Endoscopic findings and predictors of gastrointestinal lesions in children with iron deficiency anemia

Iron deficiency anemia (IDA) can be caused by occult gastrointestinal (GI) blood loss; however, the endoscopic findings in children with anemia are unclear. The study aimed to determine the frequency and factors related to lesions in children with IDA undergoing endoscopy. We retrospectively analyzed the clinical and endoscopic findings of children with a laboratory-based diagnosis of IDA. Of 58 patients, 36 (62.1%) had upper GI tract lesions, with erosive gastritis being the most common lesion. Further, 26 patients underwent concomitant colonoscopy, and 12 (46.2%) had lower GI tract lesions. Overall, 44 (75.9%) patients had lesions in either the upper or lower GI tract. Helicobacter pylori infection was detected in 13 patients (22.4%). Patients with lesions found by endoscopy had significantly lower hemoglobin level (8.9 vs. 10.0 g/dL, p = 0.047) and mean corpuscular volume (75.5 vs. 80.9 fL, p = 0.038). The proportion of patients with previous treatment for IDA was also higher in those with lesions on endoscopy. In multivariate analysis, age of ≥10 years (odds ratio [OR], 6.00; 95% confidence Interval [CI], 0.56-10.75) and positive fecal occult blood test (FOBT) findings (OR, 2.25; 95% CI, 0.14-4.52) were factors related to GI lesions. The presence of GI symptoms was not associated with GI lesions. A high proportion of GI lesions were found by endoscopy in children with IDA in this study. Endoscopy should be considered in children with IDA even without GI symptoms, especially in older children, and those with positive FOBT results.

Epidemiologic and Clinical Outcomes of Pediatric Renal Tumors in Korea: A Retrospective Analysis of The Korean Pediatric Hematology and Oncology Group (KPHOG) Data

PURPOSE

Renal tumors account for approximately 7% of all childhood cancers. These include Wilms tumor (WT), clear cell sarcoma of the kidney (CCSK), malignant rhabdoid tumor of the kidney (MRTK), renal cell carcinoma (RCC), congenital mesoblastic nephroma (CMN) and other rare tumors. We investigated the epidemiology of pediatric renal tumors in Korea.

MATERIALS AND METHODS

From January 2001 to December 2015, data of pediatric patients (0-18 years) newly-diagnosed with renal tumors at 26 hospitals were retrospectively analyzed.

RESULTS

Among 439 patients (male, 240), the most common tumor was WT (n=342, 77.9%), followed by RCC (n=36, 8.2%), CCSK (n=24, 5.5%), MRTK (n=16, 3.6%), CMN (n=12, 2.7%), and others (n=9, 2.1%). Median age at diagnosis was 27.1 months (range 0-225.5) and median follow-up duration was 88.5 months (range 0-211.6). Overall, 32 patients died, of whom 17, 11, 1, and 3 died of relapse, progressive disease, second malignant neoplasm, and treatment-related mortality. Five-year overall survival and event free survival were 97.2% and 84.8% in WT, 90.6% and 82.1% in RCC, 81.1% and 63.6% in CCSK, 60.3% and 56.2% in MRTK, and 100% and 91.7% in CMN, respectively (p < 0.001).

CONCLUSION

The pediatric renal tumor types in Korea are similar to those previously reported in other countries. WT accounted for a large proportion and survival was excellent. Non-Wilms renal tumors included a variety of tumors and showed inferior outcome, especially MRTK. Further efforts are necessary to optimize the treatment and analyze the genetic characteristics of pediatric renal tumors in Korea.

Medical Treatment of Pediatric Low-Grade Glioma

Low-grade glioma (LGG) is the most common brain tumor in children and has excellent long-term survival. With an excellent survival rate, the choice of treatment involves careful consideration of minimizing late toxicity from surgery, radiation, and chemotherapy. Surgery, radiation therapy, and chemotherapy can be used as monotherapy or in combination, providing different therapeutic ratios and complications. As a result, establishing the selection of ideal therapies has been a controversial area, presenting challenges. Recent advances in understanding molecular characteristics of pediatric LGG affect classification and treatment approaches. This review aims to overview recent developments in medical treatment in pediatric LGG.

Poor Outcome After Hematopoietic Stem Cell Transplantation Of Patients With Unclassified Inherited Bone Marrow Failure Syndromes

Classification of inherited bone marrow failure syndromes (IBMFSs) according to clinical and genetic diagnoses enables proper adjustment of treatment. Unfortunately, 30% of patients enrolled in the Canadian Inherited Marrow Failure Registry (CIMFR) with features suggesting hereditability could not be classified with a specific syndromic diagnosis. We analyzed the outcome of hematopoietic stem cell transplantation (HSCT) in unclassified IBMFSs (uIBMFSs) and the factors associated with outcome. Twenty-two patients with uIBMFSs and 70 patients with classified IBMFSs underwent HSCT. Five-year overall survival of uIBMFS patients after HSCT was inferior to that of patients with classified IBMFSs (56% vs 76.5%). The outcome of patients with uIBMFS who received cord blood was significantly lower than that of patients who received other stem cell sources (14.8% vs 90.9%). Engraftment failure was higher among patients with uIBMFS who received cord blood than those who received bone marrow. None of the following factors was significantly associated with poor survival: transfusion load, transplant indication, the intensity of conditioning regimen, human leukocyte antigen-identical sibling/alternative donor. We suggest that identifying the genetic diagnosis is essential to modulate the transplant procedure including conditioning agents and stem cell sources for better outcome and the standard CBT should be avoided in uIBMFS.

Erratum: Correction of Affiliations in the Article "Clinical Characteristics and Treatment Outcomes in Children, Adolescents, and Young-adults with Hodgkin's Lymphoma: a KPHOG Lymphoma Working-party, Multicenter, Retrospective Study"

This corrects the article on p. e393 in vol. 35, PMID: 33258329.

Clinical Characteristics and Treatment Outcomes in Children, Adolescents, and Young-adults with Hodgkin's Lymphoma: a KPHOG Lymphoma Working-party, Multicenter, Retrospective Study

BACKGROUND

Hodgkin's lymphoma (HL) constitutes 10%-20% of all malignant lymphomas and has a high cure rate (5-year survival, around 90%). Recently, interest has increased concerning preventing secondary complications (secondary cancer, endocrine disorders) in long-term survivors. We aimed to study the epidemiologic features and therapeutic outcomes of HL in children, adolescents, and young adults in Korea.

METHODS

We performed a multicenter, retrospective study of 224 patients aged < 25 years diagnosed with HL at 22 participating institutes in Korea from January 2007 to August 2016.

RESULTS

A higher percentage of males was diagnosed at a younger age. Nodular sclerosis histopathological HL subtype was most common, followed by mixed cellularity subtype. Eighty-one (36.2%), 101 (45.1%), and 42 (18.8%) patients were classified into low, intermediate, and high-risk groups, respectively. Doxorubicin, bleomycin, vinblastine, dacarbazine was the most common protocol (n = 102, 45.5%). Event-free survival rate was 86.0% ± 2.4%, while five-year overall survival (OS) rate was 96.1% ± 1.4%: 98.7% ± 1.3%, 97.7% ± 1.6%, and 86.5% ± 5.6% in the low, intermediate, and high-risk groups, respectively (P = 0.021). Five-year OS was worse in patients with B-symptoms, stage IV disease, high-risk, splenic involvement, extra-nodal lymphoma, and elevated lactate dehydrogenase level. In multivariate analysis, B-symptoms and extra-nodal involvement were prognostic factors for poor OS. Late complications of endocrine disorders and secondary malignancy were observed in 17 and 6 patients, respectively.

