Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study

OBJECTIVES

Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]).

DESIGN

Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS).

SETTING

Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020.

PATIENTS

A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822).

CONCLUSIONS

Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.

An adult right inguinal hernia and cryptorchidism treated simultaneously with laparoscopic transabdominal preperitoneal repair and laparoscopic orchiectomy: a case report

Pediatric health checkups have been mandatory for all citizens since 1966 based on the Maternal and Child Health Law in Japan, and cryptorchidism or undescended testis in adult males are rare. We report a case of an adult right inguinal hernia and cryptorchidism treated simultaneously with laparoscopic transabdominal preperitoneal repair and laparoscopic orchiectomy. A 35-year-old man came to our department with a chief complaint of bulging in the right inguinal region for several months. He was diagnosed with a right inguinal hernia and was scheduled for transabdominal preperitoneal repair. During intraoperative intraperitoneal observation, a white 30-mm mass was found in the hernia orifice. A diagnosis of right cryptorchidism was made, and transabdominal preperitoneal repair and laparoscopic orchiectomy were performed. Laparoscopic simultaneous surgery could be safely performed in an adult patient with a hernia complicated by a cryptorchidism. It can be recommended as a surgical option in such cases.

Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020)

OBJECTIVES

Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children.

DESIGN/SETTING

Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020.

PATIENTS

Critically ill children, 0 to 17 years old, undergoing TI in PICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002).

CONCLUSIONS

In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.

Extramedullary hematopoiesis in gastric wall under early gastric cancer in a man with a myeloproliferative disorder: a case report

Extramedullary hematopoiesis (EMH) is the proliferation of hematopoietic stem cells outside the bone marrow and often observed in the liver, spleen in association with myeloproliferative disorders. On the other hand, EMH in the gastric wall is extremely rare. We report a rare case of EMH foci coexisting with early gastric cancer, which resulted in severe gastrointestinal bleeding. A 70-year-old male was diagnosed with myelofibrosis 4 years ago and visited our emergency room with a complaint of hematemesis and tarry stools. Upper gastrointestinal endoscopy revealed three early-stage gastric cancers in the lower gastric body and antrum, and biopsy was performed. Persistent bleeding at the biopsy site of the hypogastric lesion led to the consideration of surgical intervention. An open distal gastrectomy was performed. Postoperative histopathological examination revealed the tumor of the lower gastric body had EMH foci associated with myelofibrosis.

Intubation practice and outcomes among pediatric emergency departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS)

BACKGROUND

Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets.

METHODS

Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpO₂ < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED.

RESULTS

A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs.

CONCLUSIONS

While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.

Small-sized Pulmonary Adenocarcinoma Manifesting Skip-like Transition from Nonsolid Nodule: A Case Report

This report shows a case with a rare small-sized lung adenocarcinoma that rapidly progressed from a nonsolid nodule (NSN) to a solid nodule (SON) over a period of just 1 year after a very long-term observation from its first detection. In 2007, the patient was an asymptomatic 52-year-old man at the time of the first detection via chest low-dose computed tomography (CT) screening as part of a periodic medical checkup at our hospital. It revealed an abnormal shadow in another location of the lung field, necessitating a more thorough examination. Then, he visited our outpatient clinic for the first time and a workup examination was performed using thin-section CT (TSCT) images, which incidentally detected a small NSN with a maximum diameter of 1.2 cm in the mid-zone of the left upper lung field. Since it did not disappear in the periodic subsequent workup examinations, the patient was informed of the suspicious early lung adenocarcinoma each time; however, the patient desired to continue watchful waiting. The radiographical properties of the NSN remained almost unchanged until 2019, but in 2020, the inside of the nodule showed a skip-like change to a SON. Finally, because of the unexpectedly fast transition, consent for lobectomy could be obtained. Surgery was then performed, 13 years after its first detection, at an age of 65 years. The pathological findings revealed a 1.2 cm, pT1bN0M0, pStage IA2-adenocarcinoma, which was 90% of the acinar subtype with positive vascular permeation. Management of a NSN, that does not resolve and/or change, must continue watchful waiting, and at the very least continue follow-up with TSCT observation to ensure the safe and appropriate timing of excision using imaging as a marker of transition.

Treatment of comatose patient from cyclobenzaprine overdose with therapeutic plasma exchange

We present a case of a 15-year-old female who was admitted in a comatose state with no spontaneous respiratory effort and absence of brainstem reflexes after cyclobenzaprine ingestion. Due to severe presentation and recent ingestion of high plasma protein binding medication with long half-life, therapeutic plasma exchange (TPE) was performed and resulted in full neurological recovery. This case explores the role of TPE as an effective treatment option for life-threatening cyclobenzaprine overdose. TPE is generally beneficial for drugs that have a low volume of distribution and high plasma protein binding. Cyclobenzaprine is known to have a relatively high volume of distribution. However, in the case of drug intoxication with relatively high-volume distribution, high protein binding, and long half-life, TPE could be effective if it is conducted promptly.

