[Controversy and boundary in the diagnose and treatment of thyroid cancer]

In recent years, the incidence of thyroid cancer has rapidly increased, whereas the mortality rate has not risen correspondingly. Therefore, scholars at home and abroad have proposed the view of overdiagnosis in thyroid cancer, sparking intense debates about the phenomenon of overdiagnosis and overtreatment. A historical review and discussion of the primary reasons for the increase in thyroid cancer incidence and the improvement in treatment outcomes are beneficial. It helps clarify that the real increase in thyroid cancer is primarily due to the higher incidence rate, rather than overdiagnosis. Additionally, it allows us to reevaluate which factors guarantee favorable efficacy in thyroid cancer.

[Effect of "one-stop" outpatient management on the control rate of multiple metabolic disorders patients]

Objective: To explore the effect of "one-stop" outpatient management on the therapeutic schedule and control rate of patients with metabolic disorders. Methods: A total of 332 patients who met the inclusion criteria were enrolled and treated regularly in the "one-stop" outpatient department of the Department of Cardiology of the Third Hospital of Peking University from November 1, 2020 to April 30, 2022. The general information, personal history, family history, drug treatment plan, blood pressure, height, weight, waist circumference, and hip circumference of patients were collected through the outpatient electronic medical record system, and patients were followed up through conducting "one-stop" comprehensive management. The baseline clinical characteristics were analyzed, and the changes of metabolic indexes, treatment conditions and control rate of patients with different metabolic disorders before and after the "one-stop" outpatient management were compared. Results: The time interval between the first visit and the last visit was 44 (26, 60) weeks in 332 patients, whose age was (57.2±13.2) years, including 219 males (66.0%). After the "one-stop" outpatient management, fasting blood glucose (FBG) [ 6.6 (5.6, 7.9) mmol/L vs 6.3 (5.6, 6.9) mmol/L], glycosylated hemoglobin A1c (HbA1c) [ (7.2±1.5) % vs (6.6±0.8) %], low density lipoprotein cholesterol (LDL-C) [ 2.70 (1.97, 3.55) mmol/L vs 2.04 (1.66, 2.63) mmol/L] and blood uric acid (UA) [ (383.7±107.1) μmol/L vs (341.2±90.6) μmol/L] all decreased significantly (all P values<0.05). The control rates of hypertension (19.8% vs 28.2%), diabetes (45.2% vs 66.5%), hyperlipidemia (54.9% vs 87.6%) and hyperuricemia (16.7% vs 49.0%) were significantly improved after the "one-stop" outpatient management (all P values<0.05). Conclusion: The "one-stop" outpatient management of cardiovascular department can significantly improve the metabolic condition and the control rate of patients with multiple metabolic disorders.

[A multicenter study on childhood Hodgkin lymphoma treated with HL-2013 regimen in China]

Objective: To evaluate the efficacy of the Hodgkin lymphoma (HL)-2013 regimen in the treatment of children with HL, and to investigate the prognostic factors of childhood HL. Methods: Clinical data of 145 children (aged ≤18 years) with newly diagnosed HL, treated with HL-2013 regimen in 8 tertiary referral centers for childhood cancer from August 2011 to April 2021 were analyzed retrospectively. All the diagnosis were confirmed by histopathological morphology and immunohistochemical examination. The clinical characteristics and treatment outcomes were summarized, and the patients were divided into different groups according to clinical characteristics. Kaplan-Meier method was used for survival analysis, and the comparison of survival rates between groups was performed with Log-rank test. Results: Of the 145 cases, there were 115 males and 30 females, the age at diagnosis was 7.9 (5.8, 10.6) years. Cervical lymph node enlargement (114 cases, 78.6%) was the common symptom of the disease, and 57 patients (39.3%) were accompanied by large masses. The most common pathological classification was mixed cell type (93 cases, 64.1%). According to the Ann Arbor staging system, there were 9 cases of stage Ⅰ, 62 cases of stage Ⅱ, 45 cases of stage Ⅲ, 29 cases of stage Ⅳ. According to the risk stratification: there were 14 cases of low-risk group, 76 cases of medium-risk group and 55 cases of high-risk group. Of all patients, 68 cases (46.9%) achieved an early complete remission (CR) after 2 courses of chemotherapy, and the CR rate was 93.8% (136/145) after first-line treatment. Disease recurrence or progression occurred in 22 cases (15.2%). Of all patients, 125 cases survived, 6 cases died and 14 cases were lost to follow-up. Among the survived cases, 123 cases were continuously at CR state,and the follow-up time was 55 (40, 76) months. The 5-year overall survival (OS) and event free survival (EFS) rates were (95.3±1.9)% and (84.2±3.0)% for the entire group, respectively. 5-year OS and EFS rates for patients with stage Ⅲ-Ⅳ were both lower than those for patients with stage Ⅰ-Ⅱ (χ²=6.28 and 7.58, both P<0.05), the 5-year OS and EFS rates for patients in high-risk group were both lower than those for patients in low-risk and medium-risk group (χ²=10.93, 7.79, both P<0.05). The 5-year OS rates for the patient with early CR and without early CR were 100.0% and (90.9±3.6)% (χ²=5.77, P=0.016). EFS rates for the patient with early CR (68 cases) and without early CR (77 cases) were (93.8±3.0)% and (75.8±5.0)% (χ²=8.78, P=0.003). Conclusions: HL-2013 regimen is significantly effective in the treatment of pediatric HL. However, the patients in high-risk group and those without early CR are prone to disease recurrence or progression. Stage Ⅲ-Ⅳ and without early CR were associated with worse prognosis.

Thyroid imaging reporting and data system (TIRADS) for ultrasound features of nodules: multicentric retrospective study in China

PURPOSE

To establish a practical and simplified Chinese thyroid imaging reporting and data system (C-TIRADS) based on the Chinese patient database.

METHODS

A total of 2141 thyroid nodules that were neither cystic nor spongy were used in the current study. These specimens were derived from 2141 patients in 131 alliance hospitals of the Chinese Artificial Intelligence Alliance for Thyroid and Breast Ultrasound. The ultrasound features, including location, orientation, margin, halo, composition, echogenicity, echotexture, echogenic foci and posterior features were assessed. Univariate and multivariate analyses were performed to investigate the association between ultrasound features and malignancy. The regression equation, the weighting, and the counting methods were used to determine the malignant risk of the thyroid nodules. The areas under the receiver operating characteristic curve (Az values) were calculated.

RESULTS

Of the 2141 thyroid nodules, 1572 were benign, 565 were malignant, and 4 were borderline. Vertical orientation, ill-defined, or irregular margin (including extrathyroidal extension), microcalcifications, solid, and markedly hypoechoic were positively associated with malignancy, while comet-tail artifacts were negatively associated with malignancy. The logistic regression equation yielded the highest Az value of 0.913, which was significantly higher than that obtained using the weighting method (0.893) and the counting method (0.890); however, no significant difference was found between the latter two. The C-TIRADS, based on the counting method, was designed following the principle of balancing the diagnostic performance and sensitivity of the risk stratification with the ease of use.

CONCLUSIONS

A relatively simple C-TIRADS was established using the counting value of positive and negative ultrasound features.

2020 Chinese guidelines for ultrasound malignancy risk stratification of thyroid nodules: the C-TIRADS

Thyroid nodules are very common all over the world, and China is no exception. Ultrasound plays an important role in determining the risk stratification of thyroid nodules, which is critical for clinical management of thyroid nodules. For the past few years, many versions of TIRADS (Thyroid Imaging Reporting and Data System) have been put forward by several institutions with the aim to identify whether nodules require fine-needle biopsy or ultrasound follow-up. However, no version of TIRADS has been widely adopted worldwide till date. In China, as many as ten versions of TIRADS have been used in different hospitals nationwide, causing a lot of confusion. With the support of the Superficial Organ and Vascular Ultrasound Group of the Society of Ultrasound in Medicine of the Chinese Medical Association, the Chinese-TIRADS that is in line with China's national conditions and medical status was established based on literature review, expert consensus, and multicenter data provided by the Chinese Artificial Intelligence Alliance for Thyroid and Breast Ultrasound.

Nomogram Including Elastography for Prediction of Contralateral Central Lymph Node Metastasis in Solitary Papillary Thyroid Carcinoma Preoperatively

Background

It is controversial whether contralateral prophylactic central neck dissection (PCND) should be performed for patients with solitary and clinical lymph node negative (cN₀) papillary thyroid carcinoma (PTC) although routine ipsilateral PCND is required.

Objective

The aim of this study was to develop an improved nomogram including clinical features, ultrasound, and acoustic radiation force impulse (ARFI) elastography for the prediction of contralateral central lymph node metastasis (CLNM) in patients with solitary and cN₀ PTC in the preoperative period.

