe that right lateral minithoracotomy may be a useful option to consider.

Late acute type A aortic dissection after coronary artery bypass grafting (CABG) is rare, and only a few cases have been published in the literature. It is important to treat cases of living graft during reoperation. We report a successful surgical treatment in a case of late acute type A aortic dissection after CABG. A 68-year-old man underwent a triple CABG (to the left anterior descending artery with left internal thoracic artery, to the left circumflex artery with left radial artery, and to the right coronary artery with right gastroepiploic artery) beating heart procedure using a centrifugal pump and pulmonary assist with closed circuit due to unstable angina pectoris in December 2007 and had presented with sudden anterior chest pain, and was found to have an ascending aortic dissection (type A) on enhanced computed tomography in May, 2009. We performed ascending artery replacement, paying special attention to the living graft performed through a median sternotomy. The postoperative course was uneventful and he was discharged on the 22nd postoperative day.

A 39-year-old woman with Marfan's syndrome was referred with a symptom of exertional dyspnea, had mitral valve regurgitation, annuloaortic ectasia with aortic valve regurgitation and Stanford B type chronic aortic dissection. She was successfully treated with a one-stage operation, consisting of aortic root replacement with the Carrel patch method, mitral valve replacement and extended replacement of the thoracic aorta (ascending, arch and thoracic descending aorta), through median sternotomy and left antero-axillary thoracotomy. This operation was performed under hypothermic circulatory arrest with continuous retrograde cerebral perfusion. The postoperative course was uneventful. Although the operation may include complicated procedures, it is important to perform a sufficient operation corresponding to the patient's condition and lesions, employing the most advanced surgical techniques, such as circulatory arrest, myocardial protection and so on.

We have done the questionnaire about patients with hepatocellular carcinoma in Yamaguchi prefecture. The result was that 304 cases were answered. The mean age was 62.1 years old, and the ratio of male to female was 3.7 to 1. Abdominal ultrasonography was examined most frequently, and the next was computed tomography as the method of diagnosis. The serum α-fetoprotein level showed less than 400ng/ml in cases of 49.3%. HBs antigen was positive in cases of 15.9%. Positive cases were significantly lower in the mean age as compared with negative cases, and the ratio of male to female was 8.2 to 1. Liver cirrhosis was complicated in cases of 84%.

A first case is a 43-year-old male. He was admitted after hard drinking, and died two days later for hepatic coma. It is thought that this case applies to a diagnostic criteria of severe alcoholic hepatitis made by a Japanese reserch group about the relation of alcohol to liver. A second case is a 45-year-old male. He was also admitted after hard drinking, but he recovered rapidly. This case was diagnosed as Zieve's syndrome, because hyperlipemia and hemolytic anemia were found.
Volumes of liver and spleen in these two cases were examined by computed tomography. Volumes of liver were more increased and those of spleen were more decreased than those of controls. In a second case a volume of liver was decreased gradually, and that of spleen was increased with recovery from sickness. It is thought that a volume of liver is increased in a patient with alcoholic hepatitis, because liver cells fall into ballooning. But the cause is unknown as yet that a volume of spleen is decreased.

A 73-year-old man diagnosed with severe aortic regurgitation by transthoracic echocardiography was referred to our hospital. Quadricuspid aortic valve was diagnosed on preoperative transesophageal echocardiography. We performed aortic valve replacement with a bioprosthetic valve. In the operation, the accessory cusp was found to be located between the right coronary and noncoronary cusps, and the cusps had multiple fenestrations near the commissures.

Purpose: In Kasugai City Hospital, we have introduced palliative care clinical pathway with a focus on decision-making support on the intention of recuperation location in addition to symptom relief. In this study, it is intended to explore the factors that make it difficult to home discharge of cancer inpatients with the intention of discharged home on the basis of the information on the clinical pathway. Methods: The subject patients were cancer inpatients who had expressed the intention of the discharge to the home during period from June 2014 to August 2015. We examined the medical records of the target patient retrospectively. Logistic regression analysis was performed in order to clarify the factors that make it difficult to home discharge. Results: Of 43 patients, 25 patients (58.1%) were discharged from the hospital to the home. As a result of logistic regression analysis (multivariate analysis), delirium and living alone have been extracted as the predictive factors that makes it difficult to home discharge. Conclusion: Delirium and living alone have been suggested as the factors that makes it difficult to home discharge of patients who wish to home discharge. Early detection and early treatment of delirium are important, and early collaboration between the hospital discharge support department and palliative care team for the living alone patient is also necessary.