Deficiency in ST2 signaling ameliorates RSV-associated pulmonary hypertension

Pulmonary hypertension (PH) observed during respiratory syncytial virus (RSV) bronchiolitis is associated with morbidity and mortality, especially in children with congenital heart disease. Yet, the pathophysiological mechanisms of RSV-associated PH remain unclear. Therefore, this study aimed to investigate the pathophysiological mechanism of RSV-associated PH. We used a translational mouse model of RSV-associated PH, in which wild-type (WT) and suppression of tumorigenicity 2 (ST2) knockout neonatal mice were infected with RSV at 5 days old and reinfected 4 wk later. The development of PH in WT mice following RSV reinfection was evidenced by elevated right ventricle systolic pressure, shortened pulmonary artery acceleration time (PAT), and decreased PAT/ejection time (ET) ratio. It coincided with the augmentation of periostin and IL-13 expression and increased arginase bioactivity by both arginase 1 and 2 as well as induction of nitric oxide synthase (NOS) uncoupling. Absence of ST2 signaling prevented RSV-reinfected mice from developing PH by suppressing NOS uncoupling. In summary, ST2 signaling was involved in the development of RSV-associated PH. ST2 signaling inhibition may be a novel therapeutic target for RSV-associated PH.NEW & NOTEWORTHY We report that the pathogenic role of ST2-mediated type 2 immunity and mechanisms contribute to RSV-associated pulmonary hypertension. Inhibiting ST2 signaling may be a novel therapeutic target for this condition.

Effect of patent ductus arteriosus on pulmonary vascular disease

The hemodynamic effects of a patent ductus arteriosus (PDA) are well known including systemic hypoperfusion and volume overload on the left ventricle. This article aims to provide a review of the long-standing effect of a hemodynamically significant PDA on the pulmonary vasculature and the role of cardiac catheterization in preterm infants with a PDA and pulmonary hypertension.

New mouse model of pulmonary hypertension induced by respiratory syncytial virus bronchiolitis

Pulmonary hypertension (PH) has been observed in up to 75% of infants with moderate to severe respiratory syncytial virus (RSV) bronchiolitis and is associated with significant morbidity and mortality in infants with congenital heart disease. The purpose of the present study was to establish a mouse model of PH secondary to RSV bronchiolitis that mimics the disease etiology as it occurs in infants. Neonatal mice were infected with RSV at 5 days of age and then reinfected 4 wk later. Serum-free medium was administered to age-matched mice as a control. Echocardiography and right ventricular systolic pressure (RVSP) measurements via right jugular vein catheterization were conducted 5 and 6 days after the second infection, respectively. Peripheral capillary oxygen saturation monitoring did not indicate hypoxia at 2-4 days post-RSV infection, before reinfection, and at 2-7 days after reinfection. RSV-infected mice had significantly higher RVSP than control mice. Pulsed-wave Doppler recording of the pulmonary blood flow by echocardiogram demonstrated a significantly shortened pulmonary artery acceleration time and decreased pulmonary artery acceleration time-to-ejection time ratio in RSV-infected mice. Morphometry showed that RSV-infected mice exhibited a significantly higher pulmonary artery medial wall thickness and had an increased number of muscularized pulmonary arteries compared with control mice. These findings, confirmed by RVSP measurements, demonstrate the development of PH in the lungs of mice infected with RSV as neonates. This animal model can be used to study the pathogenesis of PH secondary to RSV bronchiolitis and to assess the effect of treatment interventions. NEW & NOTEWORTHY This is the first mouse model of respiratory syncytial virus-induced pulmonary hypertension, to our knowledge. This model will allow us to decipher molecular mechanisms responsible for the pathogenesis of pulmonary hypertension secondary to respiratory syncytial virus bronchiolitis with the use of knockout and/or transgenic animals and to monitor therapeutic effects with echocardiography.

Severe Pulmonary Vascular Obstructive Disease After Neonatal Arterial Switch Operation for Simple Transposition of the Great Arteries

Neonatal arterial switch operation for simple dextro-transposition of the great arteries (d-TGA) has almost eliminated the occurrence of pulmonary vascular obstructive disease compared to patients who underwent Mustard or Senning procedure at an older age. We report a case of a neonate with d-TGA and intact ventricular septum who underwent arterial switch operation and yet developed severe pulmonary vascular obstructive disease within two months.

Plasma Biomarker Analysis in Pediatric ARDS: Generating Future Framework from a Pilot Randomized Control Trial of Methylprednisolone: A Framework for Identifying Plasma Biomarkers Related to Clinical Outcomes in Pediatric ARDS

OBJECTIVE

Lung injury activates multiple pro-inflammatory pathways, including neutrophils, epithelial, and endothelial injury, and coagulation factors leading to acute respiratory distress syndrome (ARDS). Low-dose methylprednisolone therapy (MPT) improved oxygenation and ventilation in early pediatric ARDS without altering duration of mechanical ventilation or mortality. We evaluated the effects of MPT on biomarkers of endothelial [Ang-2 and soluble intercellular adhesion molecule-1 (sICAM-1)] or epithelial [soluble receptor for activated glycation end products (sRAGE)] injury, neutrophil activation [matrix metalloproteinase-8 (MMP-8)], and coagulation (plasminogen activator inhibitor-1).

DESIGN

Double-blind, placebo-controlled randomized trial.

SETTING

Tertiary-care pediatric intensive care unit (ICU).

PATIENTS

Mechanically ventilated children (0-18 years) with early ARDS.