Materials and Methods

A total of 340 patients were retrospectively included as the training cohort and 170 patients as the external validation cohort. Patients were grouped according to the pathological results of contralateral CLNM. The association between the clinical characteristics, ultrasound, and ARFI elastography and the risk for contralateral CLNM were analyzed. A nomogram was established based on the result of multivariable logistic analysis to predict the risk of contralateral CLNM, which was assessed by internal and external validation.

Results

CLNM was found in 213 patients (41.8%), among whom 142 (27.8%) had ipsilateral CLNM and 95 (18.6%) had contralateral CLNM (including 68 (13.3%) with bilateral CLNM). Multivariable analysis revealed that patients with younger age, male gender, larger tumor size, closer distance from the capsule, microcalcification, and larger SWV_mean were independent predictors associated with the contralateral CLNM (P < 0.05), which was served as the basis of the nomogram. It showed good discrimination (C-index: 0.856) and calibration (χ² = 9.028, P = 0.340, Hosmer–Lemeshow test) in the training cohort, and good discrimination was maintained in the external validation cohort (C-index: 0.792).

Conclusion

The nomogram utilizing the features of ultrasound combined with ARFI elastography in preoperatively predicting the risk of contralateral CLNM in patients with solitary and cN₀ PTC was established, which showed superior performance both in internal and external validation.

Application of pediatric ocular trauma score in pediatric open globe injuries

AIM

To evaluate the predictive value of pediatric penetrating ocular trauma score (POTS) on the visual outcome in children with open globe injury.

METHODS

A retrospective study in 90 children (60 males and 30 females) aged 1-15y (average, 7.48±2.86y) with penetrating ocular trauma was performed. Each patient's POTS was calculated. The effects of POTS on final visual acuity (FVA) were examined. Correlation between factors affecting POTS and the FVA was established.

RESULTS

All patients presented with single-eye trauma. The follow-up time was 3-21mo (average, 10.23±3.54mo). Among the 90 cases of penetrating wounds, 71 eyes (78.89%) were injured in Zone I (wound involvement limited to the cornea, including the corneoscleral limbus), 17 eyes (18.89%) were injured in Zone II (wound involving the sclera and no more posterior than 5 mm from the corneoscleral limbus), and 2 eyes (2.22%) were injured in Zone III (wound involvement posterior to the anterior 5 mm of the sclera). Analysis of POTS and FVA showed important correlation between them (r=0.414, P=0.000). Initial visual acuity (P=0.00), age (P=0.02), injury location (P=0.002), traumatic cataract (P=0.00), vitreous hemorrhage (P=0.027), retinal detachment (P=0.003), and endophthalmitis (P=0.03) were found to be statistically significant factors for the FVA outcome.

CONCLUSION

Ocular trauma presents serious consequences and poor prognosis in children. The POTS may be a reliable prognostic tool in children with open globe injury.

[Risks factors for death among COVID-19 patients combined with hypertension, coronary heart disease or diabetes]

OBJECTIVE

The pathogenesis of myocardial injury upon corona virus disease 2019 (COVID-19) infection remain unknown,evidence of impact on outcome is insufficient, therefore, we aim to investigate the risk factors for death among COVID-19 patients combined with hypertension, coronary heart disease or diabetes in this study.

METHODS

This was a single-centered, retrospective, observational study. Patients of Sino-French Eco-City section of Tongji Hospital, Wuhan, China attended by Peking University Supporting Medical Team and admitted from Jan. 29, 2020 to Mar. 20, 2020 were included. The positive nucleic acid of COVID-19 virus and combination with hypertension, coronary heart disease or diabetes were in the standard. We collected the clinical data and laboratory examination results of the eligible patients to evaluate the related factors of death.

RESULTS

In the study, 94 COVID-19 patients enrolled were divided into the group of death (13 cases) and the group of survivors (81 cases), the average age was 66.7 years. Compared with the survival group, the death group had faster basal heart rate(103.2 beats/min vs. 88.4 beats /min, P=0.004), shortness of breath(29.0 beats /min vs. 20.0 beats /min, P<0.001), higher neutrophil count(9.2×10⁹/L vs. 3.8×10⁹/L, P<0.001), lower lymphocyte count(0.5×10⁹/L vs. 1.1×10⁹/L, P<0.001), creatine kinase MB(CK-MB, 3.2 μg/L vs. 0.8 μg/L, P<0.001), high sensitivity cardiac troponin Ⅰ(hs-cTnⅠ, 217.2 ng/L vs. 4.9 ng/L, P<0.001), N-terminal pro brain natriuretic peptide(NT-proBNP; 945.0 μg/L vs. 154.0 μg/L, P<0.001), inflammatory factor ferritin(770.2 μg/L vs. 622.8 μg/L , P=0.050), interleukin-2 recepter(IL-2R, 1 586.0 U/mL vs. 694.0 U/mL, P<0.001), interleukin-6(IL-6, 82.3 ng/L vs. 13.0 ng/L, P<0.001), interleukin-10(IL-10, 9.8 ng/L vs. 5.0 ng/L, P<0.001)were higher than those in the survival group. Univariate logistic regression analysis showed that the risk factors for death were old age, low non oxygen saturation, low lymphocyte count, myocardial injury, abnormal increase of IL 2R, IL-6, and IL-10. Multivariate regression showed that old age (OR=1.11, 95%CI=1.03-1.19, P=0.026), low non oxygen saturation(OR=0.85, 95%CI=0.72-0.99, P=0.041), and abnormal increase of IL-10(＞9.1 ng/L, OR=101.93, 95%CI=4.74-2190.71, P=0.003)were independent risk factors for COVID-19 patients combined with hypertension, coronary heart disease or diabetes.

CONCLUSION

In COVID-19 patients combined with hypertension, coronary heart disease or diabetes, the risk factors for death were old age, low non oxygen saturation, low lymphocyte count, myocardial injury, and abnormal increase of IL-2R, IL-6, and IL-10. Old age, low non oxygen saturation and abnormal increase of IL-10 were independent risk factors.

[The influencing factors of anemia for pregnant women between 2010-2012 in China]

Objective: To investigate the prevalence of anemia and related risk factors for pregnant women in China. Method: Based on Chinese National Nutrition and Health Surveillance 2010-2012, a total of 3 501 pregnant women were investigated from 150 counties of 31 provinces, municipalities and autonomous regions in China, using a multi-stage stratified cluster randomization sampling method. General information of pregnant women, health status, and food intake during the gestation, was collected through a questionnaire investigation. 6 ml fasting venous blood was collected for the determination of hemoglobin concentration. Data were analyzed using multiple logistic regression to investigate the prevalence of anemia and the related influencing factors. Results: The 605 of 3 501 pregnant women had anemia. The prevalence of anemia was 17.2%; and mild anemia accounted for about 61.0% (369/605). Compared with the pregnant women living in the large cities, the OR (95%CI) of those living in the poor rural areas was 1.46 (1.08-1.98). Compared with the pregnant women living in the south area of China, the OR (95%CI) of those living in the north area of China was 1.39 (1.15-1.68); Compared with the pregnant women in the first trimester, the OR (95%CI) of those in the second trimester and the third trimester were 1.79 (1.33-2.43) and 2.11 (1.56-2.85), respectively. The OR (95%CI) of pregnant women who had used folic acid supplementation within the 6 months prior to gestation was 0.76 (0.63-0.93) compared with those who had not used. Conclusion: From 2010 to 2012, the epidemic characteristics of anemia was mild for the pregnant women in China, and pregnant women residential areas, periods of pregnancy and whether to take folic acid were related to anemia.