CONCLUSION

This is the first study on the epidemiology and treatment outcomes of HL in children, adolescents, and young adults in Korea. Future prospective studies are indicated to develop therapies that minimize treatment toxicity while maximizing cure rates in children, adolescents, and young adults with HL.

Successful Sirolimus Treatment for Korean Patients with Activated Phosphoinositide 3-kinase δ Syndrome 1: the First Case Series in Korea

Activated phosphoinositide 3-kinase δ syndrome (APDS)1 is caused by gain-of-function mutations in PIK3CD, which encodes the catalytic p110δ subunit of phosphoinositide 3 kinase. We describe three patients with APDS1, the first thereof in Korea. Therein, we investigated clinical manifestations of APDS1 and collected data on the efficacy and safety profile of sirolimus, a mammalian target of rapamycin inhibitor and pathway-specific targeted medicine. The same heterozygous PIK3CD mutation was detected in all three patients (E1021K). After genetic diagnosis, all patients received sirolimus and experienced an excellent response, including amelioration of lymphoproliferation and improvement of nodular mucosal lymphoid hyperplasia in the gastrointestinal tract. The median trough level of sirolimus was 5.5 ng/mL (range, 2.8-7.5) at a dose of 2.6-3.6 mg/m². Two patients who needed high-dose, short-interval, immunoglobulin-replacement treatment (IGRT) had a reduced requirement for IGRT after initiating sirolimus, and the dosing interval was extended from 2 and 3 weeks to 4 weeks. The IgG trough level after sirolimus treatment (median, 594 mg/dL; range, 332-799 mg/dL) was significantly higher than that before sirolimus treatment (median, 290 mg/dL; range, 163-346 mg/dL) (p<0.001). One episode of elevated serum creatinine with a surge of sirolimus (Patient 2) and episodes of neutropenia and oral stomatitis (Patient 1) were observed. We diagnosed the first three patients with APDS1 in Korea. Low-dose sirolimus may alleviate clinical manifestations thereof, including hypogammaglobulinemia.

Frailty Assessment in Community-Dwelling Older Adults: A Comparison of 3 Diagnostic Instruments

OBJECTIVES

Compare the diagnostic performance of FRAIL against Fried Phenotype and Frailty Index (FI), and identify clinical factors associated with pre-frailty/frailty.

DESIGN

Cross-sectional analysis.

SETTING

Community-based screenings in Senior Activity Centres, Residents' Corners and Community Centres in northeast Singapore.

PARTICIPANTS

517 community dwelling participants aged >55 years and ambulant independently (with/ without walking aids) were included in this study. Residents of sheltered or nursing homes, and seniors unable to ambulate at least four meters independently were excluded.

MEASUREMENTS

The multidomain geriatric screen included assessments for social vulnerability, mood, cognition, sarcopenia and nutrition. Participants completed a battery of physical fitness tests for grip strength, gait speed, lower limb strength and power, flexibility, balance and endurance, with overall physical performance represented by Short Physical Performance Battery (SPPB). Frailty status was assigned on FRAIL, Fried and 35-item FI.

RESULTS

Prevalence of frailty was 1.3% (FRAIL) to 3.1% (FI). Pre-frailty prevalence ranged from 17.0% (FRAIL) to 51.2% (FI). FRAIL demonstrated poor agreement with FI (kappa=0.171, p<0.0001), and Fried (kappa=0.194, p<0.0001). A lower FRAIL cut-off ≥1 yielded significantly improved AUC of 0.70 (95%CI 0.55 to 0.86, p=0.009) against Fried, and 0.71 (95%CI 0.55 to 0.86, p=0.008) against FI. All 3 frailty measures were diagnostic of impaired physical performance on SPPB, with AUCs ranging from 0.69 on FRAIL to 0.77 on Fried (all p values <0.01). Prevalence of low socio-economic status, depression, malnutrition and sarcopenia increased significantly, while fitness measures of gait speed, balance, and endurance declined progressively across robust, pre-frail and frail on all 3 frailty instruments (p <0.05).

CONCLUSIONS

Our results suggest that different frailty instruments may capture over-lapping albeit distinct constructs, and thus may not be used interchangeably. FRAIL has utility for quick screening, and any positive response should trigger further assessment, including evaluation for depression, social vulnerability and malnutrition.

The Differential Flow of Epidural Local Anaesthetic via Needle or Catheter: A Prospective Randomized Double-blind Study

The extent of epidural anaesthesia and pattern of spread of contrast medium, using different injection techniques, has not been well documented. Therefore, in this prospective, randomized, double-blind study, the extent of anaesthesia and pattern of spread of contrast medium following an epidural bolus injection, via either a Tuohy needle or an epidural catheter, were compared.

The study had two parts. In the first, 59 of 79 patients scheduled for a lower extremity operation under epidural anaesthesia were randomly allocated to one of the two groups. Anaesthesia was achieved with an epidural injection of 10 to 15 ml (including a 3 ml test dose) of 0.75% ropivacaine and fentanyl 25 μg via either a Tuohy needle (Group N, n=31) or a catheter (Group C, n=28). The level of sensory anaesthesia was recorded. In the second part, the remaining 20 patients were randomized to initially receive 5 ml of contrast medium via either a Tuohy needle (Group NE, n=10) or a catheter (Group CE, n=10). The extent of spread was recorded radiologically.

Unilateral or missed blocks and additional dose requirement were absent in Groups N and C. No differences were found in the extent of sensory anaesthesia or the spread of contrast medium. Twenty per cent of catheter tips lay outside the lateral margins of the vertebral bodies.

We found that an epidural bolus injection, via either a Tuohy needle or a catheter, made no difference in regard to spread of local anaesthetic or contrast medium in the epidural space.

Management of immune thrombocytopenia: Korean experts recommendation in 2017

Management options for patients with immune thrombocytopenia (ITP) have evolved substantially over the past decades. The American Society of Hematology published a treatment guideline for clinicians referring to the management of ITP in 2011. This evidence-based practice guideline for ITP enables the appropriate treatment of a larger proportion of patients and the maintenance of normal platelet counts. Korean authority operates a unified mandatory national health insurance system. Even though we have a uniform standard guideline enforced by insurance reimbursement, there are several unsolved issues in real practice in ITP treatment. To optimize the management of Korean ITP patients, the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) reviewed the consensus and the Korean data on the clinical practices of ITP therapy. Here, we report a Korean expert recommendation guide for the management of ITP.

