Immune Activation following Irbesartan Treatment in a Colorectal Cancer Patient: A Case Study

Colorectal cancers are one of the most prevalent tumour types worldwide and, despite the emergence of targeted and biologic therapies, have among the highest mortality rates. The Personalized OncoGenomics (POG) program at BC Cancer performs whole genome and transcriptome analysis (WGTA) to identify specific alterations in an individual's cancer that may be most effectively targeted. Informed using WGTA, a patient with advanced mismatch repair-deficient colorectal cancer was treated with the antihypertensive drug irbesartan and experienced a profound and durable response. We describe the subsequent relapse of this patient and potential mechanisms of response using WGTA and multiplex immunohistochemistry (m-IHC) profiling of biopsies before and after treatment from the same metastatic site of the L3 spine. We did not observe marked differences in the genomic landscape before and after treatment. Analyses revealed an increase in immune signalling and infiltrating immune cells, particularly CD8+ T cells, in the relapsed tumour. These results indicate that the observed anti-tumour response to irbesartan may have been due to an activated immune response. Determining whether there may be other cancer contexts in which irbesartan may be similarly valuable will require additional studies.

100 Frailty Hot Clinics: Rapid Cga and Speciality Diagnostics Reduces Rates of Hospitalisation and Re-Attendance

Introduction

Acute hospitalisation is associated with an increased risk of progressive frailty, morbidity and subsequent institutionalisation. North Middlesex University Hospital is an Acute District General Hospital with over 550 attendances to A&E per day. Comprehensive Geriatric Assessment (CGA) is the gold standard approach for a holistic multi-disciplinary assessment (MDT) of frail patients. A rapid access daily hot clinic service for frail patients opened using quality improvement (QI) methodology to deliver rapid CGA focusing on admission avoidance and early supported discharge.

Method

4 PDSA cycles were conducted. A process map identifying key moments in patient care was derived from time studies of the first 10 patients’ journeys. Patients were triaged through the Geriatrician “hotphone” for acute admissions into the Hot Clinic. Dedicated clinic and waiting rooms were placed on the acute frailty unit (Amber) staffed by a dedicated Consultant Geriatrician and Health Care Support Worker working with the Frailty Ward Clerk, Frailty Specialist Nurse, Therapies, specialities in-reach and same-day diagnostics. A shared clerking proforma and subsequent CGA Discharge Summary were completed and emailed to the referrer the same day. Qualitative and Quantitative feedback was gained from referrers, patients and relatives through a structured questionnaire. Metrics were gathered including rate of admissions, re-attendance and use of enhanced community services.

Results

From the first 48 Hot Clinic patients, there was a low 30-day re-attendance rate (17%—for unrelated reasons), low 30-day re-admission rates (4%) and low Did Not Attend rate (6%) for new referrals and high satisfaction scores for recommending the service (9-10/10) from patients, relatives and referrers.

Conclusions

Early rapid MDT can reduce re-attendances and re-admissions to hospital in frail patients. A streamlined patient journey can be delivered by frailty-trained staff and in a suitable environment. QI Methodology enables a structured measurable approach to development of the Acute Frailty Pathway.

Current locoregional therapies and treatment strategies in hepatocellular carcinoma

Locoregional therapies (lrts) play an important role in the treatment of hepatocellular carcinoma (hcc), with the aim of increasing overall survival while preserving liver function. Various forms of lrt are available, and choosing the best one depends on technical aspects, liver morphology, tumour biology, and the patient's symptoms. The purpose of the present review article is to provide an overview of the current evidence relating to the use of percutaneous ablation, transarterial chemoembolization, and transarterial radioembolization for the curative or palliative treatment of hcc. Special situations are also reviewed, including the combined use of systemic therapy and lrt, indications and techniques for bridging to transplant and downstaging, and the use of lrt to treat patients with hcc and macrovascular invasion.

A Novel and Simple Method for Tracheal Intubation in a Swine Model: Preparing for the Era of Xenotransplantation

OBJECTIVES

Organ transplant in humans is an established therapy for a variety of end-stage organ diseases. However, due to organ shortages and lack of donors, the need for xenotransplant has gradually increased. Xenotransplantation has great potential to solve many of the problems facing organ transplantation. Pigs are being developed as xenogeneic organ donors for use in humans. In this study, we propose a novel and simple method for tracheal intubation in a swine model using neuromuscular blocking agents and laryngeal mask airway.