[Study on anemia and vitamin A and vitamin D nutritional status of Chinese urban pregnant women in 2010-2012]

Objective: To evaluate the prevalence of anemia and the nutritional status of vitamins A and D by analyzing hemoglobin, serum retinol, and serum 25-hydroxyvitamin D levels in Chinese urban pregnant women during 2010-2012. Methods: Data were obtained from the China Nutrition and Health Survey in 2010-2012. Using multi-stage stratified sampling and population proportional stratified random sampling, 2 250 pregnant women from 34 metropolis and 41 middle-sized and small cities were included in this study. Information was collected using a questionnaire survey. The blood hemoglobin concentration was determined using the cyanmethemoglobin method, and anemia was determined using the World Health Organization guidelines combined with the elevation correction standard. The serum retinol level was determined using high-performance liquid chromatography, and vitamin A deficiency (VAD) was judged by the related standard recommended by the World Health Organization. The vitamin D level was determined using enzyme-linked immunosorbent assay and vitamin D deficiency was judged by the recommendation standards from the Institute of Medicine of The National Academies. The hemoglobin, serum retinol, and serum 25-hydroxyvitamin D levels were compared, along with differences in the prevalence of anemia, VAD, and the vitamin D deficiency rate (including deficiency and serious deficiency). Results: A total of 1 738 cases of hemoglobin level, 594 cases of serum retinol level, and 1 027 cases of serum 25-hydroxyvitamin D were available for analysis in this study. The overall blood hemoglobin level (P(50) (P(25)-P(75))) was 122.70 (114.00-131.10) g/L; 123.70 (115.21-132.00) g/L for metropolis and 122.01 (113.30-130.40) g/L for middle-sized and small cities. The blood hemoglobin level of metropolis residents was significantly higher than that of middle-sized and small city residents (P=0.027). The overall prevalence of anemia was 17.0% (295/1 738). The overall serum retinol level (P(50) (P(25)-P(75))) was 1.61 (1.20-2.06) μmol/L; 1.50 (1.04-2.06) μmol/L for metropolis and 1.63 (1.31-2.05) μmol/L for middle-sized and small cities. The serum retinol level of metropolis residents was significantly higher than that of middle-sized and small city residents (P=0.033). The overall prevalence of VAD was 7.4% (47/639); 11.5% (33/286) for metropolis and 4.0% (14/353) for middle-sized and small cities. A significant difference was observed in the prevalence of VAD between metropolis and middle-sized and small city residents (P<0.001). The overall serum 25-hydroxyvitamin D level (P(50) (P(25)-P(75))) was 15.41 (11.79-20.23) ng/ml; 14.71 (11.15-19.07) ng/ml for metropolis and 16.02 (12.65-21.36) ng/ml for middle-sized and small cities. A significant difference was observed in the vitamin D level between metropolis and middle-sized and small city residents (P<0.001). The overall prevalence of vitamin D deficiency was 74.3% (763/1 027); A significant difference was observed in the prevalence of serious vitamin D deficiency between metropolis (30.64%(144/470)) and middle-sized and small city residents (26%(267/1 027))(P=0.002). There were no significant differences between blood hemoglobin level and the prevalence of anemia, VAD, and vitamin D deficiency. Conclusion: The prevalence of anemia in Chinese urban pregnant women improved from 2002 to 2012. The prevalence of vitamin D deficiency in pregnant women was generally more serious, while a certain percentage of women had VAD. The prevalence of VAD and serious vitamin D deficiency among pregnant women from metropolis was significantly higher than that of pregnant women from medium and small-sized cities.

[The vitamin D nutritional status in Chinese urban women of child-bearing age from 2010 to 2012]

Objective: To evaluate the vitamin D nutritional status in Chinese women of child-bearing age by analyzing serum 25-hydroxyvitamin D level in 2010-2012. Methods: Data were obtained from the China Nutrition and Health Survey in 2010-2012. Using cluster sampling and proportional stratified random sampling, 1 514 women of child-bearing age (18-44 years old) from 34 metropolis and 41 small and medium-sized cities were included in this study. Demographic information was collected by questionnaire and serum 25-hydroxyvitamin D concentration was determined by radioimmunoassay, in accordance with the 2010 Institute of Medicine of the National Academies standards. We compared differences in vitamin D levels, specifically serious deficiency, lack of deficiency, insufficiency, and excess. Results: The overall serum 25-hydroxyvitamin D level of Chinese urban women of child-bearing age (P(50) (P(25)-P(75))) was 20.1 (15.1-26.3) ng/ml; minorities had a significantly higher serum 25-hydroxyvitamin D level of 22.0 (15.9-27.5) ng/ml compared with women of Han nationality (19.8 (14.9-26.2) ng/ml) (χ(2)=7.02, P=0.008). The proportions of women with serious deficiency, lack of deficiency, insufficiency, and excess vitamin D were 11.6% (n=175), 37.9% (n=574), 35.1% (n=531), and 0.3% (n=5), respectively. Only 15.1% (n=229) of women of child-bearing age had normal vitamin D nutritional status. No significant differences in vitamin D nutritional status were observed according to age, body mass index, city, nationality, educational level, marital status, or household income per capita (P>0.05). Conclusion: Most Chinese urban women of child-bearing age have poor vitamin D levels and require vitamin D supplementation.

[Study on vitamin A nutritional status of Chinese urban elderly residents in 2010-2012]

Objective: To assess the vitamin A nutritional status of the Chinese urban elderly population by analyzing serum retinol level in 2010-2012. Methods: Data were collected from the Chinese National Nutrition and Health Survey in 2010-2012. Using the multi-stage stratified cluster sampling method, serum samples from elderly residents aged ≥60 years old were obtained from 34 metropolis and 41 middle-sized and small cities. Demographic data were collected using a questionnaire survey. The serum retinol concentration was determined by high-performance liquid chromatography. Vitamin A deficiency (VAD) was determined using the World Health Organization guidelines. A total of 3 200 elderly residents were included in the study. The serum retinol levels and prevalence of VAD and marginal VAD were also compared. Results: The serum retinol concentration (P(50)(P(25)-P(75))) of Chinese urban elderly residents was 1.83 (1.37-2.39) μmoL/L. Compared with middle-sized and small cities (1.91 (1.47-2.48) μmol/L), the retinol level of senior citizens in metropolis (1.70 (1.25-2.25) μmol/L) was significantly lower (P<0.001). The serum retinol levels of elderly male (1.89 (1.37-2.47) μmoL/L) was significantly higher than that of female (1.80 (1.36-2.28) μmoL/L) (P=0.001). The serum retinol concentration was 1.87 (1.42-2.43), 1.78 (1.32-2.33), and 1.71 (1.24-2.24) μmol/L for 60-69, 70-79, and ≥80 years olds, respectively. The retinol level in elderly people ≥70 years olds was significantly lower than that of 60-69 years olds (P<0.001). The overall prevalence of VAD among Chinese urban elderly residents was 4.22% (135/3 200); 6.00% (81/1 350) for metropolis residents and 2.92% (54/1 850) for middle-sized and small city residents. The overall marginal VAD rate of Chinese urban elderly residents was 8.19% (262/3 200); 10.51% (142/1 350) for metropolis residents and 6.49% (120/1 850) for medium-sized and small city residents. The prevalence of VAD and marginal VAD for males was 3.87% (61/1 577) and 8.24% (130/1 577), respectively (P<0.05). The prevalence of VAD according to age group was 3.65% (72/1 975), 4.96% (50/1 008), and 5.99% (13/217), respectively(P=0.097). The prevalence of marginal VAD according to age group was 6.99% (138/1 975), 9.82% (99/1 008), and 11.52% (25/217), respectively(P=0.05). Conclusion: Chinese urban elderly residents showed various levels of VAD, although marginal VAD was quite common. As VAD was more common in metropolis residents and older residents, specific strategies should target these populations.

[Outcome of relaying anterolateral thigh perforator flap in resurfacing the donor site wound following free anteromedial thigh perforator flap transfer for reconstruction of defect after oral tumor radical resection]

Objective: To observe the outcome of relaying anterolateral thigh (ALT) perforator flap in resurfacing the donor site wound following free anteromedial thigh (AMT) perforator flap transfer for reconstruction of defect after oral tumor radical resection. Methods: From January 2013 to January 2016, 28 patients with oral tumor underwent radical resection in our hospital, leaving defects with size ranged from 6.5 cm×3.5 cm to 11.0 cm×7.5 cm which were reconstructed by free AMT perforator flaps with size ranged from 7.0 cm×4.0 cm to 12.0 cm×8.0 cm. All the arteries of AMT perforators were anastomosed with superior thyroid arteries, while the venae comitants were anastomosed with superior thyroid venae or internal jugular venae. The donor site wounds of free AMT perforator flaps were reconstructed by relaying ALT perforator flaps with size ranged from 8.0 cm×3.5 cm to 14.0 cm×7.5 cm. The relaying ALT perforator flap and wound edge were closed directly with layer interrupted suture. Postoperatively, the patients stayed in bed and received diet through nasal feeding tube, and the ordinary diet and lower extremity exercise were carried out from one week after operation. Results: The AMT and ALT perforators existed consistently in all patients. In 16 patients the venae comitants of AMT perforator arteries were anastomosed with superior thyroid venae in end-to-end fashion, while in 12 patients with internal jugular venae in end-to-side fashion. All flaps survived uneventfully about 2 weeks after operation, and the wounds healed smoothly. All patients were followed up for 6 to 30 months after operation. The sites repaired with free AMT perforator flaps were not bulky in appearance, with two-point discrimination distances ranged from 8 to 15 mm. The movement of tongue was not obviously affected, and patients could speak and eat normally. The texture and color of the sites repaired with relaying ALT perforator flaps were close to those of the adjacent tissue, and the two-point discrimination distances of the sites repaired with relaying ALT perforator flaps were ranged from 7 to 12 mm. The function of thigh was not obviously affected, and patients could walk normally and do related daily activities. Conclusions: Reconstruction of defect after oral tumor radical resection with free AMT perforator flap can achieve good outcome, and wound in the donor site of free AMT perforator flap repaired with relaying ALT perforator flap can achieve good appearance and function recovery.