INTERVENTIONS

Blood samples were collected on days 0 (before MPT), 7, and 14 during low-dose MPT (n = 17) vs. placebo (n = 18) therapy. The MPT group received a 2-mg/kg loading dose followed by 1 mg/kg/day continuous infusions from days 1 to 7, tapered off over 7 days; placebo group received equivalent amounts of 0.9% saline. We analyzed plasma samples using a multiplex assay for five biomarkers of ARDS. Multiple regression models were constructed to predict associations between changes in biomarkers and the clinical outcomes reported earlier, including P/F ratio on days 8 and 9, plateau pressure on days 1 and 2, PaCO2 on days 2 and 3, racemic epinephrine following extubation, and supplemental oxygen at ICU discharge.

RESULTS

No differences occurred in biomarker concentrations between the groups on day 0. On day 7, reduction in MMP-8 levels (p = 0.0016) occurred in the MPT group, whereas increases in sICAM-1 levels (p = 0.0005) occurred in the placebo group (no increases in sICAM-1 in the MPT group). sRAGE levels decreased in both MPT and placebo groups (p < 0.0001) from day 0 to day 7. On day 7, sRAGE levels were positively correlated with MPT group PaO2/FiO2 ratios on day 8 (r = 0.93, p = 0.024). O2 requirements at ICU transfer positively correlated with day 7 MMP-8 (r = 0.85, p = 0.016) and Ang-2 levels (r = 0.79, p = 0.036) in the placebo group and inversely correlated with day 7 sICAM-1 levels (r = -0.91, p = 0.005) in the MPT group.

CONCLUSION

Biomarkers selected from endothelial, epithelial, or intravascular factors can be correlated with clinical endpoints in pediatric ARDS. For example, MPT could reduce neutrophil activation (⇓MMP-8), decrease endothelial injury (⇔sICAM-1), and allow epithelial recovery (⇓sRAGE). Large ARDS clinical trials should develop similar frameworks.

TRIAL REGISTRATION

https://clinicaltrials.gov, NCT01274260.

Regulation of inflammatory biomarkers by intravenous methylprednisolone in pediatric ARDS patients: Results from a double-blind, placebo-controlled randomized pilot trial

OBJECTIVE

A double-blind, randomized controlled trial showed that low-dose glucocorticoid therapy in pediatric ARDS patients is feasible and may improve both ventilation and oxygenation indices in these patients. However, the molecular mechanisms underlying potential changes in outcomes remain unclear. Based on these clinical findings, this study was designed to examine the effects of intravenous methylprednisolone on circulating inflammatory biomarkers in pediatric ARDS patients.

DESIGN

Double-blind, placebo-controlled randomized trial with blood collection on study entry and day 7.

SETTING

Tertiary care children's hospital.

PATIENTS

Children (0-18years) with ARDS undergoing mechanical ventilation.

INTERVENTIONS

35 children were randomized within 72h of mechanical ventilation. The glucocorticoid group received methylprednisolone 2mg/kg loading dose followed by 1mg/kg/day continuous infusion from days 1 to 7. Both groups were ventilated following the ARDSnet recommendations. WBC and differential cell counts, plasma cytokines and CRP levels, and coagulation parameters were analyzed on days 0 and 7.

RESULTS

At study entry, the placebo group had higher IL-15 and basophil levels. On day 7, in comparison to study entry, the placebo group had lower IL-1α, IFN-γ and IL-10 levels. The glucocorticoid group had lower INF-α, IL-6, IL-10, MCP-1, G-CSF and GM-CSF levels, and higher IL-17α levels on day 7 in comparison to study entry. Total and differential cell counts remained unchanged within the placebo group between days 0 and 7, whereas in the glucocorticoid group total WBC and platelets counts were increased on day 7. Pearson's correlation studies within the placebo and glucocorticoid groups revealed positive and negative correlations between cytokine levels, cell counts, coagulation parameters and relevant clinical parameters of disease severity identified in our previous study. Multiple regression models identified several cytokines as predictors for alterations in clinical parameters of disease severity.

CONCLUSION

This pilot study shows the feasibility of simultaneously measuring multiple inflammatory cytokines, cell counts and coagulation parameters in pediatric ARDS patients. We report statistical models that may be useful for future, larger trials to predict ARDS severity and outcomes.

Management of massive diffuse alveolar hemorrhage in a child with systemic lupus erythematosus

Diffuse alveolar hemorrhage (DAH) from systemic lupus erythematosus (SLE) is a rare but potentially life-threatening condition. We report the case of a 14-year-old female with SLE who developed hypoxia and shock secondary to severe alveolar hemorrhage. She was successfully managed by placement on extracorporeal membrane oxygenation (ECMO) followed by emergent pulmonary lobectomy and medical treatment including high-dose methylprednisolone, cyclophosphamide, intravenous immunoglobulin, and plasmapheresis.

Flt3 ligand treatment modulates parasitemia during infection with rodent malaria parasites via MyD88- and IFN-γ-dependent mechanisms

We previously showed that treatment of mice with the Flt3 ligand (Flt3L) prevents development of lethal experimental cerebral malaria and inhibits parasitemia during Plasmodium berghei ANKA (PbA) infection. In this study, we investigated the mechanisms underlying the reduction of parasitemia in Flt3L-treated mice. Studies using gene knockout mice and antibody treatment indicated that the anti-parasitemia effect of Flt3L was mediated by innate immune system and was dependent on MyD88, IFN-γ, IL-12 and natural killer (NK) cells. The number of NK cells and their ability to produce IFN-γ was enhanced in Flt3L-treated mice. Phagocytic activity of splenocytes was increased in Flt3L-treated mice after PbA infection when compared with that in untreated mice, and this activity was mainly mediated by the accumulation of F4/80(mid) CD11b(+) cells in the spleen. In both MyD88(-/-) and IFN-γ(-/-) mice, the proportion of F4/80(mid) CD11b(+) cells was not increased in the spleen of Flt3L-treated mice after infection. These correlations suggest that NK cells produce IFN-γ in Flt3L-treated mice, and accumulation of F4/80(mid) CD11b(+) cells in the spleen is promoted by an IFN-γ -dependent manner, culminating in the inhibition of parasitemia. These findings imply that Flt3L promotes effective innate immunity against malaria infection mediated by interplay among varieties of innate immune cells.