MATERIALS AND METHODS

Eight Yorkshire pigs were used for the 2 separate experiments, which were conducted 1 week apart. In the first experiment, an anesthesiologist with no previous comparable experience performed endotracheal intubation of pigs. One week later, using the same pig, a second experiment was performed by an experienced anesthesiologist. Anesthesia was induced with intramuscular injection of a mixture of 1 mg/kg xylazine (Rompun, Bayer Korea Ltd., Seoul, Korea) and 7 mg/kg Zoletil (a mixture of tiletamine hydrochloride and zolazepam hydro-chloride, Virbac Laboratory, Carros, France). The laryngeal mask was then placed, and 0.15 mg/kg vecuronium bromide was injected intravenously. Tracheal intubation was attempted after mask removal. The duration and number of intubation attempts were recorded, and the degree of intubation difficulty was scored.

RESULTS

In all cases, the laryngeal mask was easily inserted, and endotracheal intubation was successfully completed. Oxygen saturation did not fall below 95%, and there were no hypoxemia episodes. Degree of intubation difficulty and duration were not significantly different between the 2 anesthesiologists.

CONCLUSIONS

Tracheal intubation in our swine model was successfully performed using neuromuscular blocking agents and laryngeal masks without resulting in hypoxemia, with even anesthesiologists who are unfamiliar with endotracheal intubation of pigs easily able to do so using our protocol. Therefore, our protocol will enable all investigators to perform successful tracheal intubation in swine models.

Effect of aerobic exercise on cancer-associated cognitive impairment: A proof-of-concept RCT

BACKGROUND

Change in cognitive ability is a commonly reported adverse effect by breast cancer survivors. The underlying etiology of cognitive complaints is unclear and to date, there is limited evidence for effective intervention strategies. Exercise has been shown to improve cognitive function in older adults and animal models treated with chemotherapy. This proof-of-concept randomized controlled trial tested the effect of aerobic exercise versus usual lifestyle on cognitive function in postmenopausal breast cancer survivors.

METHODS

Women, aged 40 to 65 years, postmenopausal, stages I to IIIA breast cancer, and who self-reported cognitive dysfunction following chemotherapy treatment, were recruited and randomized to a 24-week aerobic exercise intervention (EX; n = 10) or usual lifestyle control (CON; n = 9). Participants completed self-report measures of the impact of cognitive issues on quality of life (Functional Assessment of Cancer Therapy-Cognitive version 3), objective neuropsychological testing, and functional magnetic resonance imaging at baseline and 24 weeks.

RESULTS

Compared to CON, EX had a reduced time to complete a processing speed test (trail making test-A) (-14.2 seconds, P < .01; effect size 0.35). Compared to CON, there was no improvement in self-reported cognitive function and effect sizes were small. Interestingly, lack of between-group differences in Stroop behavioral performance was accompanied by functional changes in several brain regions of interest in EX compared to CON at 24 weeks.

CONCLUSION

These findings provide preliminary proof-of-concept results for the potential of aerobic exercise to improve cancer-related cognitive impairment and will serve to inform the development of future trials.

Health-Related Quality of Life of Kidney Transplantation Patients: Results from the KoreaN Cohort Study for Outcome in Patients With Kidney Transplantation (KNOW-KT) Study

BACKGROUND

As patient and graft survival rates have been improving after kidney transplantation, health-related quality of life (HR-QOL) has become an important indicator of effective treatment. This study aimed to evaluate changes in HR-QOL after kidney transplantation.

MATERIALS AND METHODS

The KoreaN cohort study for Outcome in patients With Kidney Transplantation (KNOW-KT) is a multicenter, observational, 9-year, cohort study. The HR-QOL of patients in the KNOW-KT study was assessed before transplantation and 2 years after transplantation using the Kidney Disease Quality of Life Short Form (KDQOL-SF) including chronic kidney disease targeted area and the Medical Outcome Study 36-item Short Form Health Survey (SF-36). Multivariate linear regression was used to identify significant factors associated with follow-up QOL scores.

RESULTS

A total of 175 patients from 8 centers were analyzed. All QOL scores including the total QOL score, chronic kidney disease targeted score, and SF-36 at the 2-year follow-up were significantly increased compared to baseline values. Both physical and mental scale scores were improved after transplantation.

CONCLUSION

The QOL scores for both the mental and physical scales were improved at 2 years after kidney transplantation. High glomerular filtration rate at 2 years, high baseline QOL score, and low body mass index were associated with good follow-up QOL scores. Kidney transplantation for an Asian population with end-stage renal disease can result in better QOL as well as better patient and graft survival.

Personalized oncogenomics in the management of gastrointestinal carcinomas-early experiences from a pilot study

BACKGROUND

Gastrointestinal carcinomas are genomically complex cancers that are lethal in the metastatic setting. Whole-genome and transcriptome sequencing allow for the simultaneous characterization of multiple oncogenic pathways.