[Study on vitamin A nutritional status of 6- to 17-year-old urban children and adolescents between 2010 and 2012 in China]

Objective: To investigate the vitamin A nutritional status of 6- to 17-year-old urban children and adolescents by analyzing serum retinol level, between 2010 and 2012 in China. Methods: Data were obtained from the China Nutrition and Health Survey in 2010-2012. Using multi-stage stratified sampling and the population proportional stratified random sampling method, 6 617 children aged 6-17 years from 32 metropolis and 41 middle-sized and small cities of China were selected. The questionnaire survey was used to collect demographic information. Blood samples were analyzed using high-performance liquid chromatography to determine serum retinol concentration, and the World Health Organization guidelines were used to evaluate the nutritional status of vitamin A. Vitamin A levels, vitamin A deficiency, and marginal vitamin A deficiency in children with different characteristics were compared. Results: A total of 3 785 cases with valid samples were obtained. The overall mean serum retinol concentration level was (1.49±0.71) μmol/L; the mean serum retinol concentration was (1.55±0.69) μmol/L for metropolis and (1.49±0.75) μmol/L for middle-sized and small cities (P>0.05). The mean serum retinol concentration was (1.52±0.78) μmol/L for boys and (1.47±0.68) μmol/L for girls (P>0.05). The mean serum retinol concentration level was (1.46±0.70) μmol/L for 6- to 11-year-old children and (1.54±0.65) μmol/L for 12- to 17-year-old children (P<0.05). The total vitamin A deficiency rate and marginal vitamin A deficiency rate was 7.69% (291/3 785) and 18.57% (703/3 785), respectively. The vitamin A deficiency rate was 8.00% (36/450) for metropolis and 7.64% (65/3 335) for middle-sized and small cities; 8.12% (155/1 908) for boys and 7.25% (136/1 877) for girls; and 8.04% (171/2 115) for 6- to 11-year-old children and 7.18% (120/1 670) for 12- to 17-year-old children. No significant differences were observed for region, sex, or age (P>0.05). The marginal vitamin A deficiency rate was 19.11% (86/450) for metropolis and 18.50% (617/3 335) for middle-sized and small cities; 18.19% (347/1 908) for boys and 18.97% (356/1 877) for girls, with no significant differences observed (P>0.05). The marginal vitamin A deficiency rate was 16.54% (350/2 115) for 6- to 11-year-old children and 21.13% (353/1 670) for 12- to 17-year-old children (P<0.05). Conclusion: The vitamin A nutritional status of 6- to 17-year-old Chinese urban children and adolescents between 2010 and 2012 has improved, and the gap between cities is narrowing. However, vitamin A deficiency overall remains high, especially in younger children, and requires specific attention.

[Modified pedicled thoracoacromial artery perforator flap for the repair of complex pharyngocutaneous fistula: a retrospective review of 9 cases]

Objective: To report our experience in the application of modified pedicled thoracoacromial artery perforator (TAAP) flap for the repair of complex pharyngocutaneous fistula. Methods: Between December 2011 and September 2015, modified pedicled TAAP flaps were used to repair pharyngocutaneous fistulas in 9 patients. All patients were males, and ranged in age from 28 to 72 years old. Fistula size ranged from 4.5 cm×2.5 cm to 6.5 cm×4.5 cm, and the TAAP skin paddle size ranged from 7.0 cm×4.0 cm to 8.0 cm×5.0 cm. Neck defect size ranged from 4.0 cm×3.0 cm to 6.0 cm×4.0 cm, and the TAAP skin paddle size ranged from 5.5 cm×3.5 cm to 7.0 cm×5.0 cm. Results: All 9 flaps survived smoothly and all the donor sites were closed directly, with no flap vascular crisis and necrosis. The mean hospitalization of patients was 10.4 days. Postoperative barium swallow showed no hypopharyngeal stenosis or fistula recurrence. The follow-up time ranged from 8 to 32 months. The appearance of neck was good and all patients accepted oral diet. Only linear scar was left on the donor site, with no significant impairment of the function of pectoralis major muscle. Conclusion: Modified pedicled TAAP flap is suitable for the repair of complex pharyngocutaneous fistula.

Prevention of postoperative nausea and vomiting after intrathecal morphine for Cesarean section: a randomized comparison of dexamethasone, droperidol, and a combination

BACKGROUND

Intrathecal morphine provides good analgesia after cesarean delivery but the side effects include nausea and vomiting. Low-dose droperidol (0.625 mg) combined with dexamethasone 4 mg is postulated to have an additive antiemetic effect with less side effects. We therefore compared single doses of dexamethasone and droperidol alone with a low-dose combination of the two, to prevent spinal morphine-induced nausea and vomiting after cesarean section.

METHODS

In a double-blind study, 120 women undergoing elective cesarean section under spinal anesthesia (using 0.5% bupivacaine 10 mg and morphine 0.2 mg) were allocated randomly to receive dexamethasone 8 mg, droperidol 1.25 mg, dexamethasone 4 mg and droperidol 0.625 mg, or placebo, before the end of surgery. The incidences of nausea and vomiting, sedative score, pain score, and side effects were recorded.

RESULTS

The incidence of nausea and vomiting within 6 h postoperatively was lower and incidence of no nausea and vomiting for 24 h postoperatively was significantly higher for the combination group compared to the placebo group and the dexamethasone only group. Sedation scores within 3 h postoperatively and incidence of restlessness for the combination group were significantly lower than in the droperidol only group.

CONCLUSION

An additive antiemetic effect and no significant side effects were shown for the combination of dexamethasone 4 mg and droperidol 0.625 mg. This combination was more effective than either dexamethasone 8 mg or droperidol 1.25 mg alone in preventing nausea and vomiting after spinal anesthesia using 0.5% bupivacaine and morphine 0.2 mg.

Lithographically patterned nanowire electrodeposition

Nanowire fabrication methods can be classified either as 'top down', involving photo- or electron-beam lithography, or 'bottom up', involving the synthesis of nanowires from molecular precursors. Lithographically patterned nanowire electrodeposition (LPNE) combines attributes of photolithography with the versatility of bottom-up electrochemical synthesis. Photolithography defines the position of a sacrificial nickel nanoband electrode, which is recessed into a horizontal trench. This trench acts as a 'nanoform' to define the thickness of an incipient nanowire during its electrodeposition. The electrodeposition duration determines the width of the nanowire. Removal of the photoresist and nickel exposes a polycrystalline nanowire--composed of gold, platinum or palladium--characterized by thickness and width that can be independently controlled down to 18 and 40 nm, respectively. Metal nanowires prepared by LPNE may have applications in chemical sensing and optical signal processing, and as interconnects in nanoelectronic devices.

Identification of a tumor suppressive critical region mapping to 3p14.2 in esophageal squamous cell carcinoma and studies of a candidate tumor suppressor gene, ADAMTS9

A gene critical to esophageal cancer has been identified. Functional studies using microcell-mediated chromosome transfer of intact and truncated donor chromosomes 3 into an esophageal cancer cell line and nude mouse tumorigenicity assays were used to identify a 1.61 Mb tumor suppressive critical region (CR) mapping to chromosome 3p14.2. This CR is bounded by D3S1600 and D3S1285 microsatellite markers. One candidate tumor suppressor gene, ADAMTS9, maps to this CR. Further studies showed normal expression levels of this gene in tumor-suppressed microcell hybrids, levels that were much higher than observed in the recipient cells. Complete loss or downregulation of ADAMTS9 gene expression was found in 15 out of 16 esophageal carcinoma cell lines. Promoter hypermethylation was detected in the cell lines that do not express this gene. Re-expression of ADAMTS9 was observed after demethylation drug treatment, confirming that hypermethylation is involved in gene downregulation. Downregulation of ADAMTS9 was also found in 43.5 and 47.6% of primary esophageal tumor tissues from Hong Kong and from the high-risk region of Henan, respectively. Thus, this study identifies and provides functional evidence for a CR associated with tumor suppression on 3p14.2 and provides the first evidence that ADAMTS9, mapping to this region, may contribute to esophageal cancer development.