The Usefulness of Platelet-derived Microparticle as Biomarker of Antiplatelet Therapy in Kawasaki Disease

Little is known about platelet dynamics and the effect of antiplatelet therapy in Kawasaki disease (KD). This study sought to define platelet activation dynamics in KD patients by assaying platelet-derived microparticles (PDMPs). We measured plasma PDMPs levels in 46 patients with KD using an enzyme-linked immunosorbent assay (ELISA). Blood samples were collected before, at 2-5 days, and 9-15 days after intravenous immunoglobulin (IVIG) infusion, 2 months and 4-5 months after the onset of KD. We measured PDMP levels in 23 febrile and 10 afebrile control patients. In the acute phase of KD patients, PDMP levels increased significantly after IVIG treatment (12.04 ± 5.58 nmol before IVIG infusion vs. 19.81 ± 13.21 nmol at 2-5 days after IVIG infusion, P = 0.006). PDMP levels were negatively correlated with age and positively correlated with procalcitonin levels in the acute phase of KD. No significant difference was found in PDMP levels between KD patients with and without coronary artery lesion (CAL). Elevated PDMP levels after IVIG therapy significantly decreased below the pre-IVIG level in subacute phase (19.81 ± 13.21 nmol at 2-5 days after IVIG infusion vs. 8.33 ± 2.02 nmol at 9-15 days after IVIG infusion, P < 0.001), and PDMP levels stayed below the pre-IVIG level in the convalescent phase, during which antiplatelet therapy was given. However, PDMP levels rebounded after discontinuing aspirin in 17 patients. In conclusion, enhanced platelet activation was noted before treatment of KD and peaked immediately after IVIG treatment. Recurrent rising of PDMP levels was observed after discontinuing aspirin, although there were no significant differences between the PDMP levels at 2 months after the onset of KD and those at 4-5 months after the onset of the disease.

Higher Gemcitabine Dose Was Associated With Better Outcome of Osteosarcoma Patients Receiving Gemcitabine-Docetaxel Chemotherapy

BACKGROUND

Efficacy of gemcitabine and docetaxel (GEM + DOC) chemotherapy in patients with recurrent or refractory osteosarcoma was evaluated.

METHODS

Data of 53 patients from 9 institutions, who received GEM (675 or 900 mg/m(2) on days 1 and 8) and DOC (100 mg/m(2) on day 8), were retrospectively reviewed.

RESULTS

GEM + DOC was administered as adjuvant (n = 25) or palliative chemotherapy (n = 28). Patients received a median 3 courses (range, 1-10 courses). Objective response rate (CR + PR, where CR is complete response and PR is partial response) and disease control rate (CR+ PR + SD, where SD is stable disease) were 14.3% and 28.6%, respectively. Disease control rate was higher in patients receiving 900 mg/m(2) GEM than in patients receiving 675 mg/m(2) (50.0% vs. 12.5%, P = 0.03). Higher GEM dose was associated with better survival, both in adjuvant (1-year overall survival, 90.9 ± 8.7% vs. 38.5 ± 13.5%, P = 0.002) and palliative settings (50.0 ± 14.4% vs. 31.3 ± 11.6%, P = 0.04).

CONCLUSIONS

Further studies are necessary to investigate the efficacy of more aggressive and higher doses of GEM + DOC chemotherapy in osteosarcoma.

Efficacy of Pulsed Electromagnetic Therapy for Chronic Lower Back Pain: A Randomized, Double-blind, Placebo-controlled Study

This randomized, double-blind, placebo-controlled clinical trial studied the effectiveness of pulsed electromagnetic therapy (PEMT) in patients with chronic lower back pain. Active PEMT ( n = 17) or placebo treatment ( n = 19) was performed three times a week for 3 weeks. Patients were assessed using a numerical rating scale (NRS) and revised Oswestry disability scores for 4 weeks after therapy. PEMT produced significant pain reduction throughout the observation period compared with baseline values. The percentage change in the NRS score from baseline was significantly greater in the PEMT group than the placebo group at all three time-points measured. The mean revised Oswestry disability percentage after 4 weeks was significantly improved from the baseline value in the PEMT group, whereas there were no significant differences in the placebo group. In conclusion, PEMT reduced pain and disability and appears to be a potentially useful therapeutic tool for the conservative management of chronic lower back pain.

Improved Outcome of a Reduced Toxicity-Fludarabine, Cyclophosphamide, plus Antithymocyte Globulin Conditioning Regimen for Unrelated Donor Transplantation in Severe Aplastic Anemia: Comparison of 2 Multicenter Prospective Studies

Hematopoietic stem cell transplantation (HSCT) is a curative therapy for severe aplastic anemia (SAA); however, the optimal conditioning regimen for HSCT with an unrelated donor has not yet been defined. A previous study using a fludarabine (FLU), cyclophosphamide (Cy), and antithymocyte globulin (ATG) conditioning regimen (study A: 50 mg/kg Cy once daily i.v. on days -9, -8, -7, and -6; 30 mg/m(2) FLU once daily i.v. on days -5, -4, -3, and -2; and 2.5 mg/kg of ATG once daily i.v. on days -3, -2, and -1) demonstrated successful engraftment (100%) but had a high treatment-related mortality rate (32.1%). Therefore, given that Cy is more toxic than FLU, we performed a new phase II prospective study with a reduced-toxicity regimen (study B: 60 mg/kg Cy once daily i.v. on days -8 and -7; 40 mg/m(2) FLU once daily i.v. on days -6, -5, -4, -3, and -2; and 2.5 mg/kg ATG once daily i.v. on 3 days). Fifty-seven patients were enrolled in studies A (n = 28) and B (n = 29), and donor type hematologic recovery was achieved in all patients in both studies. The overall survival (OS) and event-free survival (EFS) rates of patients in study B was markedly improved compared with those in study A (OS: 96.7% versus 67.9%, respectively, P = .004; EFS: 93.3% versus 64.3%, respectively, P = .008). These data show that a reduced-toxicity conditioning regimen with FLU, Cy, and ATG may be an optimal regimen for SAA patients receiving unrelated donor HSCT.

Development of real-time PCR for detection and quantitation of Streptococcus parauberis

Streptococcus parauberis is an increasing threat to aquaculture of olive flounder, Paralichthys olivaceus Temminck & Schlegel, in South Korea. We developed a real-time polymerase chain reaction (PCR) method using the TaqMan probe assay to detect and quantify S. parauberis by targeting the gyrB gene sequences, which are effective for molecular analysis of the genus Streptococcus. Our real-time PCR assay is capable of detecting 10 fg of genomic DNA per reaction. The intra- and interassay coefficient of variation (CV) values ranged from 0.42-1.95%, demonstrating that the assay has good reproducibility. There was not any cross-reactivity to Streptococcus iniae or to other streptococcal/lactococcal fish pathogens, such as S. agalactiae and Lactococcus garvieae, indicating that the assay is highly specific to S. parauberis. The results of the real-time PCR assay corresponded well to those of conventional culture assays for S. parauberis from inoculated tissue homogenates (r = 0.957; P < 0.05). Hence, this sensitive and specific real-time PCR is a valuable tool for diagnostic quantitation of S. parauberis in clinical samples.