[Three primary cancers of pulmonary cancer, malignant melanoma and esophageal cancer; report of a case]

A 61-year-old man, who had medical history of hepatitis type C, surgery for malignant melanoma of the lower limb, endoscopic mucosal resection for esophageal cancer, was pointed out a pulmonary nodule in the right middle lobe by surveillance computed tomography after 5 years of surgery for melanoma. Pathology of esophageal cancer was squamous cell carcinoma limited in mucosa without lymphatic nor venous invasion. The nodule gradually enlarged and respiratory endoscopic examination could not establish pathological diagnosis. Thoracoscopy-assisted pulmonary biopsy revealed squamous cell carcinoma, and right middle lobectomy with mediastinal node dissection was performed. Histological examination showed moderately differentiated squamous cell carcinoma without lymph node involvement. The stage of lung cancer was T1N0M0, stage IA. Although 9 months have passed since surgery for lung cancer, recurrence of each malignancy has not been detected.

In-Situ Observation of UV/Ozone Oxidation of Silicon using Spectroscopic Eli Psometry

Initial oxidation process of silicon in UV/ozone ambient has been monitored using a multi-wavelength, in-situ spectroscopic ellipsometry. Ozone gas was chemically formed by photochemical reaction of oxygen under ulUmviolet illuimination. The oxide growth was monitored for hydrogenated silicon surfaces as functions of oxygen gas flow rate, gas pressure and wafer temperature. Initial oxidation rates were very high at almost all the temperatures. The oxidation rate was 0.2 nm/min about ten times higher than that for thermal oxidation without UV light at low temperatures. The accelerated oxidation was probably due to an electric field effect on the oxidation of back-bond silicon by active oxygen atoms included in the ozone gas.

Dermatoglyphic Asymmetry is Related to Perceptual Asymmetry and to Interhemispheric Transmission

The numbers of ridges on the fingertips is asymmetrical between hands and is also sexually dimorphic. Most people have more ridges on the right hand (rightward dermatoglyphic asymmetry; R >) and men typically have more ridges than women. The direction of dermatoglyphic asymmetry has been shown to be related to patterns of cognitive abilities in men and women and to perceptual asymmetry in homosexual men. W e assessed presumptively heterosexual, right-handed men and women who had either R > (n = 35) or L > (n = 30) ridge count, on: (1) dichotic listening to words; (2) two tachistoscopic tasks sampling visual field asymmetries (dot location and letter identification); and (3) a tachistoscopic task designed to examine interhemispheric transmission. L > subjects had a smaller right-ear advantage than R > subjects, but this was accounted for by an increased incidence of an atypical left-ear advantage in the L > group. Visual field asymmetries were also smaller in the L > group but the asymmetry measures did not reach significance, with the exception of an increased incidence of an atypical field advantage (left) for letter recognition only. On the interhemispheric transfer task, L > subjects performed relatively faster on tasks requiring interhemispheric comparisons than did R > subjects. These findings confirm an association between the direction of dermatoglyphic asymmetry and aspects of brain organisation.

[Assessment of surgical treatment for lung cancer with pericardial or left atrial invasion]

We evaluated surgical results for the patients who underwent pulmonary resection combined with pericardial or left atrial resection due to locally advanced non-small cell lung cancer (NSCLC). Seven patients who underwent pericardial resection (T3 group) and 4 patients who underwent resection of the left atrium (T4 group) were included in this study, and clinical findings and prognosis were evaluated. Eight patients underwent pneumonectomy, and others underwent lobectomy or bilobectomy. Histology of the cancer was squamous cell carcinoma in all patinets. As for pathological node involvement, N0/N1 disease was 72.7% and N2 disease was 27.3%. Induction chemotherapy was performed in 75.0% of T4 group. Adjuvant chemotheraphy was performed in 71.4% of T3 group and 75.0% of T4 group. Five-year-survival was 57.1% in T3 group and 25.0% in T4 group. Five-year-survival was 62.5% in N0/N1 disease and 0% in N2 disease. Statistical significance in prognosis was seen in lymph node status (p = 0.0317). Extended resection of pericardium or left atrium for patients with N2 disease of NSCLC is not recommended. When invasion to pericardium or left atrium is diagnosed during surgery, extended resection should be indicated in patient without N2 metastasis.

Does hypercapnia ameliorate hyperoxia-induced lung injury in neonatal rats?