Clinical association of anti-golgi autoantibodies and their autoantigens

Anti-Golgi autoantibodies (AGAs) and their targets have been reported from several diseases. However, the association of AGAs, selective autoantigens and related clinical diseases is still obscure. In this study, the presence of AGAs in the sera of 5983 patients was screened to explore the association of AGAs and clinical diseases. By means of indirect immunofluorescence using HEp-2 cells, sera of 12 patients bearing AGAs were identified. The location of recognized Golgi autoantigen(s) was confirmed by the treatment of monensin and double immunostaining using beta-COP. Using the immunoelectron microscopy, AGA immunoreactivity was clearly demonstrated at a stack structure, characteristic of the Golgi complex. Furthermore, analysis of the 12 AGA-positive sera by Western blot revealed at least 15 components of Golgi antigens with relative molecular weights ranging from 54 to 350 kDa, and several Golgi autoantigens identified may be novel. Notably, over half of the AGA-positive cases found belong to non-autoimmune diseases, particularly hepatic disorder. This study presents the association of AGAs, components of the Golgi complex and clinical diseases.

Combined use of esmolol and nicardipine to blunt the haemodynamic changes following laryngoscopy and tracheal intubation

We examined the effect of different combinations of esmolol and nicardipine upon the circulatory response to tracheal intubation. One hundred patients were randomly allocated into five groups of twenty to receive pretreatments of saline or different combinations of esmolol (0.5 or 1.0 mg x kg(-1)) and nicardipine (15 or 30 microg x kg(-1)). Significant tachycardia persisted over a 5-min period after intubation in all five groups compared with baseline levels (p < 0.05). Patients receiving esmolol 1.0 mg x kg(-1) and nicardipine 30 g x kg(-1) showed no significant change in systolic blood pressure after tracheal intubation compared with baseline and significant lower peak systolic blood pressure than those receiving saline (p = 0.023).

Effect of thiopental, propofol, and etomidate on vincristine toxicity in PC12 cells

Neurotoxicity is the dose-limiting side-effect of vincristine in cancer therapy. Using the nerve growth factor (NGF)-dependent neurite outgrowth and cell proliferation of the PC12 pheochromocytoma cell line as an in vitro assay, the protective effect of different intravenous anesthetics was assessed. Vincristine (1 nmol/L) significantly decreased the percentage of neurite-forming cells from 68% +/- 9% to 27% +/- 7% within a 3-day incubation period. The longer neurites (> 2 x cell body) in particular proved to be extremely sensitive to vincristine (from 17% +/- 4% to 0% of total neurite-expressing cells). Flow cytometry results revealed an S-phase percentage of 15.85% +/- 3.25% after NGF induction, with vincristine reducing this percentage to 0.68% +/- 0.38%. Reversal of the inhibitory effect of vincristine was noted in the cells treated with thiopental or propofol but not etomidate. Bicuculline partially antagonized the protective effect of thiopental and propofol in both studies. We conclude that thiopental and propofol, but not etomidate, have a protective effect in vincristine-induced neurotoxicity. The protective effect produced by thiopental and propofol is probably secondary to activation of GABAA receptors.

Effect of pretreatment with ketorolac on propofol injection pain

BACKGROUND

: Pain on injection is still a major problem with propofol. We performed this study to compare different doses of intravenous (i.v.) ketorolac with and without venous occlusion and its effect on the incidence and the severity of the pain after propofol injection.

METHODS

We conducted a prospective, randomized and double-blind study of 180 patients (20-60 years of age.) scheduled to undergo elective surgery. Six groups of patients were generated: group A received normal saline (NS) 2 ml i.v.; groups B, C, D received ketorolac 10 mg in 2 ml NS with venous occlusion (VO) and a subsequent propofol injection at either 30, 60 or 120 s; groups E and F received ketorolac 15 mg and 30 mg in 2 ml NS and propofol was injected after 60 s. The pain perception was assessed during injection of propofol in all patients.

RESULT

: The incidence of propofol-associated injection pain was for A: 46.7%; B: 43.4%; C: 23.3%; D:16.7%; E: 20%, and F: 10%. The incidence of pain following propofol injection was reduced by i.v. ketorolac 10 mg with venous occlusion for 120 s. Furthermore, i.v. ketorolac 15 mg and 30 mg but not 10 mg following propofol injection after 60 s without venous occlusion revealed significant pain reduction when compared to saline group. There was no difference in venous sequelae at 7 days postoperatively between the groups.

CONCLUSION

Our results suggested that pretreatment with i.v. 15 and 30 mg ketorolac reduces pain following propofol injection. Moreover, pretreatment with i.v. ketorolac 10 mg with venous occlusion for 120 s achieves the same pain relief effect.

Intrathecal clonidine decreases spinal nitric oxide release in a rat model of complete Freund's adjuvant induced inflammatory pain

A long-lasting antihyperalgesic effect has been demonstrated for intrathecal (IT) clonidine, an alpha2-adrenergic agonist. In the present study, the mechanism and antihyperalgesic effects of IT clonidine were examined post-treatment in a rat model of Complete Freund's Adjuvant (CFA)-induced inflammatory hyperalgesia. Using a chronic model of spinal cord dialysis, we examined the effect of the adjuvant-induced inflammation on spinal release of nitric oxide (NO) and the development of chronic pain and assessed the antinociceptive effects and mechanisms of the alpha2-adrenergic agonist, clonidine (IT). Chronic, persistent inflammatory pain was induced by left hind paw injection of 0.3 ml CFA prepared in a mixture with Mycobacterium butyricum. Rats were randomly assigned to groups receiving IT clonidine in discrete doses of 1, 10 or 50 microg, 3 or 24 hr post-inflammation. Measurement of total NOx (NO + NO2- + NO3-) was used to determine NO release into the cerebrospinal fluid. Rat thermal antinociception was assessed using a radiant heat thermal hyperalgesia model. CFA injection resulted in significant thermal hyperalgesia throughout the four days of observation. A dose-dependent suppression of thermal hyperalgesia and spinal NO release was observed after IT clonidine treatment. Evidence from this CFA-induced inflammatory pain model suggests that clonidine's spinal antihyperalgesic mechanisms act through inhibition of spinal NO release.

Changes in the levels of nitric oxide synthase and protein kinase C gamma following kainic acid receptor activation in the rat spinal cord

In this study, we evaluated the levels of nitric oxide synthase, both neuronal and induced (nNOS and iNOS, respectively), cyclooxygenase-1 and 2 (COX-1 and COX-2) and protein kinase C gamma (PKCgamma) and correlated these with algogenic behavior following spinal kainic acid (KA) receptor activation in rats. Thirty adult male Sprague-Dawley rats were randomly assigned into six groups (n=5). Groups A, B, and C received 0.5 g kainic acid intrathecally and were analyzed at 3, 6, 24 h after injection, respectively. Groups D, E, and F received saline and were analyzed at 3, 6, 24 h after injection, respectively. We observed for behavioral changes in the rats following intrathecal KA injection and analyzed the protein levels of NOS, COX and PKCgamma by Western blotting techniques. Importantly, we clarified the potential roles of PKCgamma in the regulation of nNOS and COX-2 following intrathecal injection with KA in the rat spinal cord. COX-2 protein was detected but not significantly changed in the lumbosacral spinal cord at 3, 6, and 24 h following intrathecal KA injection (P>0.05). In contrast, nNOS protein was detected at higher levels in comparison with normal spinal cord at 6 and 24 h after intrathecal administration of KA (P<0.05). PKCgamma also increased significantly at 3, 6, and 24 h after intrathecal KA injection when compared with the baseline level (P<0.05). On the other hand, COX-1 and iNOS were not detected in either normal or KA treated spinal cords. These results provide strong in vivo evidence to support the idea that nNOS but not COX-2, plays an important role in spinal KA receptor activation. Furthermore, up-regulation of PKCgamma is involved in KA induced algogenic behavior in rats.

Adenomatous polyposis coli gene mutation and decreased wild-type p53 protein expression in oral submucous fibrosis: a preliminary investigation

OBJECTIVE

The purpose of this study was to identify the adenomatous polyposis coli (APC) tumor suppressor gene mutation and level of wild-type p53 protein expression in patients with oral submucous fibrosis (OSF).

STUDY DESIGN

Cells from OSF and control subjects were cultured in Dulbecco modified Eagle medium with 10% fetal bovine serum at 37 degrees C. Genomic DNA was extracted from cultured cells and used as a template for polymerase chain reaction amplification of the APC tumor suppressor gene. The presence of wild-type p53 protein in cell lysates of cultured cells was analyzed by Western blot. Data were analyzed by the sign test for nonparametric samples and by analysis of variance.