METHODS

We report 3 cases of metastatic gastrointestinal carcinoma in patients enrolled in the Personalized Onco-Genomics program at the BC Cancer Agency. Real-time genomic profiling was combined with clinical expertise to diagnose a carcinoma of unknown primary, to explore treatment response to bevacizumab in a colorectal cancer, and to characterize an appendiceal adenocarcinoma.

RESULTS

In the first case, genomic profiling revealed an IDH1 somatic mutation, supporting the diagnosis of cholangiocarcinoma in a malignancy of unknown origin, and further guided therapy by identifying epidermal growth factor receptor amplification. In the second case, a BRAF V600E mutation and wild-type KRAS profile justified the use of targeted therapies to treat a colonic adenocarcinoma. The third case was an appendiceal adenocarcinoma defined by a p53 inactivation; Ras/raf/mek, Akt/mtor, Wnt, and notch pathway activation; and overexpression of ret, erbb2 (her2), erbb3, met, and cell cycle regulators.

SUMMARY

We show that whole-genome and transcriptome sequencing can be achieved within clinically effective timelines, yielding clinically useful and actionable information.

In-plane three-step needle insertion technique for ultrasound-guided continuous femoral nerve block after total knee arthroplasty: a retrospective review of 488 cases

BACKGROUND

Continuous femoral nerve block (CFNB) improves postoperative analgesia after total knee arthroplasty (TKA). The aim of this study was to investigate the clinical efficacy and complications of our in-plane three-step needle insertion technique that was devised to reduce the risk of direct femoral nerve injury during CFNB in anesthetized patients.

METHODS

This retrospective study included 488 patients who had undergone TKA. Ultrasound (US)-guided CFNB was performed under general or spinal anesthesia using an in-plane, three-step needle insertion technique. The success rate and difficulties of catheter placement, clinical efficacy of analgesia, and complications were recorded.

RESULTS

Femoral catheters were placed with a 100% success rate. In 488 patients, real-time US imaging revealed easy separation of the fascia iliaca and the femoral nerve following injection of local anesthetic through a Tuohy needle. Verbal numerical rating scale pain scores (0-10) were 2.0 ± 1.2, 3.5 ± 1.9, 3.2 ± 1.7, 2.9 ± 1.3, and 2.5 ± 1.1 at 1, 6, 12, 24 and 48 h postoperatively. No femoral hematoma, femoral abscess, or neurologic complications, including paresthesia or neurologic deficits, were observed during the 8-week follow-up period.

CONCLUSIONS

This retrospective study suggests that an in-plane three-step needle insertion technique for CFNB may reduce the risk of femoral nerve injury in anesthetized patients.

Cardiac Arrest due to a Vagal Reflex Potentiated by Thoracic Epidural Analgesia

Reflex bradycardia and cardiac arrest may be the result of a vagal reflex, which can occur during a variety of surgical procedures. We report a patient who developed cardiac arrest as a result of a vagal reflex that was potentiated by thoracic epidural analgesia during general anaesthesia. A 53-year-old man was scheduled for subtotal gastrectomy because of an early gastric adenocarcinoma. After an epidural catheter had been inserted, general anaesthesia was induced. During surgery, an abdominal self-retaining retractor was set up but bradycardia and cardiac arrest developed. The patient returned to a normal sinus rhythm after successful resuscitation. We conclude that bradycardia as a result of a vagal reflex is mediated by potent abdominal wall traction and is potentiated by epidural analgesia. Early diagnosis and proper treatment can allow a full recovery, even in high-risk patients.

Thoracic Epidural Clonidine Attenuates Haemodynamic Responses Induced by Endobronchial Intubation

Laryngoscopy and endobronchial intubation usually cause transient hypertension and tachycardia. We investigated whether thoracic epidurally injected 3 μg/kg clonidine attenuates cardiovascular responses to intubation compared with 2 μg/kg fentanyl and 1 mg/kg lidocaine. Epidural catheterization was performed at the T6–T7 or T7–T8 intervertebral space, and saline or clonidine in saline was injected 20 min before anaesthetic induction. Anaesthesia was induced using 5 mg/kg thiopental sodium and 0.1 mg/kg vecuronium. Laryngoscopy and endobronchial intubation were performed 2 min later. Mean blood pressure and heart rate were measured throughout anaesthetic induction. In the control group and the fentanyl group, mean blood pressure and heart rate 3 min after endobronchial intubation were elevated significantly compared with baseline. In the clonidine group, however, mean blood pressure and heart rate did not increase compared with baseline. The control group had higher mean blood pressure and heart rate than the clonidine group 3 min after endobronchial intubation. Thoracic epidural clonidine may attenuate the haemodynamic response to endobronchial intubation.