Abstract A28: NFATC3-PLA2G15 fusion transcript identified by RNA-sequencing promotes tumor progression in colorectal cancer cells

In order to identify novel fusion transcripts in colorectal cancer, we carried out paired-end RNA sequencing in 28 human colorectal cancer cell lines. Fusion transcript candidates were identified using ChimeraScan and FusionMap tools. We obtained 1380 candidates having 4 or more read counts and spanning reads. Among the candidates, we selected 27 candidates for validation which harbors genes related to the Wnt signaling pathway or kinases according to KEGG or DAVID. After the targeted gene filtering step, validation using RT-PCR with fusion specific primers finally resulted in 2 intra- and 1 inter-fusion transcripts. Intra-fusion transcripts were NFATC3-PLA2G15 and AKAP13-PDE8A and inter-fusion transcript was KRT8-PKM2 each identified in colo-320, SW-480 and SNU-1235, respectively. The fusion junctions were confirmed by Sanger sequencing. NFATC3-PLA2G15 fusion transcripts consisted of exon 1-9 of NFATC3 (nuclear factor of activated T-cells, cytoplasmic 3) gene and exon 2-6 of the PLA2G15 (Phospholipase A2, Group 5) gene and both located on the same chromosome 16q. NFATC3 is known as transcription factor in the Wnt signaling pathway and regulates function of the target genes like cell proliferation, invasion and epithelial-to-mesenchymal transition (EMT). Under the experiments using siRNA in the colo-320 cell carrying fusion transcript, knockdown of the NFATC3-PLA2G15 fusion transcript decreased mRNA and protein expression of mesenchymal markers, namely vimentin (VIM), Twist-related protein 1 (TWIST1) and fibronectin (FN), and increased epithelial markers, E-cadherin (CDH1) and claudin-1 (CLDN1). Fusion transcripts knockdown also led to decrease of the invasion ability regulated by above markers. Moreover, soft agar assay showed inhibition of colony formation after fusion transcript knockdown. Fusion transcript downregulation also resulted in decrease of cell proliferation and mRNA and protein expression of cyclin D but increase in p27 level. The knockdown did not have influence in the fusion negative cell line. Collectively, these results suggest that the NFATC3-PLA2G15 fusion transcript is involved in invasion and proliferation of colorectal cancer cells.

Citation Format: JE Jang, HP Kim, SH Lee, DW Lee, YJ Lim, SW Han, TY Kim. NFATC3-PLA2G15 fusion transcript identified by RNA-sequencing promotes tumor progression in colorectal cancer cells. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr A28.

Sevoflurane post-conditioning increases nuclear factor erythroid 2-related factor and haemoxygenase-1 expression via protein kinase C pathway in a rat model of transient global cerebral ischaemia

BACKGROUND

The antioxidant mechanism of sevoflurane post-conditioning-induced neuroprotection remains unclear. We determined whether sevoflurane post-conditioning induces nuclear factor erythroid 2-related factor (Nrf2, a master transcription factor regulating antioxidant defence genes) and haemoxygenase-1 (HO-1, an antioxidant enzyme) expression, and whether protein kinase C (PKC) is involved in Nrf2 activation, in a rat model of transient global cerebral ischaemia/reperfusion (I/R) injury.

METHODS

Eighty-six rats were assigned to five groups: sham (n=6), control (n=20), sevoflurane post-conditioning (two cycles with 2 vol% sevoflurane inhalation for 10 min, n=20), chelerythrine (a PKC inhibitor; 5 mg kg(-1) i.v. administration, n=20), and sevoflurane post-conditioning plus chelerythrine (n=20). The levels of nuclear Nrf2 and cytoplasmic HO-1 were assessed 1 or 7 days after ischaemia (n=10 each, apart from the sham group, n=3).

RESULTS

On day 1 but not day 7 post-ischaemia, Nrf2 and HO-1 expression were significantly higher in the sevoflurane post-conditioning group than in the control group. Chelerythrine administration reduced the elevated Nrf2 and HO-1 expression induced by sevoflurane post-conditioning.

CONCLUSIONS

Sevoflurane post-conditioning increased Nrf2/HO-1 expression via PKC signalling in the early phase after transient global cerebral I/R injury, suggesting that activation of antioxidant enzymes may be responsible for sevoflurane post-conditioning-induced neuroprotection in the early phase after cerebral I/R injury.

Efficacy and safety of micafungin for the prophylaxis of invasive fungal infection during neutropenia in children and adolescents undergoing allogeneic hematopoietic SCT

The objective of this study was to evaluate the efficacy and safety of micafungin for the prevention of invasive fungal infection (IFI) during the neutropenic phase of allogeneic hematopoietic SCT (allo-HSCT) in children and adolescents. This was a prospective, multicenter, open-label, single-arm study. Micafungin was administered i.v. at a dose of 1 mg/kg/day (max 50 mg) from the beginning of conditioning until neutrophil engraftment. Treatment success was defined as the absence of proven, probable, possible or suspected IFI through to 4 weeks after therapy. From April 2010 to December 2011, 155 patients were enrolled from 11 institutions in Korea, and 147 patients were analyzed. Of the 147 patients, 121 (82.3%) completed the protocol without premature interruption. Of the 132 patients in whom micafungin efficacy could be evaluated, treatment success was achieved in 119 patients (90.2%). There was no proven fungal infection in any patient. The number of patients with probable, possible and suspected IFI was two, two and nine, respectively. Thirty-five patients (23.8%) experienced 109 adverse events (AEs) possibly related to micafungin. No patients experienced grade IV AEs. Two patients (1.4%) discontinued micafungin administration due to adverse effects. None of the deaths were related to the study drug.

Unrelated donor cord blood transplantation for non-malignant disorders in children and adolescents

This study analyzes the data reported to the Korean Cord Blood Registry between 1994 and 2008, involving children and adolescents with non-malignant diseases. Sixty-five patients were evaluated in this study: SAA (n = 24), iBMFS, (n = 16), and primary immune deficiency/inherited metabolic disorder (n = 25). The CI of neutrophil recovery was 73.3% on day 42. By day 100, the CI of acute grade II-IV graft-versus-host disease was 32.3%. At a median follow-up of 71 months, five-yr OS was 50.7%. The survival rate (37.5%) and CI of neutrophil engraftment (37.5%) were lowest in patients with iBMFS. Deaths were mainly due to infection, pulmonary complications, and hemorrhage. In a multivariate analysis, the presence of >3.91 × 10(5) /kg of infused CD34 + cells was the only factor consistently identified as significantly associated with neutrophil engraftment (p = 0.04) and OS (p = 0.03). UCBT using optimal cell doses appears to be a feasible therapy for non-malignant diseases in children and adolescents for whom there is no appropriate HLA-matched related donor. Strategies to reduce transplant-related toxicities would improve the outcomes of UCBT in non-malignant diseases.

Antioxidant and Anti-inflammatory Activity of Eurycoma Longifolia Jack, A Traditional Medicinal Plant in Malaysia

Tongkat Ali (Eurycoma longifolia Jack, family, Simaroubaceae) is traditionally used in Malaysia as health supplement for hypertension, diarrhea, aches, persistent fever, malaria, sexual insufficiency, dysentery, and glandular swelling. In this study, hydroalcoholic extract of Eurycoma longifolia Jack was studied for its antioxidant and in-vitro anti-inflammatory properties. The antioxidant activity (free radical scavenging) was evaluated to determine the total antioxidant capacity of extract Eurycoma longifolia Jack. The DPPH assay showed significant antioxidant activity in all concentrations (10, 25, 50,100 and 250 µg/ml). The antioxidant property of the extract was compared with the values of ascorbic acid, a standard antioxidant. Human RBC (HRBC) stbilization method was utilized to evaluate the in-vitro anti-inflammatory activity of the extract. The extract showed a significant anti-inflammtory activity in all the concentrations tested (25, 50,100, 250, 500 and 1000 µg/ml) and the activity was increased in a concentration dependent manner.