Therapeutic hypercapnia (TH), an intentional inhalation of CO(2), has been shown to improve pulmonary function in certain models of lung injury. We tested the null hypothesis that TH does not improve hyperoxic lung injury in neonatal rats. The prospective, randomized study was set at Research laboratory in Children's Hospital. Forty-five newborn rats were randomly assigned to three groups (n = 15/group), and exposed to 96 h of normoxia (FiO(2) = 0.21), hyperoxia (FiO(2) > 0.98), and TH (FiO(2) = 0.95, FiCO(2) = 0.05). Lung histology, wet-weight to dry-weight ratio, and concentrations of pro- and anti-inflammatory cytokines (IL-1beta, IL-6, TNF-alpha, and IL-10) were used to evaluate pulmonary damage. Using a scale of 0-4, the total scores for lungs hypercellularity, inflammation, and hemorrhage was significantly increased from a median value of 1.5 in normoxia to 2.5 in hyperoxia (P < 0.05) and 3.0 with TH (P < 0.001, nonparametric ANOVA). The interstitial space relative to the alveolar space, as a measure of hypercellularity, was increased by 18% during hyperoxia and by 44% with TH compared with normoxia. TH significantly increased the size of the interstitial space by 22% compared with hyperoxia (P < 0.001). The lung wet-weight to dry-weight ratio was increased by 10% in both hyperoxic groups (P < 0.001). Both hyperoxic groups showed significant reductions in the concentration of IL-1beta compared with normoxia (P < 0.001), whereas the ratio of IL-1beta to IL-10 was significantly decreased, indicating an anti-inflammatory trend. TH does not prevent histological manifestations of hyperoxic lung injury in spontaneously breathing neonatal rats and may worsen the outcome.

Immunological response to (1,4)-alpha-D-glucan in the lung and spleen of endotoxin-stimulated juvenile rats

We investigated the effects of (1,4)-alpha-D-glucan (alpha-DG), a novel immune stimulatory drug from Tinospora cordifolia, on the concentration of pro- and anti-inflammatory cytokines (interleukin [IL]-1beta, IL-6, tumour necrosis factor-alpha [TNF-alpha], gamma-interferon [IFN-gamma] and IL-10) in the lung and spleen of endotoxin-stimulated juvenile rats. Experimental groups (n = 16/group) included controls with an intraperitoneal injection of saline, endotoxaemic rats with a non-lethal dose of 10 mg/kg Escherichia coli endotoxin, and endotoxaemic rats treated with two doses of 10 mg/kg alpha-DG, intraperitoneally, 2 and 4 hr after endotoxin injection. At 24 hr of treatment, rats were euthanized and lungs and spleen were removed for cytokines determination and lung injury. Endotoxaemia increased IL-1beta concentration by fivefold in both organs, while creating a moderate pulmonary hypercellularity (demonstrated by about 11% increase in the alveolar-septal thickening and 11% decrease in the alveolar-interstitial space ratio). In the lung, alpha-DG treatment reduced concentrations of IL-1beta by 30% (p > 0.05), IL-6 by 43% (p < 0.01), IFN-gamma by 46% (p < 0.01) and the anti-inflammatory cytokine, IL-10, by 31% (p > 0.05) compared to endotoxaemia. In the spleen, alpha-DG treatment decreased the ratio of IL-1beta to IL-10 by 55% (p < 0.05), demonstrating an anti-inflammatory trend. These data suggest that alpha-DG differentially modulates cytokine response in the lung and spleen and modifies the pro- and anti-inflammatory balance during an early period of endotoxaemia in juvenile rats.

Outcomes of 23- and 25-gauge transconjunctival sutureless vitrectomies for idiopathic macular holes

BACKGROUND/AIMS

To assess the outcomes of 23-gauge sutureless transconjunctival vitrectomies (TSV), as compared with 25-gauge TSV in macular hole surgeries.

METHODS

A retrospective, consecutive, interventional case series of 47 eyes with idiopathic macular holes treated by 23- or 25-gauge TSV were analysed.

RESULTS

The operative time was 37.2 (SD 8.9) min with 23-gauge TSV and 34.2 (8.7) min with 25-gauge TSV (p = 0.388). The anatomical success rate was 96% with 23-gauge TSV and 92% with 25-gauge TSV (p>0.999). The logarithm of the minimum angle of resolution of best-corrected visual acuity (BCVA) at the sixth postoperative month was 0.19 (0.16) with 23-gauge TSV and 0.19 (0.25) with 25-gauge TSV (p = 0.521). Postoperative improvement in BCVA was comparable between the two TSVs. IOP on postoperative day 1 was lower with 25-gauge TSV (12.3 (4.9) mm Hg) than with 23-gauge TSV (17.4 (5.8) mm Hg) (p = 0.036). Complications included retinal break, intraoperative bleeding and slippage of the infusion cannula with 23-gauge TSV, while retinal detachment and postoperative hypotony occurred in the 25-gauge TSV group (p = 0.570).

CONCLUSION

23-gauge TSV appears to be as safe and effective as 25-gauge TSV in macular hole surgery.

[Thymic carcinoid tumor with Cushing syndrome]

A case of a 71-year-old male with ectopic adrenocorticotropic polypeptide (ACTH)-producing thymic carcinoid tumor presenting Cushing's syndrome was reported. This patient had symptoms of fatigue and a polyposia for 2 years before a mediastinal tumor was detected. Chest computed tomography (CT) scan demonstrated an anterior mediastinal mass, and serum ACTH and cortisol level revealed very high. Secretion of cortisol was not inhibited in an 8-mg dexamethazone suppression test. We diagnosed ectopic ACTH-producing tumor, and performed complete excision of the thymus including thymic tumor. Histologically, the tumor demonstrated typical carcinoid with the positivity of ACTH immunostaining. After the operation, ACTH and cortisol levels were reduced and the clinical symptoms were improved rapidly. We have concluded that it is important to control serum perioperative cortisol level for the prevension of morbidity.