Response to angiotensin blockade with irbesartan in a patient with metastatic colorectal cancer

BACKGROUND

A patient suffering from metastatic colorectal cancer, treatment-related toxicity and resistance to standard chemotherapy and radiation was assessed as part of a personalized oncogenomics initiative to derive potential alternative therapeutic strategies.

PATIENTS AND METHODS

Whole-genome and transcriptome sequencing was used to interrogate a metastatic tumor refractory to standard treatments of a patient with mismatch repair-deficient metastatic colorectal cancer.

RESULTS

Integrative genomic analysis indicated overexpression of the AP-1 transcriptional complex suggesting experimental therapeutic rationales, including blockade of the renin-angiotensin system. This led to the repurposing of the angiotensin II receptor antagonist, irbesartan, as an anticancer therapy, resulting in the patient experiencing a dramatic and durable response.

CONCLUSIONS

This case highlights the utility of comprehensive integrative genomic profiling and bioinformatics analysis to provide hypothetical rationales for personalized treatment options.

Comparative net cost impact of the utilization of panitumumab versus cetuximab for the treatment of patients with metastatic colorectal cancer in Canada

OBJECTIVE

Clinical practice guidelines support the use of the epidermal growth factor receptor (EGFR) inhibitors panitumumab and cetuximab for the treatment of metastatic colorectal cancer (mCRC) after failure of other chemotherapy regimens, based on significant clinical benefits in patients with wild-type KRAS. The purpose of the analysis was to compare provincial hospital costs when using panitumumab vs cetuximab with or without irinotecan in this patient population using a Net Impact Analysis (NIA) approach.

METHODS

The NIA determined the total per patient cost of the reimbursed regimens of panitumumab vs cetuximab in British Columbia, Alberta, Manitoba, Ontario, and Québec. Utilization of healthcare resources related to EGFR inhibitor infusions, follow-up monitoring, and treatment of adverse events (AEs) were also included. Healthcare resource use including drugs, medical supplies, laboratory testing, oncology infusion time, and healthcare professionals' time was obtained through expert consultation and the use was then multiplied by the province-specific cost of each resource. Numerous sensitivity analyses were conducted.

RESULTS

Based on the dosing regimens in place in each province, the total annual per patient cost of panitumumab ranged from $22,203-$32,600, while the total annual per patient cost of cetuximab treatment varied from $30,321-$40,908. Treatment with panitumumab resulted in lower costs in all cost categories including drug acquisition, infusion preparation/administration, patient monitoring, and AE management. Per patient savings with panitumumab ranged from a low of $3815 in British Columbia to a high of $10,603 in Ontario. In sensitivity analyses, panitumumab remained cost saving in all scenarios where the savings ranged from $150-$16,006 per patient.

CONCLUSIONS

Treating chemorefractory mCRC patients with panitumumab rather than cetuximab reduced healthcare resource costs. Provincial healthcare savings achieved with the use of panitumumab could potentially be re-allocated to other cancer treatments, although further study would be needed to validate this assumption.

Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 2: treatment

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy is used to treat vte; however, patients with cancer have unique clinical circumstances that can often make decisions surrounding the administration of therapeutic anticoagulation complicated. No national Canadian guidelines on the management of established cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin is the treatment of choice for cancer patients with established vte. Direct oral anticoagulants are not recommended for the treatment of vte at this time. Specific clinical scenarios, including the presence of an indwelling venous catheter, renal insufficiency, and thrombocytopenia, warrant modifications in the therapeutic administration of anticoagulation therapy. Patients with recurrent vte should receive extended (>3 months) anticoagulant therapy. Incidental vte should generally be treated in the same manner as symptomatic vte. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, levels of anti-factor Xa could be checked at baseline and periodically thereafter in patients with renal insufficiency. Follow-up and education about the signs and symptoms of vte are important components of ongoing patient care.