Safety and effects of prophylactic defibrotide for sinusoidal obstruction syndrome in hematopoietic stem cell transplantation

BACKGROUND

Sinusoidal obstruction syndrome (SOS) is a serious complication of hematopoietic stem cell transplantation (HSCT), with a mortality rate of up to 90%. We report our experience on the use of defibrotide for SOS prophylaxis in HSCT.

MATERIAL AND METHODS

We retrospectively reviewed data of 49 patients who received defibrotide as SOS prophylaxis during the course of HSCT at the National Cancer Center, Goyang, Korea, between August 2005 and July 2008.

RESULTS

Thirty-four patients (69.4%) were classified as a high-risk group for developing SOS. Defibrotide was well-tolerated, without any grade 3 or 4 toxicity. The median value of maximum total bilirubin within 100 days after HSCT was within the normal range. SOS was diagnosed in only 1 patient, who underwent autologous HSCT due to relapsed medulloblastoma. There was no day 100 treatment-related mortality in our study.

CONCLUSIONS

Defibrotide appears to be a safe prophylaxis for SOS. This study suggests that it could be effective to use prophylactic defibrotide in advance to improve HSCT outcomes in patients at risk of SOS.

Predictive factors of symptomatic cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in adult patients with moyamoya disease

BACKGROUND

Symptomatic cerebral hyperperfusion (SCH) is a potential complication after superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis in patients with moyamoya disease. This retrospective study was designed to determine factors associated with SCH after STA-MCA anastomosis in adult moyamoya patients.

METHODS

Eighty-two adult moyamoya patients undergoing STA-MCA anastomosis between July 2005 and December 2010 were enrolled. Laboratory data such as haemoglobin and white blood cell (WBC) count, preoperative (patient characteristic data, initial clinical manifestation, the angiographic staging), intraoperative (surgical time, the operative side, anaesthetic technique, fluid balance, arterial pressure, arterial partial pressure of carbon dioxide, the lowest haematocrit, and intraoperative transfusion), and postoperative (arterial pressure, Acute Physiology and Chronic Health Evaluation II score) data were collected and used as predictable factors for postoperative SCH, in which a focal intense increase in cerebral blood flow at the anastomosis site was shown in postoperative single-photon emission computed tomography.

RESULTS

Among 82 patients with 99 surgeries, 39 patients (47 sides, 47%) suffered from transient neurological deterioration due to SCH from 1 to 9 days after operation (median: 2 days), which was sustained for 1-14 days (median: 7 days). The operation on the dominant hemisphere [odds ratio (OR), 5.09; 95% confidence interval (CI), 2.07-12.54, P<0.001] was an independent risk factor for SCH. Also, WBC count on postoperative day 1 was significantly correlated with SCH (OR 1.19; 95%CI, 1.02-1.38, P=0.029).

CONCLUSIONS

The operation on the dominant hemisphere and increased postoperative WBC count may be associated with SCH after STA-MCA anastomosis in adult-onset moyamoya patients.

Tianeptine vs amitriptyline for the treatment of irritable bowel syndrome with diarrhea: a multicenter, open-label, non-inferiority, randomized controlled study

BACKGROUND

Tricyclic antidepressants have good efficacy in irritable bowel syndrome with diarrhea (IBS-D), but their clinical use is limited by considerations of tolerability. Tianeptine, another antidepressant, acts as a selective serotonin reuptake enhancer. We compared tianeptine with amitriptyline for the treatment of patients with IBS-D.

METHODS

We undertook a multicenter, randomized, open-label, non-inferiority clinical study that compared tianeptine with amitriptyline, each in combination with probiotics, for the treatment of IBS-D. Subjects were randomized to receive tianeptine (37.5 mg)/probiotics (Bacillus subtilis + Streptococcus faecium) or amitriptyline (10 mg)/probiotics (Bacillus subtilis + Streptococcus faecium) for 4 weeks. A total of 228 patients were analyzed by the intention-to-treat approach. The primary efficacy endpoint was the proportion of patients who had global relief of IBS symptoms at week 4. The secondary efficacy endpoints were intensity of abdominal pain/discomfort, stool frequency/consistency, quality of life, and overall satisfaction with treatment.

KEY RESULTS

At week 4, non-inferiority of the tianeptine group to the amitriptyline group (treatment difference -15.1%; 95% CI -26.6% to -3.8%) was shown, with 81.1% (99 of 122 patients) of the patients in the tianeptine group and 66.0% (70 of 106 patients) in the amitriptyline group reporting global relief of IBS symptoms. The secondary endpoints also demonstrated non-inferiority of the tianeptine group to the amitriptyline group. Adverse events such as dry mouth and constipation were significantly lower in the tianeptine group than the amitriptyline group (P<0.05).

CONCLUSIONS & INFERENCES

Tianeptine is not inferior to amitriptyline for treating IBS-D in terms of both efficacy and tolerability.

Corrective osteotomy in forearm fracture malunion improves functional outcome in adults

Malunions of forearm fractures in adults can present with limitation of forearm rotation, or as distal radioulnar joint instability with functional impairment. This contrasts with paediatric patients in whom malunions of similar severities are often better tolerated. We did a retrospective review of six adult patients after corrective forearm osteotomy for symptomatic malunited forearm shaft fractures. The corrective operations were done between 7 and 168 months after initial injury, using oblique or wedge osteotomies. Median follow-up was 22.5 months. The patients recovered well, with statistically significant improvement in forearm rotation and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. No significant complications occurred.

Current status of pediatric umbilical cord blood transplantation in Korea: a multicenter retrospective analysis of 236 cases

We report the outcome of 236 pediatric umbilical cord blood transplantations (UCBT) performed in Korea. Given that the sources of the grafts were mostly unrelated donors (n = 226; 95.8%), only the results of unrelated UCBT were included for all statistics. The most frequent primary disease was acute leukemia (n = 167). In total, 91.7% of recipients were seropositive for cytomegalovirus (CMV). The median doses of nucleated cells and CD34+ cells were 4.84 × 10(7)/kg and 2.00 × 10(5)/kg, respectively. The median times to neutrophil (>0.5 × 10(9)/L) and platelet recovery (>20 × 10(9)/L) were 18 and 45 days, respectively. Grade 2-4 acute graft-versus-host-disease (GVHD) and chronic GVHD developed in 41.1 and 36.1% of cases, respectively. Forty-five patients developed CMV disease. The 5-year overall and event-free survival were 47.5 and 36.9%, respectively. Multivariate analysis revealed that adverse factors for survival of the whole cohort were total body irradiation-based conditioning (P = 0.007), salvage transplant (P = 0.001), failure to achieve early complete chimerism (P < 0.0005), and CMV disease (P = 0.001). The outcomes of the single- and double-unit UCBT (n = 64) were similar, while double-unit recipients were heavier (P < 0.0005) and older (P < 0.0005). We conclude that double-unit UCBT is a reasonable option for older or heavier children and that the thorough surveillance of CMV infection and the development of an effective CMV therapeutic strategy may be especially important for Korean children, whose CMV seroprevalence exceeds 90%.