Infection dynamics of Centrocestus armatus cercariae (Digenea: Heterophyidae) to second intermediate fish hosts

The infection dynamics of Centrocestus armatus cercariae with respect to second intermediate fish hosts were investigated using cercariae collected from naturally infected Semisulcospira libertina. Cercariae survival and infectivity were recorded at 2-hr intervals. Survival remained constant but decreased abruptly at 30 hr of age. An age-dependent model presented the best-fit curve for the survival data (r2 0.936), implying that cercariae tended to allocate resources equally among themselves and then died once those resources were depleted. Cercariae infectivity remained constant over the first 10 hr of life and then declined; an age-dependent model also provided a better fit (r2 = 0.956). The transmission rate of C. armatus cercariae to the fish host was relatively low near the time of emergence from the snail host but peaked at 85% after 1 hr and then maintained a plateau period until 5 hr of exposure to fish. The pattern of transmission was also investigated initially at varying densities of cercariae and then by maintaining a constant cercariae density but varying the total number. Results revealed that the pattern of transmission was frequency-dependent.

The role of bisphosphonates and bone health issues in Japanese Breast Cancer patients: Efficacy of alendronate with aromatase inhibitors

10777

Background: Adjuvant hormonal therapy for postmenopausal breast cancer is now one of the most significant therapies in the world. From the results of the ATAC trial and the ITA trial, standard hormonal therapy for postmenopausal breast cancer has changed from tamoxifen to aromatase inhibitor. However concerning the rate of bone-relating complications including bone fracture, osteoporosis, a decrease in bone mineral density (BMD), aromatase inhibitor is reported higher than tamoxifen. According to the 2003 ASCO guidelines on the role of bisphosphonates in women with breast cancer, most women with newly diagnosed breast cancer are at risk of osteoporosis due to either their age or their breast cancer treatment. The Panel recommended an algorithm for patient management to maintain bone health. The purpose of the study is to investigate the efficacy of bisphosphonate for prevention from osteoporosis by aromatase inhibitor in Japanese women with breast cancer. Methods: From 2002 to 2004, we experienced 92 cases of postmenopausal Japanese women who underwent breast cancer operations and take aromatase inhibitor after operations in Tokyo Medical University hospital. We selected two medicines. One is Anastrozole (ArimidexR) as an aromatase inhibitor, and the other is Alendronate (BonalonR) as a bisphosphonate medicine.We investigated the change of BMD, calcium, bone absorption marker like NTX, I-CTP. Results: The value of NTX which patients take Alendronate with Anastrozole decreased about 40% than which patients take Anastrozole alone. Also the rate of bone-relating complications is lower.The mean value of BMD, % YAM, T-score, Z-score is 0.86, 81.0, −1.52, 1.47, respectively. Conclusions: The results suggest the efficacy of bisphosphonate for prevention from bone-relating complications osteoporosis by aromatase inhibitor in Japanese women with breast cancer.

No significant financial relationships to disclose.

Clinical significance of 99mTc-DTPA-galactosyl human serum albumin liver scintigraphy in follow-up patients with biliary atresia

PURPOSE

Technetium 99m DTPA-galactosyl human serum albumin (GSA) liver scintigraphy was performed in follow-up patients with biliary atresia, and its clinical significance was investigated.

METHODS

Between 1994 and 2001, GSA liver scintigraphy was performed 153 times in 57 follow-up patients. HH15, LHL15, and H/L15 (HH15/LHL15) were obtained. Patients were divided into 3 groups according to the clinical status (good, n = 17; fair, n = 24; poor, n = 16). The correlation between these parameters and liver function tests was examined. Twenty-six patients of the 57 underwent 3 serial GSA scintigraphies and also were divided into 3 groups (good, n = 13; fair, n = 8; poor, n = 5). (3rd/1st)H/L15 (3rd H/L15/1st H/L15) was obtained and compared.

RESULTS

H/L15 had a correlation with serum albumin and serum cholinesterase. H/L15 was statistically different among 3 groups (good, 0.97 +/- 0.15; fair, 0.94 +/- 0.09; poor, 1.12 +/- 0.21; P <.05). Although most patients in the good (10 patients; 76.9%) and fair (7 patients; 87.5%) groups showed (3rd/1st)H/L15 of less than 1.1, 3 patients (60%) in the poor group showed (3rd/1st)H/L15 of more than 1.1. (3rd/1st)H/L15 in the poor group was significantly higher than those in good and fair groups (P <.05).

CONCLUSIONS

Technetium 99m-GSA liver scintigraphy is useful to assess the functional hepatic reserve in follow-up patients with biliary atresia. Serial assessment with GSA scintigraphy can provide the trend of the patient's liver condition and can estimate the prognosis of the liver.