RESULTS

The results showed that the APC gene of explant cultured cells from OSF patients (8/8) had a CGA-to-GGA transition mutation at codon 498 that resulted in an Arg-to-Gly missense mutation (P <.01). All (8/8) normal HGF cultures revealed expression of the wild-type APC protein. Cells cultured from 7 of 8 OSF patients were also found to have a single nucleotide deletion at nucleotide 1494 that resulted in creating a stop codon (TGA) at codon 504 (P <.01). This created a premature signal for the endpoint of translation and thus resulted in the generation of a truncated protein product that encodes a polypeptide of 503 amino acid residue. It was found that wild- type p53 protein in human gingival fibroblast cell cultures was significantly higher than in OSF cells (P <.01).

CONCLUSION

Alterations of the APC and wild-type p53 tumor suppressor genes in OSF may imply a risk for progression to oral cancer.

Intrathecal bupivacaine with morphine or neostigmine for postoperative analgesia after total knee replacement surgery

PURPOSE

To compare the postoperative analgesic efficacy and safety of intrathecal (IT) neostigmine and IT morphine in patients undergoing total knee replacement under spinal anesthesia.

METHODS

Sixty patients scheduled for elective total knee replacement under spinal anesthesia were randomly divided into three equal groups which received IT 0.5% hyperbaric bupivacaine 15 mg with either normal saline 0.5 mL, neostigmine 50 microg, or morphine 300 microg. The maximal level of sensory block, duration of analgesia, time to use of rescue analgesics, the overall 24-hr and four-hour interval visual analogue scale (VAS) pain score, and the incidence of adverse effects were recorded for 24 hr after administration.

RESULTS

There was no significant difference in maximal level of sensory block among the three groups. The morphine group had a later onset of postsurgical pain and longer time to first rescue analgesics than the neostigmine group (P <0.05). Overall 24-hr VAS pain scores were significantly higher in the saline group vs the morphine and neostigmine groups (P <0.05). Motor block lasted significantly longer in the neostigmine group than in the morphine and saline groups (P <0.05). The incidence of adverse effects was similar in the neostigmine and morphine groups except for pruritus (70%) occurring more frequently in the morphine group than in the neostigmine and saline groups (0%; P <0.05). Overall satisfaction rates were better in the neostigmine group than in the morphine and saline groups (P <0.05).

CONCLUSIONS

IT neostigmine 50 microg produced postoperative analgesia lasting about seven hours with fewer side effects and better satisfaction ratings than IT morphine 300 microg.

Carbon dioxide laser induced airway fire during larynx surgery: case report

The precision intrinsic hemostatic properties of the laser have led to its wide use in modern clinical medicine especially in microscopic airway surgery. However, the intense heat generated by the high energy density of the surgical laser can convert combustible tubes into veritable torches, cause catastrophic fires, and result in severe injury to the patient. This is of particular importance when high energy is used on the continuous mode or when the endotracheal tube is repeatedly hit by the laser at the same spot. Most reported laser-induced complications result from the laser beam inadvertently falling on the areas that are not intended to be exposed. We report a case of a trans-tracheostomy tube fire occurring during carbon dioxide (CO2) laser surgery. Aluminum-tape wrapping did not prevent this complication. It was found that the ignition of a trans-tracheostomy tube was caused by the laser striking an unprotected portion of the tube during resection of granuloma of the trachea.

Intrathecal magnesium sulfate attenuates algogenic behavior and spinal amino acids release after kainic acid receptor activation in rats

Activation of N-methyl-D-asparate (NMDA) receptor and non-NMDA classes of glutamate receptors play a key role in spinal nociceptive processing. Using with a lumbar intrathecal (IT) catheter and a loop dialysis catheter in lightly anesthetized (1% isoflurane) rats, the effect of IT pre-treatment with magnesium sulfate (100, 300 or 500 microg) on IT kainic acid (KA: 1 microg; non-NMDA receptor agonist) evoked amino acids (AAs) release and corresponding behavior was examined. IT KA produced significant increases (mean+/-SD of % baseline concentration) in dialysate concentrations of aspartate (424+/-88%), glutamate (241+/-35%) and taurine (398+/-58%). IT pre-treatment with MgSO(4) resulted in a dose-dependent suppression of the evoked algogenic behavior and aspartate release. These data suggest that activation of spinal KA receptors provides a powerful stimulus for secondary spinal excitatory AAs release and corresponding appearance of pain behavior. The regulation of this release by magnesium suggests the possible role of this divalent cation in regulating this excitatory effect of non-NMDA receptor activation.

The effect of dexamethasone on postoperative pain and emesis after intrathecal neostigmine

We evaluated the effect of a single dose of dexamethasone on the incidence and severity of postoperative nausea and vomiting (PONV) after intrathecal injection of tetracaine plus neostigmine. Sixty ASA physical status I patients scheduled for inguinal herniorrhaphy were studied with a randomized, double-blinded, placebo-controlled protocol. The dexamethasone group (Group D) received 10 mg of dexamethasone IV before performance of spinal anesthesia, whereas the placebo group (Group P) received saline. Spinal anesthesia was performed with intrathecal injection of 15 mg tetracaine plus neostigmine 100 microg in both groups. Pain, PONV, and other side effects were evaluated 24 h after surgery. The duration and severity of analgesia and the incidence of PONV were not significantly different between the two groups. Our results demonstrate that a single dose of dexamethasone (10 mg) did not potentiate the analgesic effect or reduce the incidence of PONV after intrathecal injection of tetracaine and neostigmine.

IMPLICATIONS

The results of our evaluation of the effect of IV dexamethasone versus saline control on analgesia and nausea and vomiting after intrathecal neostigmine and tetracaine suggest that IV dexamethasone did not enhance the analgesic effect of neostigmine or reduce the incidence of emesis after intrathecal administration.

Effect of isoflurane versus nicardipine on blood flow of lumbar paraspinal muscles during controlled hypotension for spinal surgery

STUDY DESIGN

This study compared the effects of isoflurane and nicardipine on regional blood flow of the lumbar paraspinal muscles.

OBJECTIVES

The purpose of this study was to determine whether treatment with hypotensive agents result in ischemia of the lumbar paraspinal muscles, thereby facilitating surgical procedures.

SUMMARY OF BACKGROUND DATA

Despite the general acceptance of controlled hypotension as effective in reducing blood loss during spinal surgery, the changes of blood flow that occur at the lumbar paraspinal muscles when this technique is applied remain unclear. The use of laser Doppler flowmetry allows changes of muscle blood flow to be easily detected in real time with minimal invasion, thereby allowing differences among distinct pharmacological approaches for induction and maintenance of controlled hypotension to be evaluated.

METHODS

The prehypotensive and hypotensive (reduction of mean arterial pressure by 20 mm Hg) blood flow of the lumbar paraspinal muscles were assessed with a laser Doppler flowmeter in 40 patients undergoing lumbar spinal surgery. The first half of the patients (n = 20) received isoflurane, whereas the second half received nicardipine to achieve arterial hypotension.

RESULTS

Compared with the prehypotensive state, during the hypotensive state, patients in the isoflurane group exhibited a 17% to 46% (mean, 33.7%) decrease in lumbar paraspinal muscle blood flow, whereas patients in the nicardipine group exhibited a 24% to 177% (mean, 82.5%) increase in lumbar paraspinal muscle blood flow. Statistical analysis showed a significant difference in the changes of flux after induced hypotension between the isoflurane and nicardipine group (P < 0.001).

CONCLUSIONS

Depending on the pharmacological treatment used to achieve arterial hypotension in spine surgery, there will be either a reduction in paraspinal muscle blood flow (ischemia) or an enhancement of this blood flow (hyperemia).

Coronary artery bypass grafting on the beating heart using the octopus method--a case report

A 74-year-old male was admitted due to chest tightness for one month. He had received percutaneous transilluminal coronary angioplasty (PTCA) because of single-vessel disease one year ago. Cardiac catheterization examination carried out during this admission revealed 90% stenosis of the left anterior descending coronary artery (LAD) and circumflex branch (CX). Because another attempt of PTCA was considered not optimal, the patient was advised to undergo surgical grafting to which he consented. After expediently balancing the merits and demerits of every practicable surgical procedure--the essential determinant in selection of which was that the patient's condition and criteria of indication of that procedure were in perfect harmony--we decided to carry out minimally invasive direct coronary artery bypass (MIDCAB) with the application of Octopus tissue stabilizer. We report the surgical course and anesthetic management of the patient and discourse some detail in MIDCAB.

Failure of prevention against postoperative vomiting by ondansetron or prochlorperazine in patients undergoing gynecological laparoscopy

BACKGROUND

Ondansetron has been approved for the treatment and prevention of postoperative emesis. Since it is presumably considered to possess potent antiemetic effect with fewer side effects, the administration of ondansetron to inhibit emesis in patients following gynecological laparoscopic surgery might be recommendable. Hence, we examined the effects of intravenous ondansetron at dosage of 4 and 8 mg in comparison with intravenous prochlorperazine at 5 mg and placebo.