STUDY DESIGN: Case control study. PURPOSE: To identify the most significant laboratory marker for early detection of surgical site infection (SSI) using multiple logistic regression analysis. OVERVIEW OF LITERATURE: SSI is a serious complication of spinal instrumentation surgery. Early diagnosis and treatment are crucial. METHODS: We retrospectively reviewed the laboratory data of patients who underwent posterior lumbar instrumentation surgery for degenerative spinal disease from January 2003 to December 2014. Six laboratory markers for early SSI detection were considered: renewed elevation of the white blood cell count, higher at 7 than 4 days postoperatively; renewed elevation of the C-reactive protein (CRP) level, higher at 7 than 4 days postoperatively; CRP level of >10 mg/dL at 4 days postoperatively; neutrophil percentage of >75% at 4 days postoperatively; lymphocyte percentage of <10% at 4 days postoperatively; and lymphocyte count of <1,000/µL at 4 days postoperatively. RESULTS: Ninety patients were enrolled; five developed deep SSI. Multivariate regression analysis showed that a lymphocyte count of <1,000/µL at 4 days postoperatively was the sole significant independent laboratory marker for early detection of SSI (p=0.037; odds ratio, 11.9; 95% confidence interval, 1.2–122.7). CONCLUSIONS: A lymphocyte count of <1,000/µL at 4 days postoperatively is the most significant laboratory marker for early detection of SSI.
Biomarkers* ; C-Reactive Protein ; Case-Control Studies ; Early Diagnosis ; Humans ; Leukocyte Count ; Leukocytes ; Logistic Models ; Lymphocyte Count ; Lymphocytes ; Lymphopenia* ; Neutrophils ; Odds Ratio ; Retrospective Studies ; Spinal Diseases ; Surgical Wound Infection*

STUDY DESIGN: Case-control study. PURPOSE: To identify the characteristics of candidate indexes for early detection of surgical site infection (SSI). OVERVIEW OF LITERATURE: SSI is a serious complication of spinal instrumentation surgery. Early diagnosis and treatment are crucial for the welfare of the patient postoperation. METHODS: We retrospectively reviewed laboratory data of patients who underwent posterior lumbar instrumentation surgery for degenerative spine disease. The sensitivity and specificity of six laboratory markers for early detection of SSI were calculated: greater elevation of the white blood cell count at day 7 than at day 4 postoperatively, greater elevation of the C-reactive protein (CRP) level at day 7 than at day 4 postoperatively, a CRP level of >10 mg/dL at 4 days postoperatively, neutrophil percentage of >75% at 4 days postoperatively, a lymphocyte percentage of <10% at 4 days postoperatively, and a lymphocyte count of <1,000/µL at 4 days postoperatively. Statistical analysis was via Fisher's exact test and a p-value of <0.05 was considered significant. RESULTS: In total, 85 patients were enrolled. Of these, five patients developed deep SSI. The sensitivity and specificity of each index were as follows: index 1, 20.0% and 77.5%; index 2, 20.0% and 83.8%; index 3, 40.0% and 97.5%; index 4, 40.0% and 86.3%; index 5, 0% and 96.3%; and index 6, 80.0% and 80.0%. A significant difference was noted for indexes 3 and 6. CONCLUSIONS: A CRP level of >10 mg/dL at 4 days postoperatively would be useful for definitive diagnosis of SSI, and a lymphocyte count of <1,000/µL at 4 days postoperatively would be a useful screening test for SSI. Although laboratory markers for early detection of SSI have been frequently reported, we believe that it is important to understand the characteristics of each index for a precise diagnosis.
Biomarkers ; C-Reactive Protein* ; Case-Control Studies ; Diagnosis ; Early Diagnosis ; Humans ; Leukocyte Count ; Lymphocyte Count ; Lymphocytes ; Lymphopenia* ; Mass Screening ; Neutrophils ; Retrospective Studies ; Sensitivity and Specificity ; Spine