A Meta-Analysis of Renal Function After Adult Cardiac Surgery With Pulsatile Perfusion

The aim of this meta-analysis was to determine whether pulsatile perfusion during cardiac surgery has a lesser effect on renal dysfunction than nonpulsatile perfusion after cardiac surgery in randomized controlled trials. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were used to identify available articles published before April 25, 2014. Meta-analysis was conducted to determine the effects of pulsatile perfusion on postoperative renal functions, as determined by creatinine clearance (CrCl), serum creatinine (Cr), urinary neutrophil gelatinase-associated lipocalin (NGAL), and the incidences of acute renal insufficiency (ARI) and acute renal failure (ARF). Nine studies involving 674 patients that received pulsatile perfusion and 698 patients that received nonpulsatile perfusion during cardiopulmonary bypass (CPB) were considered in the meta-analysis. Stratified analysis was performed according to effective pulsatility or unclear pulsatility of the pulsatile perfusion method in the presence of heterogeneity. NGAL levels were not significantly different between the pulsatile and nonpulsatile groups. However, patients in the pulsatile group had a significantly higher CrCl and lower Cr levels when the analysis was restricted to studies on effective pulsatile flow (P < 0.00001, respectively). The incidence of ARI was significantly lower in the pulsatile group (P < 0.00001), but incidences of ARF were similar. In conclusion, the meta-analysis suggests that the use of pulsatile flow during CPB results in better postoperative renal function.

An unexpected increase of entropy in a sleepwalking disorder patient during propofol and remifentanil anesthesia: a case report

We report a case of increased values of entropy parameters Response Entropy (RE) and State Entropy (SE) during intravenous general anesthesia in a sleepwalking patient. An ASA class II, 64-year-old woman with stress incontinence underwent mid-urethral sling surgery. Prior to surgery, the patient had been administered paroxetine, valproic acid and clonazepam for the treatment of sleepwalking disorder. After 10 min of target-controlled infusion of propofol and remifentanil, entropy values increased up to 94 (RE) and 88 (SE) for 10 min. The target effect-site concentrations of anesthetics increased from 4 to 7 µg/ml propofol and 4 ng/ml remifentanil, at which point values fell back to adequate anesthesia levels. Episodes of recall or of explicit memories did not occur during the anesthesia. In conclusion, sleepwalking patients with long-term use medications may need increment of anesthetic dose caused by the anesthetic drug metabolism activation or impairment or immaturity of inhibitory circuits in brain.

Perioperative chemotherapy for gastroesophageal cancer in British Columbia: a multicentre experience

BACKGROUND

In 2006, perioperative epirubicin, cisplatin, and 5-fluorouracil (ecf), compared with surgery alone, demonstrated a significant survival benefit in resectable gastroesophageal cancers. We report the results of our experience with that protocol.

METHODS

The BC Cancer Agency (bcca) is a multicentre institution that treats most oncology patients for the province. Characteristics of the 83 bcca patients with localized gastric, gastroesophageal junction, or lower esophageal cancer who initiated perioperative chemotherapy either ecf or epirubicin, cisplatin, and capecitabine (ecx) from 2008 to 2011 were abstracted to an anonymous database and analyzed.

RESULTS

Of the 83 patients in the cohort [66 men; median age: 62 years (range: 37-79 years)], 87.9% completed 3 cycles of perioperative chemotherapy, and 93.9% (n = 78) underwent an attempt at surgery (2 patients died of chemotherapy toxicities, 1 refused surgery, and 2 developed disease progression before surgery). In 11 of the surgeries (14.1%), tumours could not be resected because of unresectability (n = 1), liver metastasis (n = 1), and peritoneal carcinomatosis (n = 9). One patient died of surgical complications. The 6 patients (7.2%) who achieved a pathologic complete response are all alive and recurrence-free. Of 46 patients (55.4%) who subsequently began postoperative chemotherapy, 44.5% completed 3 cycles. Estimated median survival was 40.3 months. Weight loss was the only significant prognostic factor for worse overall survival.

CONCLUSIONS

Our multicentre experience confirmed the feasibility of the magic protocol in a real-world scenario and showed that ecx is also an adequate regimen in the perioperative setting. Weight loss was the only significant prognostic factor for worse overall survival. All patients who achieved a pathologic complete response are recurrence-free after a median follow-up of 40.3 months.

Ahnak functions as a tumor suppressor via modulation of TGFβ/Smad signaling pathway

We provide detailed mechanisms of Ahnak-mediated potentiation of transforming growth factor β (TGFβ) signaling, which leads to a negative regulation of cell growth. We show that Smad3 interacts with Ahnak through MH2 domain and that Ahnak stimulates Smad3 localization into nucleus leading to potentiating TGFβ-induced transcriptional activity of R-Smad. Moreover, overexpression of Ahnak resulted in growth retardation and cell cycle arrest through downregulation of c-Myc and cyclin D1/D2. We describe results from analyses of Ahnak^−/− mouse model expressing middle T antigen in a mammary gland-specific manner (MMTV^Tg/+Ahnak^−/−), which showed significantly progressed hyperplasia of mammary glands compared with MMTV^Tg/+Ahnak^+/+. Finally, we screened multiple human breast cancer tissues and showed that the expression of Ahnak in cancer tissues is lower than that in control tissues by 50%. Taken together, these data indicate that Ahnak mediates a negative regulation of cell growth and acts as novel tumor suppressor through potentiation of TGFβ signaling.