METHODS

A total of 120 patients were allocated randomly into 3 groups. Group 1 patients who served as control were given NaCl 0.9% 4 mL (placebo) intravenously (i.v.); patients in group 2 and group 3 were given ondansetron 4 mg ondansetron 8 mg i.v. respectively; patients in group 4 were given prochlorperazine 5 mg i.v. Premedication was omitted.

RESULTS

Logistic regression analysis adjusted for prognostic factors revealed no significant difference between 5 mg prochlorperazine group and 4 mg or 8 mg ondansetron group as compared over the 24 h study period.

CONCLUSIONS

The results of this study suggest that i.v. 4 or 8 mg ondansetron and 5 mg prochlorperazine were not effective in prevention of postoperative emesis in patients undergoing gynecological laparoscopy. Since the cost of ondansetron is high, its routine use for prevention against postoperative nausea and vomiting is not be recommended clinically because of its uncertain benefit.

Transient spinal cord ischemia in rat: the time course of spinal FOS protein expression and the effect of intraischemic hypothermia (27 degrees C)

1. In the present study, we characterize the time course of spinal FOS protein expression after transient noninjurious (6-min) or injurious (12-min) spinal ischemia induced by inflation of a balloon catheter placed into the descending thoracic aorta. In addition, this work examined the effects of spinal hypothermia on FOS expression induced either by ischemia or by potassium-evoked depolarization (intrathecal KCl). 2. Short-lasting (6-min) spinal ischemia evoked a transient FOS protein expression. The peak expression was seen 2 hr after reperfusion in all laminar levels in lumbosacral segments. At 4 hr of reperfusion, more selective FOS expression in spinal interneurons localized in the central part of laminae V-VII was seen. At 24 hr no significant increase in FOS protein was detected. 3. After 12 min of ischemia and 2 hr of reflow, nonspecific FOS expression was seen in both white and gray matter, predominantly in nonneuronal elements. Intrathecal KCl-induced FOS expression in spinal neurons in the dorsal horn and in the intermediate zone. Spinal hypothermia (27 degrees C) significantly suppressed FOS expression after 6 or 12 min of ischemia but not after KCl-evoked depolarization. 4. Data from the present study show that an injurious (but not noninjurious) interval of spinal ischemia evokes spinal FOS protein expression in glial cells 2 hr after reflow. The lack of neuronal FOS expression corresponds with extensive neuronal degeneration seen in this region 24 hr after reflow. Noninjurious (6-min) ischemia induced a transient, but typically neuronal FOS expression. The significant blocking effect of hypothermia (27 degrees C) on the FOS induction after ischemia but not after potassium-evoked depolarization also suggests that simple neuronal depolarization is a key trigger in FOS induction.

Comparison of pulsed-field gel electrophoresis and coagulase gene restriction profile analysis techniques in the molecular typing of Staphylococcus aureus

Pulsed-field gel electrophoresis (PFGE) and coagulase gene restriction profile (CRP) analysis techniques were used to analyze 71 Staphylococcus aureus isolates recovered from nine food-borne disease outbreaks. Twenty-two PFGE profiles and 11 CRPs were identified, with discrimination indices of 0.86 and 0.72, respectively. In addition, the variable regions of the coagulase genes of 39 isolates were sequenced and showed extensive identity, indicating that this is not an efficient alternative for the molecular typing of S. aureus.

Transpedicular instrumentation as an adjunct in the treatment of thoracolumbar and lumbar spine tuberculosis with early stage bone destruction

OBJECT

Because modern imaging techniques now allow for early diagnosis of spinal tuberculosis, more conservative management options are possible. The authors evaluated the effectiveness of transpedicular instrumentation for treatment of thoracolumbar and lumbar spinal tuberculosis in patients with mild bone destruction and the main symptom of "instability catch" (a sudden painful "snap" that occurs when one extends from a forward bent to an upright position).

METHODS

Eighteen patients (nine men and nine women, age range 49-71 years) with spinal tuberculosis were treated with transpedicular instrumentation that was supplemented with posterolateral fusion and chemotherapy. All patients were wheelchair dependent or bed-ridden due to severe instability catch, with a mean symptom duration of 2.5 months (range 1-6 months). Two contiguous vertebrae were involved in 17 patients, and a single vertebrae was involved in one. In five patients mild neurological deficits (Frankel Grade D) were present. During surgery, the screws were implanted into the two nonaffected pedicles nearest the lesion to stabilize the involved segments. No attempt at radical debridement or neural decompression was undertaken. The follow-up period ranged from 21 to 40 months. Postoperatively the instability catch was relieved within 10 days (excellent outcome) and within 1 month (good outcome) in seven and eight patients, respectively, and within 3 months (fair outcome) in two; in the remaining patient, the symptom did not resolve (poor outcome). A short duration of symptoms (generally < 3 months) and bone destruction of less than 50% in the involved vertebral bodies were observed in patients who made a good or excellent outcome. During the follow-up period, good maintenance of spinal alignment, stabilization of the involved segment, and resolution of the inflammatory process were shown; however, there was no strong evidence that fusion had occurred at the bony defect. Patients in whom a fair outcome was achieved experienced a longer duration of symptoms, and in each, one vertebral body with greater than 50% bone destruction was demonstrated. However, good maintenance of spinal alignment was also shown during the follow-up period. The patient whose outcome was poor had the longest history (6 months) of symptoms and the most extensive involvement of the spine (> 50% destruction of two adjacent lumbar vertebral bodies). Postoperatively, implant failure occurred and the patient developed a wound infection.

CONCLUSIONS

Transpedicular instrumentation provides rapid relief of instability catch and prevents late angular deformity in patients with thoracolumbar and lumbar spinal tuberculosis in whom limited (< 50%) bone destruction of the involved vertebral bodies has been shown and whose main symptom is instability catch.

Protein kinase C isoforms during the development of deciduomata in pregnant rats

In this study, we determined the expression of protein kinase C (PKC) isoforms during pregnancy. At pregnant duration, PKC alpha was down-modulated in the deciduomata but not in the myometrium. Down-modulation was compatible with the increase in cell mitosis, which reached a maximum at 8-9 days. On the other hand, PKC zeta was not down-modulated. It was increased both in the cytosolic and particulate fractions of the deciduomata, and paralleled the frequency of decidual cell mitosis. The other PKC isoform of delta was also increased, but it was associated with the cell regression. Therefore, these findings confirmed that the variable expression of PKC isoforms in decidualizing tissue may be involved in the modulation of decidual cell growth.

Protein kinase C isoforms during the development of deciduomata in pseudopregnant rats

In this study, we determined the expression of protein kinase C (PKC) isoforms during trauma-induced decidualization. The findings revealed that at least five PKC isoforms (alpha, delta, zeta, iota and lambda) were present in both control and decidualized tissues. After trauma-stimulation, PKC alpha was down-modulated in the deciduomata but not in the myometrium. Down-modulation was compatible with the increase in cell mitosis which reached a maximum at 2-3 days. On the other hand, PKC zeta was not down-modulated. It was increased both in the deciduomata and myometrium, and paralleled the frequency of decidual cell mitosis. The PKC isoforms of delta, iota and lambda were also increased, but they were associated with the depression of cell mitosis. Therefore, these findings suggested that the variable expression of PKC isoforms in trauma-induced decidualizing tissue in pseudopregnant rats may be involved in the modulation of decidual cell growth.

Lidocaine concentrations in plasma and cerebrospinal fluid after systemic bolus administration in humans

Preclinical studies suggest that systemic lidocaine acts at the level of the spinal dorsal horn to inhibit hyperalgesia resulting from nerve injury, yet no clinical data are available to support this view. Therefore, we sought to characterize the time course of lidocaine in the plasma and cerebrospinal fluid (CSF) after an IV bolus injection of lidocaine 2 mg/kg in patients scheduled for surgery involving spinal anesthesia. Sixty-five patients were randomly allocated to one of five study groups (n = 13 per group) receiving IV lidocaine before CSF/ plasma sampling at 5, 10, 15, 30, or 60 min. Gas chromatographic analysis of these samples revealed a fast but transient peak (5-15 min) in lidocaine plasma levels (1.7+/-0.16 microg/mL), which declined rapidly thereafter. Only small concentrations of IV lidocaine were found in the CSF (6%- 8% of plasma concentration), but this fraction remained stable from 15 min until termination of the experiment. No statistical correlation was observed between plasma and CSF lidocaine levels. These data suggest that because of the prolonged availability of lidocaine at the spinal dorsal horn level, systemic administration of lidocaine suppresses central sensitization within the spinal cord after nerve injury in humans.