The effect of remote ischaemic preconditioning on myocardial injury in patients undergoing off-pump coronary artery bypass graft surgery

In several recent clinical trials on cardiac surgery patients, remote ischaemic preconditioning (RIPC) showed a powerful myocardial protective effect. However the effect of RIPC has not been studied in patients undergoing off-pump coronary artery bypass graft surgery. We evaluated whether RIPC could induce myocardial protection in off-pump coronary artery bypass graft surgery patients. Patients undergoing elective off-pump coronary artery bypass graft surgery were randomly allocated to the RIPC (n = 65) or control group (n = 65). After induction of anaesthesia, RIPC was induced by four cycles of five-minute ischaemia and reperfusion on the upper limb using a pneumatic cuff. Anaesthesia was maintained with sevoflurane, remifentanil and vecuronium. Myocardial injury was assessed by troponin I before surgery and 1, 6, 12, 24, 48 and 72 hours after surgery. There were no statistical differences in troponin I levels between RIPC and control groups (P = 0.172). Although RIPC reduced the total amount of troponin I (area under the curve of troponin increase) by 26%, it did not reach statistical significance (RIPC group 53.2 +/- 72.9 hours x ng/ml vs control group 67.4 +/- 97.7 hours x ng/ml, P = 0.281). In this study, RIPC by upper limb ischaemia reduced the postoperative myocardial enzyme elevation in off-pump coronary artery bypass graft surgery patients, but this did not reach statistical significance. Further study with a larger number of patients may be needed to fully evaluate the clinical effect of RIPC in off-pump coronary artery bypass graft surgery patients.

Reduced-dose craniospinal radiotherapy followed by high-dose chemotherapy and autologous stem cell rescue for children with newly diagnosed high-risk medulloblastoma or supratentorial primitive neuroectodermal tumor

Background

In this study, we investigated the effects of reduced-dose craniospinal radiotherapy (CSRT) followed by tandem high-dose chemotherapy (HDCT) with autologous stem cell rescue (ASCR) in children with a newly diagnosed high-risk medulloblastoma (MB) or supratentorial primitive neuroectodermal tumor (sPNET).

Methods

Between March 2005 and April 2007, patients older than 3 years with a newly diagnosed high-risk MB or sPNET were enrolled. The patients received two cycles of pre-RT chemotherapy consisting of cisplatin, etoposide, vincristine, and cyclophosphamide (cycle A), and carboplatin, etoposide, vincristine, and ifosphamide (cycle B), followed by CSRT with 23.4 Gy and local RT with 30.6 Gy. After four cycles of post-RT chemotherapy (cycles A, B, A, and B), tandem double HDCT with ASCR was performed.

Results

A total of 13 patients (MB=11, sPNET=2) were enrolled. Of these, one patient progressed, one patient died of septic shock after the second cycle of B, and one patient relapsed after the third cycle of B. The 3-year event-free survival (EFS) rate of the patients intended for HDCT was 76.9%, whereas the 3-year EFS rate of the patients who received HDCT was 100%. No treatment-related mortality occurred during HDCT.

Conclusion

Although the follow-up period was short and the patient cohort was small in size, the results of this study are encouraging. The limited toxicity and favorable EFS rate observed in children treated with reduced-dose CSRT followed by HDCT and ASCR warrant further exploration in a larger study population.

Normalization of red cell enolase level following allogeneic bone marrow transplantation in a child with Diamond-Blackfan anemia

We describe a girl with Diamond-Blackfan anemia with accompanying red cell enolase deficiency. At the age of 9 yr old, the patient received allogeneic bone marrow transplantation from her HLA-identical sister who had normal red cell enolase activity. While the post transplant DNA analysis with short tandem repeat has continuously demonstrated a stable mixed chimerism on follow-up, the patient remains transfusion independent and continues to show a steady increase in red cell enolase activity for over two and a half years following bone marrow transplantation.

Osseointegration of anodized titanium implants under different current voltages: a rabbit study

The oxide layer that covers a titanium surface is extremely stable and appears to have excellent biocompatibility, which can result in successful osseointegration. The aim of this study was to analyse the characteristics of an oxide layer formed by anodic oxidation (anodization), and to evaluate the extent of bone healing around the anodized implant. The screw-type implants were made of commercially pure titanium (Grade 2). The Group 1 samples had a turned surface, and three other types of experimental specimens were anodized under constant voltages of 190 V (Group 2), 230 V (Group 3) and 270 V (Group 4). The surface characteristics of each sample type were inspected. Removal torque was measured after a 4-week healing period and the histomorphometric analysis was performed 6 weeks after implantation in rabbit tibiae. There was an increase in both the size and number of pores as the anodizing voltage increased. The Ra value of the Group 4 samples was higher than those in the Group 1 and 2 samples (P < 0.05). Group 3 showed a difference compared with Group 1 (P < 0.05). A thicker oxide layer, which contained crystalline (anatase) TiO(2) with the inclusion of some electrolytes (Ca, P), was formed at the higher anodizing voltage. Group 4 had higher removal torque values and percentages of bone-to-implant contact than the other groups (P < 0.05). The anodized titanium implants showed more intimate and stronger connections with peri-implant bone during early osseointegration than the turned titanium implants in this experimental model.

Management outcome and the role of manipulation in slipped capital femoral epiphysis

PURPOSE

To examine and compare treatment outcomes for slipped capital femoral epiphysis (SCFE).

METHODS

24 patients with acute or acute-on-chronic SCFE underwent preoperative traction, 13 of them followed by in situ screw fixation (group A), and the remaining 11, manipulation with screw fixation (group B). Their treatment outcomes (according to the Aadalen criteria) and complications were compared.

RESULTS

There were 2 treatment failures and one poor outcome in patients with acute SCFE (2 had avascular necrosis and one had slight pain with mild limitation of hip movement). The risk of developing avascular necrosis was significantly higher in patients with acute rather than acute-on-chronic or chronic slips. No significant differences were evident between groups A and B with regard to age, sex, ethnicity, outcomes, and preoperative and postoperative changes in the Southwick headshaft angle.

CONCLUSION

Patients with acute or acute-on-chronic SCFE can be safely managed with straight-leg traction for up to 6 days, followed by in situ screw fixation without manipulation. Manipulation is not recommended in such slips, due to a higher avascular necrosis risk.