Associations between drug use and risk behaviours for HIV and sexually transmitted infections among female sex workers in Yunnan, China

This is a cross-sectional study of 399 subjects conducted to explore the association between drug use and risk behaviour for HIV and sexually transmitted infections (STIs) among female sex workers (FSWs), and also to study the prevalence of HIV/STIs among drug-using FSWs (DUFSWs) and non-DUFSWs in Yunnan province of China. Demographic information, mobility, sexual and drug-using behaviours were collected and subjects were tested for HIV/STIs. Mean age was 27 years (SD = ±7.8) and 94 (23.6%) tested positive for recent opiate use. Compared with non-DUFSWs, DUFSWs had a significantly higher prevalence of HIV (38% versus 4%, P ≤ 0.001), herpes simplex virus type 2 (HSV-2; 92% versus 60%, P ≤ 0.001) and STIs (95.7% versus 69.2%, P ≤ 0.001). DUFSWs had a significantly longer duration of commercial sex work compared with non-DUFSWs (median 5 versus 1 years, P ≤ 0.001), and had at least two clients in the last working day. DUFSWs were also more likely to work in low-end commercial sex venues and frequented a greater number of work locations than non-DUFSWs. Compared with non-DUFSWs, DUFSWs were more likely to exhibit riskier sexual behaviours and greater workplace mobility. Interventions targeting drug-related behavioural changes are needed urgently in this population in order to reduce rates of HIV and STIs.

Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery

Background

Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter.

Methods

Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge.

Results

Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur.

Conclusions

The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

Prophylactic use of midazolam or propofol at the end of surgery may reduce the incidence of emergence agitation after sevoflurane anaesthesia

Sevoflurane is associated with a high incidence of emergence agitation in children. Midazolam and propofol have been examined with the aim of reducing emergence agitation after sevoflurane anaesthesia. However the effect of both drugs on emergence agitation is still controversial. Therefore we designed this study to measure the effect of midazolam or propofol at the end of surgery on emergence agitation during the recovery period. One hundred and one children, aged one to 13 years, undergoing strabismus surgery were enrolled in this randomised double-blind study. Anaesthesia was induced and maintained with sevoflurane in N2O/O2. Children were randomly assigned to receive midazolam 0.05 mg/kg (group M, n = 35), propofol 1 mg/kg (group P, n = 31) or saline (group S, n = 35). A four-point scale was used to evaluate recovery characteristics upon awakening and during the first hour after emergence from anaesthesia. The incidence of emergence agitation in group M was 42.9% (15/35), in group P 48.4% (15/31) and in group S 74.3% (26/35). The incidence of emergence agitation in groups M and P was significantly less than in group S. The emergence time was prolonged for patients in groups M and P compared to group S. There was no significant difference in the incidence of emergence agitation or in emergence times between the groups P and M. We conclude that propofol or midazolam administration before the end of surgery may be effective in reducing the incidence of emergence agitation in children undergoing strabismus surgery under sevoflurane anaesthesia.

Components of sleep quality and sleep fragmentation in rheumatoid arthritis and osteoarthritis

OBJECTIVES

Poor sleep is increasingly recognized as contributing to a decreased quality of life, increased morbidity/mortality and heightened pain perception. The purpose of the present study was to assess components of sleep quality and self-identified contributors to sleep fragmentation in rheumatoid arthritis (RA) and osteoarthritis (OA) patient populations.

METHODS

Consecutive RA and OA clinic patients were invited to participate in a self-administered questionnaire study which included the validated multi-domain Pittsburgh Sleep Quality Index (PSQI), visual analogue scales for pain, fatigue, global functioning, modified Health Assessment Questionnaire (mHAQ), stress scores, the Centre for Epidemiologic Studies-Depression (CES-D) score, the 36-item short form (SF-36) quality of life measure, the Rheumatoid Arthritis Disease Activity Index (RADAI), the Epworth Sleepiness Scale (ESS), Berlin score for obstructive sleep apnoea (OSA) risk and the International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria.