IMPLICATIONS

Cerebrospinal fluid concentrations of lidocaine after its systemic bolus delivery in humans indicate that the spinal cord may be the major site of antinociceptive action by this route of drug administration.

Effect of postprepared sperm parameters and insemination specimen volume on the outcome of intrauterine insemination

BACKGROUND

The purpose of the present study was to identify the postprepared sperm parameters affecting the outcome of intrauterine insemination and to find out whether the volume of insemination specimen was a determinant factor in the rate of successful conception.

MATERIALS AND METHODS

A retrospective study including 306 couples was designed. The patients were inseminated with either 1.0 or 0.5 ml of prepared specimens. The pregnancy rates were compared using the chi-square test. Logistic regression was chosen for multivariant analysis of the parameters.

RESULTS

The only parameter significantly affecting the success rate was the postprepared sperm motility (p = 0.033). The pregnancy rate was 27.91% in cases with > or = 95% sperm motility. Only two patients with less than 75% sperm motility conceived. The pregnancy rates in cases with 0.5 ml and 1.0 ml inseminations were 12.12% and 16.13%, respectively. This difference was statistically insignificant (p = 0.427).

CONCLUSION

The postprepared sperm motility was the only parameter predicting the successful rate of intrauterine insemination. Seventy-five percent sperm motility can be used as a cut-off value for selecting patients. The volume of insemination specimen did not influence the outcome. Insemination with 1 ml of fluid was just as effective as insemination with 0.5 ml.

A study of an endothelin antagonist from a Chinese anti-snake venom medicinal herb

Because it is well known that endothelin (ET) plays an important role in the pathogenesis of cardiovascular diseases, antagonists of ET for clinical use are very important. Because ET and some snake toxins have a homologous structure and similar biologic actions the effect of Chinese anti-snake venom herbal medicines on ET bioactivity was investigated both in vivo and in vitro. Hong Bei Si Chou [Cissus assamica (Laws.) Craib] is a herbal medicine used to treat snake bite in Guangxi province. It was found that all the different fractions of EtOH extraction, the EtOAc part of the EtOH extraction, and resverotrol (3,4'5-trihydroxytransstilbene) isolated from the EtOAc part could antagonize ET both in vivo and in vitro. These three fractions transiently relaxed ET-contracted isolated rat aortic ring in a dose-dependent manner. They also antagonized the lethal effects of ET-1 in mice and inhibited blood pressure elevation induced by ET-1. The results have shown that it is possible to find ET antagonists in Chinese anti-snake venom medicinal herbs. In the future, our work should shed new light on the treatment of cardiovascular diseases in which ET is involved.

Effect of patient position and hypotensive anesthesia on inferior vena caval pressure

STUDY DESIGN

This is a prospective study to measure the inferior vena caval pressure of 20 patients in different positions and different states of blood pressure.

OBJECTIVES

Because the inferior vena caval pressure could affect the vertebral venous pressure, which in turn may influence blood loss during lumbar spinal surgery, this study was designed to provide the quantitative data necessary to stress the importance of patient positioning and to assess the effect of controlled hypotension on inferior vena caval pressure.

SUMMARY OF BACKGROUND DATA

Positioning patients with a pendulous abdomen and controlled hypotension has been practiced widely during lumbar spinal surgery. It is generally believed that the former will help reduce vertebral venous engorgement and the latter will produce a bloodless surgical wound. However, there have been no complete studies in which quantitative changes of inferior vena caval pressure resulting from different positions was examined. In addition, it would be interesting to know what happens to inferior vena caval pressure during induced hypotension. Could there be an adverse effect on the inferior vena caval pressure during the hypotensive state?

METHODS

An intravenous catheter was introduced into the inferior vena cava in each of 20 patients undergoing spinal surgery. In each patient, the inferior vena caval pressure was measured when the patient was supine, prone on a conventional pad, and prone on a Relton-Hall frame. It was followed by isoflurane-induced hypotension with reduction of mean arterial pressure by 20 mm Hg.

RESULTS

In this series, the inferior vena caval pressure ranged from 8.2 to 23.4 mm Hg (with a mean of 15.3 mm Hg) when patients were positioned prone on a conventional pad. However, when they were subsequently positioned prone on a Relton-Hall frame, the inferior vena caval pressure decreased dramatically to a range of 4.6 to 13.6 mm Hg (with a mean of 8.2 mm Hg). In each patient the measured inferior vena caval pressure when positioned prone on a conventional pad was 1.5 times greater than that measured with the patient positioned on a Relton-Hall frame. There was a statistically significant difference between these two positions (F = 75.996; P < 0.05). The patients' mean arterial pressure ranged from 92 to 105 mm Hg before induced hypotension. During this time, the inferior vena caval pressure ranged from 4.1 to 13.1 mm Hg (mean, 8.2 mm Hg). During the hypotensive state, the patients' inferior vena caval pressure was found to range from 4.2 to 13.6 mm Hg (mean, 8.1 mm Hg). In each patient the hypotensive interior vena caval pressure may be slightly higher or lower than the baseline pressure. However, the variation never exceeded 1.7 mm Hg. Statistically, there was no significant difference between these two periods (t = 0.956; P > 0.05).

CONCLUSIONS

A device allowing the patient's abdominaL viscera to hang freely while the patient is in a prone position significantly reduces their inferior vena caval pressure. The patients also has a constant inferior vena caval pressure during isoflurane-induced hypotension.

Postoperative analgesia by intra-articular neostigmine in patients undergoing knee arthroscopy

BACKGROUND

Recently, the spinal administration of neostigmine was shown to produce a dose-dependent analgesia. However, this analgesia is limited by adverse effects. The purpose of this study was to examine the analgesic action of peripheral muscarinic receptors by administering intra-articular neostigmine after operation in patients undergoing knee arthroscopy.

METHODS

Sixty patients (classified as American Society of Anesthesiologists status I or II) having arthroscopic meniscus repair during general anesthesia were randomized to receive, in a double-blind manner, after operation 125, 250, or 500 microg intra-articular neostigmine; 2 mg intra-articular morphine; or as control groups intra-articular saline or 500 microg neostigmine given subcutaneously (s.c.). Visual analog pain scores (VAS), duration of analgesia as defined by first demand for patient-controlled analgesia by morphine, and subsequent 48-h consumption of morphine were evaluated.

RESULTS

Intra-articular (500 microg) neostigmine resulted in significant VAS reduction 1 h after injection compared with patients given intra-articular saline and with those given intra-articular morphine. Analgesia lasted longer after 500 microg intra-articular neostigmine (350 +/- 126 min) compared with intra-articular morphine (196 +/- 138 min; P < 0.05) or with the control groups (intra-articular saline, 51 +/- 11 min; s.c. neostigmine, 46 +/- 8 min; P < 0.05). The need for supplementary analgesia was significantly higher in control groups than for patients given intra-articular morphine or 500 microg intra-articular neostigmine. No significant analgesic effects were observed for the two lower doses of intra-articular neostigmine. Among all study groups, no adverse effects were observed.

CONCLUSIONS

Intra-articular injection of the acetylcholinesterase inhibitor neostigmine produced a moderate but significant analgesic effect. Several mechanisms such as the hyperpolarization of neurons, reduction in the release of pronociceptive neurotransmitters, or activation of the nitric oxide-cyclic guanosine monophosphate pathway might mediate this peripheral cholinergic antinociception by elevating endogenous acetylcholine.

Localization of protein kinase C alpha and zeta during the decidualization in pseudopregnant rats

Our previous data showed that at least five PKC isoforms (alpha, delta, zeta, lambda and tau) were present in the decidualization. In this study, we then localized the PKC alpha and zeta by immunohistochemistry in the decidualized uterine tissues. The decidualized uterine tissues were induced by trauma-stimulation and fixed in formalin. The immunofluorescence were photographed by confocal microscope. The data revealed that the fluorescence of PKC alpha was present in the deciduomata and myometrium. In the deciduomata, PKC alpha was mainly located in the surrounding nuclear. This phenomenon of localization was especially performed on day 2 and 3 of the decidualization, just on the time of higher frequence of cell mitosis. Since the myometrium with hypertrophy did not display the phenomenon of perinuclear localization, these suggested that the expression and localization of PKC alpha may be associated with the cell proliferation. On the other hand, the PKC zeta was also present and distributed broadly in the deciduomata and myometrium. This expression was increased and similar to the previous Western blot studies. Thus, the data confirmed that the various expression and localization of PKC isoforms may be correlated with the development of deciduomata.