Biological responses of anodized titanium implants under different current voltages

The oxide layer of a titanium surface is very stable, and seems to result in excellent biocompatibility and successful osseointegration. The purpose of this study was to investigate the effects of high anodic oxidation voltages on the surface characteristics of titanium implants and the biologic response of rabbit tibiae. Bone tissue responses were evaluated by removal torque tests and histomorphometric analysis. Screw-shaped implants with microthreads were made of commercially pure titanium (Grade II). We prepared anodized implants under 300 V (group I), 400 V (group II), 500 V (group III) and 550 V (group IV). The surface characteristics of specimens were inspected according to three categories: surface morphology, surface roughness and oxide layer thickness. The screw-shaped implants were installed in rabbit tibiae. The removal torque values were measured and histomorphometric analysis was done after 1- and 3-month healing periods. Data indicate that as anodic oxidation voltage increased above 300 V, oxide layer thickness increased rapidly and pore size also increased. The roughness values of the implants increased with voltage up to 500 V, but decreased at 550 V. In the removal torque test, group III showed higher values than groups I and II at a statistically significant level (P < 0.05) after a 1-month healing period. In histomorphometric analysis, groups III and IV, after a 3-month healing period, showed greater bone to implant contact ratios for the total implant surface than did group I (P < 0.05).

Effects of insertion conditions on tissue strain and vascular damage during neuroprosthetic device insertion

Long-term integration of neuroprosthetic devices is challenged by reactive responses that compromise the brain-device interface. The contribution of physical insertion parameters to immediate damage is not well described. We have developed an ex vivo preparation to capture real-time images of tissue deformation during device insertion using thick tissue slices from rat brains prepared with fluorescently labeled vasculature. Qualitative and quantitative assessments of damage were made for insertions using devices with different tip shapes inserted at different speeds. Direct damage to the vasculature included severing, rupturing and dragging, and was often observed several hundred micrometers from the insertion site. Slower insertions generally resulted in more vascular damage. Cortical surface features greatly affected insertion success; insertions attempted through pial blood vessels resulted in severe tissue compression. Automated image analysis techniques were developed to quantify tissue deformation and calculate mean effective strain. Quantitative measures demonstrated that, within the range of experimental conditions studied, faster insertion of sharp devices resulted in lower mean effective strain. Variability within each insertion condition indicates that multiple biological factors may influence insertion success. Multiple biological factors may contribute to tissue distortion, thus a wide variability was observed among insertions made under the same conditions.

Comparison between high and low molecular weight hyaluronates in knee osteoarthritis patients: open-label, randomized, multicentre clinical trial

Efficacy and safety of high and low molecular weight hyaluronates in knee osteoarthritis patients were compared in a randomized, open-label trial. Patients in the high molecular weight hyaluronate group were treated once weekly for 3 weeks and in the low molecular weight group once weekly for 5 weeks. We evaluated weight-bearing pain, degree of flexion, swelling and knee tenderness; frequency and amount of rescue medication; patient and investigator global assessment of pain, and safety over 12 weeks after final injection of study medication. Significant improvements in pain and WOMAC-Likert scores were observed in both groups, but not between groups. Knee joint pain improvement was noted in both groups by patients and investigators during follow-up. Close correlation was observed between patient- and investigator-reported data. There was no significant difference in side-effects between the groups. In conclusion, the efficacy and safety of high and low molecular weight hyaluronate are similar.

Seizure control of Gamma Knife radiosurgery for non-hemorrhagic arteriovenous malformations

OBJECTIVES

Although radiosurgery has been found to be a safe and effective alternative treatment, seizure outcome of arteriovenous malformation (AVM) radiosurgery has not been documented in detail. We report the effect of Gamma Knife radiosurgery (GKRS) on seizures associated with AVMs and discuss the various factors that influence the prognosis.

MATERIAL AND METHODS

Between 1992 and 2004, 246 patients were treated with GKRS for AVMs at Kyung-Hee medical center. Forty five (17.0%) patients have non-hemorrhagic AVMs and presenting symptom was seizure. Two patients of all were excluded from this study due to loss of follow-up after radiosurgery. In this study, retrospective analysis of clinical characteristics, radiologic findings, radiosurgical seizure outcome were performed.

RESULTS

There were 32 male and 11 female with age ranging from 10 to 74 years (mean 35 years). Type of seizure included: general tonic clonic (n = 28); focal motor or sensory (n = 7); partial complex (n = 8). The location of AVM was temporal (n = 18); frontal (n = 9); deep seated (n = 7): parietal (n = 5); occipital (n = 4). Follow-up period was from 8 months to 12 years (mean 46 months). Mean volume was 6.2 cc (2.7-20), mean marginal and maximal dosage was 19.5 (17-26) and 36.6 Gy (13-50). During follow-up after radiosurgical treatment, 23 (53.5%) of 43 patients were seizure-free, 10 (23.3%) had significant improvement, were unchanged in 8 (18.6%) and aggravated in 2 (4.6%) patients. In 33 patients, follow-up angiography or MRI was performed. Complete obliteration was achieved in 16 (49.0%) patients, partial obliteration in 13 (39.0%). Four were unchanged (12.0%). Of 33 patients with follow-up performed, 26 were followed for over 2 years. Eleven (84.6%) of 13 patients with complete obliteration were seizure-free (p < 0.005). Four (36.3%) of 13 with partial obliteration and unchanged remained seizure-free. Fifteen patients had experienced intractable seizure before radiosurgery. After radiosurgery, seizures disappeared in 8 (53%) patients. Seizure frequently decreased in 5 (33%) and 2 patients (14%) were unchanged but none was aggravated. Five (71%) of 7 patients with complete obliteration were seizure-free and 2 (40%) of 5 patients with partial obliteration were seizure-free.

CONCLUSION

Up to now, controversy about resective surgery or radiosurgery as treatment of seizure related to AVMs still remains. In this study, we experienced that Gamma Knife radiosurgery is commonly performed to treat AVMs and can improve symptomatic seizure associated with AVMs. To clarify the mechanism of seizure control in AVMs radiosurgery is difficult, but it seems to be closely related to hemodynamic effects after radiosurgery.

Intrathecal clonidine does not reduce post-spinal shivering

BACKGROUND

After general or epidural anesthesia, clonidine is known to be effective in suppressing established shivering. The aim of this study was to assess the preventive effect of intrathecal clonidine on post-spinal shivering compared with intravenous (i.v.) clonidine.

METHODS

One hundred and fifty patients scheduled for orthopedic surgery were randomly allocated into three groups to receive either 1 microg/kg clonidine i.v. (IV group) or the same volume of isotonic saline (control and IT groups) at 5 min before spinal anesthesia. Spinal anesthesia was performed with 12-15 mg hyperbaric bupivacaine 0.5% plus either 1 ml of saline (control and IV groups) or 150 microg clonidine (IT group). Shivering was evaluated for a period of 90 min and graded as none, mild, moderate, and severe.

RESULTS

Twenty patients (40%) in the control group and 17 patients (34%) in the IT group showed shivering compared with four (8%) in the IV group. Patients with moderate-to-severe shivering were only seen in the control and IT group, and the maximal intensity of shivering was not different between the two groups. Patients in the IV group were significantly more sedated than the other groups.

CONCLUSIONS

The intrathecal administration of clonidine 150 microg fails to prevent post-spinal shivering; by contrast, we have confirmed that i.v. clonidine 1 microg/kg is an effective method to prevent shivering in patients undergoing spinal anesthesia for orthopedic surgery.