Effect of basic fibroblast growth factor on vascularization in esophagus tissue engineering

We carried out an experimental study to evaluate the effect of basic fibroblast growth factor (bFGF)-containing collagen gel on vascularization in esophageal tissue engineering. We compared an acellular collagen sponge scaffold and an acellular collagen gel scaffold in combination with bFGF using a canine model. The construct was implanted in the cervical esophagus and the regenerated tissue was evaluated one month after surgery. Histological analysis confirmed a significantly large amount of blood vessels in the bFGF-containing collagen gel group as compared to the collagen gel group without bFGF (bFGF (-)). However, in the collagen sponge groups, no difference was observed between the bFGF (+) group and the bFGF (-) group. These results showed that bFGF-containing collagen gel is suitable not only for an acellular scaffold for tissue engineering but also for an effective tropic factor vehicle in vivo.

Functional analysis of the tissue-engineered stomach wall

We have established a method for in situ tissue engineering of the stomach in a canine model using an acellular collagen scaffold graft. The current study was conducted to evaluate the functional aspects of the tissue-engineered stomach wall. The anterior wall of the stomach in beagle dogs was replaced with a collagen sponge scaffold measuring 4 x 4 cm. At 16 weeks after implantation, the animals were sacrificed and the stomach specimens were evaluated immunohistochemically and physiologically. Regeneration of the proton pump and thin muscle layer, which are essential for mechanical and chemical digestion by the stomach, was observed in the tissue-engineered gastric tissue. However, acetylcholine-induced contraction was not observed in the tissue-engineered stomach wall. Although there is still room for improvement, the tissue-engineered stomach wall had a highly organized structure, and it is anticipated that this approach could eventually become an alternative for stomach reconstruction after gastrectomy.

Experimental study on tissue engineering of the small intestine by mesenchymal stem cell seeding

BACKGROUND

We have succeeded in regenerating the small intestine by the use of tissue engineering techniques. However, the regenerated intestine proved to lack the muscle layer, which is essential for functional peristalsis. To induce regeneration of the muscle layer, we focused on autologous mesenchymal stem cells (MSC) as a source of muscle tissue. The aim of this study was to investigate the effect of MSC seeding onto the collagen scaffold on induction of the muscle layer.

MATERIALS AND METHODS

We used six female beagle dogs. The small intestine was resected over a length of 5 cm and reconstructed by a collagen sponge graft in the same way as in our previous study. Autologous MSC derived from bone marrow (10(7) cells) were seeded onto the collagen sponge just before implantation. Animals were sacrificed at 2, 4, and 16 weeks after surgery, and specimens were examined histologically.

RESULTS

All six dogs survived until the scheduled time of sacrifice. At 4 weeks, regeneration of the intestine was observed at the reconstructed site. Cells positive for alpha-smooth muscle actin appeared on the scaffold in the MSC-seeded group. However, they disappeared by 16 weeks and only a thin muscle layer regenerated beneath the mucosal layer, although the regenerated mucosal layer covered the luminal surface of the regenerated intestine.

CONCLUSIONS

MSC seeding induced a transient distribution of cells positive for alpha-smooth muscle actin on the scaffold, but did not induce regeneration of the muscle layer. Further investigation is necessary to achieve this aim.

Differentiation of Toxocara canis and T. cati eggs by light and scanning electron microscopy

In this study, we investigated the morphological identification of Toxocara canis and T. cati eggs on the basis of light and scanning electron microscopic (SEM) observations. T. canis and T. cati eggs used in this study were recovered from the uteri of respective gravid female worms. Measurement of egg size was not helpful in the differentiation of these species, because approximately 90% of eggs measured were of similar size. Using SEM, we were able to differentiate T. canis eggs from T. cati eggs based on their respective characteristic surface structures. Both species have subspherical eggs with markedly pitted surfaces like those of a golf ball, but the surface pitting in T. canis is more coarse than that in T. cati. In this study, however, these differences were not absolute, as 16% of T. canis and 29% of T. cati eggs showed surface pitting that was uncharacteristic of their species. Of the 16% of T. canis eggs that could not be differentiated by surface structure, 3% had pitting resembling T. cati, and the remaining 13% showed intermediate type surface pitting. Similarly, 5% of T. cati eggs resembled T. canis, and 25% of these were of intermediate type. Light microscopic observation yielded results similar to those of SEM, indicating that light microscopy is also a useful tool for the identification of Toxocara eggs.

A large sex difference on a two-dimensional mental rotation task

Mental rotation tests require participants to identify rotated versions of a target stimulus. The Vandenberg Mental Rotations Test depicts rotations in 3-D space and typically yields one of the largest established cognitive sex differences favoring males. It is presently unclear whether this male advantage is related to the nature of rotations depicted in 3-D space or to the high level of difficulty of this task. The present study developed a new test depicting picture plane, or 2-D, rotations. When task difficulty within this 2-D test was varied, a male advantage as large as that seen on the Vandenberg test was found for the difficult component. These findings suggest that processing in 3 dimensions is not a necessary condition for a large sex difference on tests of mental rotation.

A large sex difference on a two-dimensional mental rotation task

Mental rotation tests require participants to identify rotated versions of a target stimulus. The Vandenberg Mental Rotations Test depicts rotations in 3-D space and typically yields one of the largest established cognitive sex differences favoring males. It is presently unclear whether this male advantage is related to the nature of rotations depicted in 3-D space or to the high level of difficulty of this task. The present study developed a new test depicting picture plane, or 2-D, rotations. When task difficulty within this 2-D test was varied, a male advantage as large as that seen on the Vandenberg test was found for the difficult component. These findings suggest that processing in 3 dimensions is not a necessary condition for a large sex difference on tests of mental rotation.