RESULTS

The study population included 145 RA and 78 OA patients. PSQI global scores were >5 in 62% of RA and 67% of OA patients. Multivariate analysis identified global functioning and the CES-D to be independent predictors for higher global PSQI scores in RA patients, whereas in OA patients predictors were the mHAQ and SF-36 mental component summary. Abnormalities in subjective sleep assessment, sleep latency, sleep duration, sleep efficiency, daytime dysfunction and increased sleep-aid medication use were observed in both populations. The most common abnormality reported by both RA and OA patients was increased sleep fragmentation. The most frequent self-identified cause for sleep disturbance was 'need to use the washroom' by 51% of RA and 49% of OA patients, and, second most common, 'pain' was identified as a cause for awakening by 33% of RA and 45% of OA patients.

CONCLUSIONS

A high prevalence of abnormal sleep quality in both RA and OA patient populations was observed. The most common abnormality was sleep fragmentation, with an increased sleep disturbance score. 'Need to use the washroom' and 'pain' were the most common self-identified reasons for awakening from sleep. A review of sleep hygiene, optimization of urological status, and rheumatological disease symptomatic control may prove beneficial in terms of sleep health.

Postoperative renal function in patients is unaltered after robotic-assisted radical prostatectomy

Background

Pneumoperitoneum with an intra-abdominal pressure (IAP) of 14 mmHg is known to decrease renal function. Robotic-assisted radical prostatectomy (RARP) requires an IAP of more than 15 mmHg for operation. Therefore, we retrospectively investigated whether patients who underwent RARP experienced renal insufficiency during the postoperative period (at postoperative days 7 and 30).

Methods

One hundred patients who underwent RARP were enrolled in this study. Preoperative serum blood urea nitrogen (BUN) and serum creatinine (Cr) levels were measured. Creatinine clearance (CrCl) was calculated using the Cockcroft and Gault formula. CrCl was calculated at 1 day before surgery (baseline), 2 hr postoperatively, and at 1, 3, 7, and 30 days postoperatively (POD 1, POD 3, POP 7, and POD 30). Patients were assigned to abnormal CrCl (n = 52) or normal CrCl groups (n = 48) on the basis of these measurements.

Results

Significant inter-group differences in BUN, Cr, and CrCl were observed at all postoperative time points. BUN and Cr decreased significantly at postoperative 2 hr and POD 1, 3, and 7 versus baseline in both groups, whereas CrCl increased significantly at postoperative 2 hr and POD 1, 3, and 7 versus baseline in both groups. However, BUN, Cr, and CrCl were similar at POD 30 and preoperatively in the two groups.

Conclusions

RAPR, which requires an IAP of 15-20 mmHg for more than 4 hr, does not induce renal dysfunction during the postoperative period, and even in those patients with an abnormal CrCl.

Effect of propofol on cardiac function and gene expression after ischemic-reperfusion in isolated rat heart

Background

The aim of this study was to examine the cardiac function and transcriptional response of the heart to propofol after ischemia-reperfusion.

Methods

Rat hearts were Langendorff-perfused using the modified Krebs-Henseleit buffer, and took 20 min stabilizing periods, 40 min ischemia periods, and then 120 min reperfusion period. The hearts were divided into 5 groups; Control: 180 min perfusion after stabilization, Ischemic: 40 min global ischemia after stabilization, followed by 120 min reperfusion, Pre: 2 µM propofol treatment was preformed only before ischemia, Post: 2 µM propofol treatment was performed only during reperfusion after ischemia, Pre/Post: 2 µM propofol treatment was performed both before and after ischemia. The measurement for cardiac performances, such as left ventricular developed pressure (LVDP), rate of left ventricular pressure generation (dP/dt), heart rate, and coronary flow were obtained. The expression profiles of isolated mRNA were determined by using Agilent microarray and real time-polymerase chain reaction (RT-PCR) was used to confirm the microarray results for a subset of genes.

Results

The Post group showed better LVDP and dP/dt than the Ischemic group. But there were no significant differences in heart rate and coronary flow among the groups. On the results of RT-PCR, the expressions of Abcc9, Bard1, and Casp4 were increased, but the expressions of Lyz, Casp8, and Timp1 were decreased in the Post group compared with the Ischemic group.

Conclusions

This study suggests that 2 µM propofol may provide cardioprotective effect, and modulate gene expression such as apoptosis, and K_ATP ion channel related-genes during reperfusion in the isolated rat hearts.