Efficacy of Prophylactic Ondansetron in a Patient-Controlled Analgesia Environment

We conducted a prospective, randomized, double-blind, placebo-controlled trial to examine the efficacy of prophylactic ondansetron on post-operative nausea and vomiting (PONV) during opioid patient-controlled analgesia (PCA). In total, 374 patients using opioid PCA, but otherwise considered to be low risk for PONV, were randomly allocated to ondansetron (4 mg given intravenously and 16 mg added into the PCA pump) or saline (control group). PONV was evaluated in terms of nausea graded on a visual analogue scale, and the number of patients who experienced emetic episodes or needed rescue anti-emetics in the 48-h post-operative period. Patient satisfaction for PCA was scored at the end of the evaluation period. The only difference between the two groups was the higher number of headaches in the ondansetron group. In patients using opioid PCA, but with no other high risk factors for PONV, prophylactic ondansetron does not have any clinical benefit.

Combined use of autologous transfusion techniques to avoid allogeneic transfusion in spinal fusion surgery with instrumentation

This study conducted a retrospective review of the medical records of 321 patients to delineate the efficacy of the combined use of autologous transfusion (AT) techniques. Transfusion profiles between an AT and homologous transfusion (HT) group were compared. A much lower proportion of patients were exposed to allogeneic blood in the AT group (13%) than in the HT group (98%, p<0.001). In the AT group, a significantly smaller proportion of patients were exposed to allogeneic blood in patients transfused with three or four AT techniques (8%) than those with one or two techniques (29%, p<0.05). A febrile reaction (11% of patients) after a reinfusion of post-operatively shed blood was the only side effect associated with an AT. In conclusion, an AT is effective for preventing the exposure of allogeneic blood in spinal fusion surgery. The combined use of multiple AT techniques may further improve its efficacy.

Clinical trial of esmolol-induced controlled hypotension with or without acute normovolemic hemodilution in spinal surgery

BACKGROUND

Drug-induced controlled hypotension (CH) combined with acute normovolemic hemodilution (ANH) is being widely used for blood conservation in surgical patients. The purpose of this study was to investigate the efficacy and safety of esmolol-induced CH combined with ANH (hematocrit down to 28%).

METHODS

Thirty patients who were scheduled to receive spinal surgery were randomly divided into two groups: an esmolol-induced CH alone group (esmolol group, n=15) and a CH-ANH combined group (E-ANH group, n=15). Controlled hypotension was induced with esmolol 500 micro g/kg, followed by a continuous infusion of 0-300 micro g/kg/min to maintain mean arterial pressure at 55-65 mmHg.

RESULTS

The mean infusion rate of esmolol in the esmolol-ANH group was 46+/-6 micro g/kg/min (mean+/-SD), which was significantly lower than the 77+/-9 micro g/kg/min used in the esmolol group (P<0.05). The number of units of homologous blood (packed RBC) transfused perioperatively was 2.2+/-0.6 units in the esmolol-ANH group, which was significantly less than 4.3+/-0.4 units used in the esmolol group (P<0.01). While O2 delivery decreased significantly during CH, O2 consumption remained unchanged in both groups. No complications resulted from CH or ANH in any of the groups.

CONCLUSION

Our data suggest that ANH of moderate degree can be combined with esmolol-induced CH to improve blood conservation in surgical patients.

Coiling of lumbar epidural catheters

BACKGROUND

The difficulties in threading an epidural catheter to vertebral levels remote to the puncture level have been well documented. This study was undertaken to determine the length that a single orifice epidural catheter can be threaded into the lumbar space without coiling (coiling length), and whether this is affected by the direction of the epidural needle bevel.

METHODS

Forty-five young male patients scheduled for surgery under epidural analgesia were enrolled. The epidural space was identified using a midline approach at the L(2-3) or L(3-4) interspace with the loss of resistance to air technique. A 19-G single-orifice epidural catheter (Flextip Plus, Arrow International, Inc, Reading, PA, USA) was inserted through a Tuohy needle oriented either cephalad (n=20) or caudad (n=25). During insertion, the path and the position of the catheter tip was determined by fluoroscopy using iohexol dye.

RESULTS

The median coiling length was 2.8 cm, ranging from 1.0 to 8.0 cm. Only 13% of epidural catheters could be threaded 4 cm beyond the tip of the needle without coiling. No significant difference was found in coiling length between the cephalad group (2.9 cm) and the caudad group (2.5 cm).

CONCLUSION

This study demonstrates that coiling length is independent of whether the bevel of the Tuohy needle is directed cephalad or caudad. We recommend that an optimal insertion depth of an end-hole single orifice catheter is 3 cm.

Initial contact angle measurements on variously treated dental/medical titanium materials

The cell attachment to bioapplicable titanium surfaces is an important parameter in the area of clinical implant dentistry and medicine. A major consideration in designing implants has been to produce surfaces that promote desirable responses in the cells and tissues contacting the implants. In this study, three titanium materials (commercially pure titanium - CPT -, Ti-6Al-4V, and TiNi) were treated mechanically, chemically, mechano-chemically, and thermally to produce concave surfaces with varying roughness. Using four media (distilled water, 1% NaCl aqueous solution, a suspension of human neutrophils, and a suspension of the MG-63 osteoblast-like cells), the initial contact angles were measured. Six readings (three drops each measured by two observers) were collected for each material and for each medium. The interclass correlation coefficients were used for the group comparisons. A one-way analysis of variance (ANOVA) and Tukey's HSD (honestly significant difference) statistical analyses were employed. It was found, for CPT, that (1) statistically, there were no significant differences among four media in contact angles, (2) the contact angle increased linearly with average roughness when the angles were higher than 45 degrees, and (3) the contact angle decreased linearly with roughness when the angle was less than 45 degrees.

Nurses' assessment of postoperative pain: can it be an alternative to patients' self-reports?

This study was designed to evaluate whether the nurses' assessment of postoperative pain can be an alternative to patients' self-reporting. We examined 187 patients receiving postoperative intravenous patient-controlled analgesia. The nurses assessed the patients' pain with three pain indices (therapeutic efficacy, pain intensity, and facial pain expression) 8 hr after operation. The patients recorded their resting and movement pain using 100-mm visual analog scales immediately following the nurses' assessment. There was an acceptable correlation between overall pain measurement assessed by patients and that assessed by nurses (canonical correlation coefficient=0.72, p=0.0001). The resting pain was more reliably reflected than the movement pain in overall measurement assessed both by nurses and by patients. Among the three pain indices assessed by nurses, the pain intensity most reliably reflected the patients' self-reports. The pain intensity assessed with a simple verbal descriptor scale therefore is believed to be an effective alternative to the patients' self-reports of postoperative pain at rest. However, it mirrored the patients' self-reports during movement less reliably. Therapeutic efficacy and facial pain expression indices were not effective alternatives to patients' self-reporting.

Cytotoxic polyacetylenic alcohols from the marine sponge Petrosia species

New polyacetylenic alcohols (1-5) have been isolated as cytotoxic principles from the marine sponge Petrosia sp. The compounds were particularly cytotoxic against a human melanoma cell line (SK-MEL-2). The gross structures were established on the basis of NMR and MS data, and the absolute configuration was determined by the modified Mosher's method.