Possible implications of the induction of human heme oxygenase-1 by nitric oxide donors

To explore the involvement of nitric oxide (NO) in the induction of heme oxygenase-1, an essential enzyme in heme catabolism, we studied the effects of NO donors on the expression of heme oxygenase-1 mRNA in HeLa human cervical cancer cells. Treatment with each of three NO donors, sodium nitroprusside, 3-morpholinosydnonimine, and S-nitroso-L-glutathione, caused noticeable increases in the expression levels of heme oxygenase- mRNA, but not heme oxygenase-2 mRNA. On the other hand, nitrite or 8-bromo cGMP exerted no noticeable effect on the levels of heme oxygenase-1 mRNA. We showed that sodium nitroprusside also increased the levels of heme oxygenase-1 protein. The sodium nitroprusside-mediated increase in heme oxygenase-1 mRNA levels was abolished by treatment with actinomycin D. The expression levels of heme oxygenase-1 mRNA were also increased by NO donors in human melanoma and neuroblastoma cell lines. Thus, the observed induction of heme oxygenase-1 may represent an important response to NO or NO-related oxidative stress. The half lives of heme oxygenase-1 and heme oxygenase-2 mRNAs were estimated to be about 3.2 h and more than 5 h, respectively.

Sex, sexual orientation and sex hormones influence human cognitive function

Superior performance by women on a task requiring object location memory has challenged the traditional view that men excel on all spatial tasks. Sexual orientation is also associated with variation in cognitive ability pattern, but such association appears to be more consistent for a real-world targetting task than for paper-and-pencil spatial tests. Finally, there is increasing evidence that early exposure to sex hormones has lasting effects on problem-solving behaviour; moreover, current fluctuations in sex hormones in both men and women are associated with changes in cognitive pattern.

Sex differences for speech and manual skill

Young men and women were compared on the speeded repetition of speech (ns = 20 and 18, respectively) and manual movements (ns = 37 and 38). The repetition of a single speech or manual movement was used as a measure of baseline speed, against which to compare a sequence of movements. Males tended to be faster at repeating a single movement, but using baseline speed as a covariate resulted in a female advantage for the repetition of a sequence of movements. It was concluded that men have a basic motor-speed advantage, but that women may be faster at programming a sequence of speech or manual movements. The results are discussed with respect to sexual variation in the neural organization of motor programming systems.

Estrogen replacement therapy may protect against intellectual decline in postmenopausal women

Postmenopausal women over the age of 50, who were either on estrogen replacement therapy (N = 21) or not (N = 33), were assessed on several sexually dimorphic cognitive functions. The two groups were strictly equivalent in age, education, and vocabulary score (an abbreviated measure of past intelligence). Overall, women on therapy had better scores than those not on therapy, regardless of whether the specific function favored men or women. Previous history of reproductive surgery had no effect on scores. Estrogen may guard against some of the intellectual decline which is to be expected postmenopausally.

Sexual orientation and performance on sexually dimorphic motor tasks

Performance of homosexual and heterosexual men and women on two motor tasks which reliably demonstrate sex differences in opposite directions was examined. A Throw-to-Target Task and the Purdue Pegboard were administered to undergraduate students matched for age and program of study. A two-way ANOVA (Sex x Sexual Orientation) of the Throw data showed a significant interaction, F(1, 90) = 16.22, p < or = 0.001, and a trend for an effect of sex, F(1, 90) = 3.72, p < 0.06. Heterosexual men outperformed heterosexual women, whereas gay men threw less accurately and lesbians tended to throw more accurately than their heterosexual counterparts. Differences in sports history or hand strength did not account for these effects. Analysis of the Pegboard scores found no interaction or main effect of sexual orientation, but the effect of sex was significant, F(1,63) = 7.01, p < or = 0.02. Regardless of sexual orientation, women outperformed men and this difference remained significant even when a measure of finger size was partialed out. This study provides new evidence suggesting an association between sexual orientation and motor-performance profiles. As with cognitive tasks, the motor-performance profiles of homosexuals are composites of some male-typical and some female-typical abilities. To the extent that sociological factors have been controlled, the study suggests that both sexual orientation and motor/cognitive predispositions may have early biological contributions.

Dermatoglyphic asymmetry and sexual orientation in men

Dermal ridges on the fingertips are formed early in fetal life and remain unchanged throughout the life span. The researchers examined dermatoglyphic characteristics (total ridge count and directional ridge asymmetry) in homosexual and heterosexual men. There was no difference between the 2 groups of men in total ridge count, but more gay men demonstrated leftward asymmetry than did nongay men. Although this effect was not accounted for by differences in hand preference, an association was observed between leftward dermatoglyphic asymmetry and an increased incidence of adextrality in homosexual men, but not in heterosexual men. These findings are consistent with a biological contribution to sexual orientation and indicate that such an influence may occur early in prenatal life.

The relationship between testosterone levels and cognitive ability patterns

The cognitive performance of normal men and women was studied, grouped according to whether the subjects had relatively high or low salivary testosterone (T) concentrations. Men with lower T performed better than other groups on measures of spatial/mathematical ability, tasks at which men normally excel. Women with high T scored higher than low-T women on these same measures. T concentrations did not relate significantly to scores on tests that usually favor women or that do not typically show a sex difference. These results support suggestions of a nonlinear relationship between T concentrations and spatial ability, and demonstrate some task specificity in this respect.