A Comparison of Consumption and Recovery Profiles According to Anaesthetic Circuit Mode using a New Multifunctional Closed-Circuit Anaesthesia System during Desflurane Anaesthesia: A Clinical Study

This clinical study compared induction time, consumed anaesthetic dose, and haemodynamic and recovery profiles when using a new type of multifunctional anaesthesia machine (Zeus®) in semi-closed or closed circuit modes. Sixty female patients undergoing gynaecological surgery were randomly assigned to three groups and received desflurane anaesthesia through a semi-closed circuit (SCC) at fresh gas flow rates of 4 l/min (SCC 4 l/min) or 2 l/min (SCC 2 l/min), or through a closed circuit (CC). Anaesthesia was maintained at the minimum alveolar concentration for blocking the adrenergic response to painful stimulus (MACBAR) (4.6% end-tidal desflurane) during each operation. The time required to reach MACBAR was significantly shorter and the dose of desflurane was significantly smaller in the CC group compared with the other groups. There were no differences in haemodynamic and recovery profiles between the groups. It is concluded that the CC mode allowed a faster and more reliable induction, lower anaesthetic consumption and stable haemodynamic and recovery profiles.

Paroxysmal atrial fibrillation developed during incomplete epidural anesthesia -A case report-

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia, and occurs in organic heart disease such as rheumatic, atherosclerotic and hypertensive heart disease. In recent studies, the sympathetic and parasympathetic nervous systems have been shown to have important roles in initiating paroxysmal AF. We report here a patient who developed paroxysmal AF that might be a result of an imbalance of the sympathetic-parasympathetic systems due to epidural anesthesia, and that was potentiated by pain with inadequate analgesia. A 69-year-old woman was scheduled for operation of a right-sided ankle fracture. Twenty minutes after epidural drug injection, paroxysmal AF occurred. Even after intravenous administration of esmolol and digoxin, AF continued. After transfer to the intensive care unit, her heart rate gradually decreased and AF disappeared. During perioperative anesthetic management, the proper preoperative prevention and intraoperative treatment are needed in AF high-risk patients.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome: A case report

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.

The effect of increasing operating room capacity on day-of-surgery cancellation

Several studies have been conducted to evaluate the utilisation of the operating room, a fixed resource, in terms of conditions that prevent day-of-surgery cancellation due to deficient operative capacity. In this study, we surveyed the causes and overall rates of elective surgery cancellation and then compared the number of cancellations that occurred before and after the installation of additional operating rooms. We surveyed all patients undergoing elective surgery for 100 days prior to and after the installation of additional operating rooms. The causes for cancellations were divided into six categories: departmental issues, abnormal laboratory results, patient denial, inadequate preparation, over-booking and other issues. The departmental causes were further divided into four categories: ward overflow, scheduling date errors, unavailable surgeons and other issues. The number of overall cancelled cases and scheduled cases increased following the increase in operating room capacity, although this increase was not statistically significant. However; the cancellation ratio rose significantly after the operating room capacity was increased. The primary reasons for cancellation prior to the increase in operating room capacity were departmental issues, over-booking and abnormal laboratory data, in that order. After the operating room capacity was increased, the primary reasons for cancellation were departmental issues, abnormal laboratory data and over-booking, in that order Taken together the results of this study indicate that increased operating room capacity can prevent cancellation due to over-booking. However; the numbers of cancellations due to ward overflow exceeded the numbers of cancellations that occurred as a result of over-booking. In conclusion, increasing the operating room capacity is not an appropriate option for preventing the cancellation of operations.

Effect of muscle relaxant on entropy during propofol anesthesia

BACKGROUND

The purpose of this study was to investigate whether muscle relaxant affect the values of Entropy, response entropy (RE) or state entropy (SE) during propofol anesthesia.

METHODS

Eighty patients (ASA I) scheduled for elective surgery under general anesthesia were randomly assigned to four groups. Anesthesia was maintained at a SE value of 80 (80 +/- 2) using target controlled infusion (TCI) of propofol. After maintaining SE 80 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group I and same volume of normal saline was intravenously injected in group II. After maintaining SE 60 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group III and same volume of normal saline was injected intravenously in group IV. The mean arterial pressure, heart rate, SE and RE were measured before anesthetic induction and up to 5 min after vecuronium or normal saline injection in each group.

RESULTS

SE and RE were not changed in group II, but significantly decreased in group I (P < 0.05, respectively). In group III and IV, SE and RE were not changed in both groups. There were no significant hemodynamic changes among the four groups.

CONCLUSIONS

These results suggest that the effect of muscle relaxant on Entropy vary according to the baseline values of RE or SE during propofol anesthesia.

Common peroneal nerve palsy after robotic assisted laparoscopic colectomy: A case report

Common peroneal nerve palsy after surgery with lithotomy position has been widely reported, but it is an unexpected complication after surgery with supine position. We report a patient who developed common peroneal nerve palsy after surgery with supine position. A 55-year old man is planed for robotic assisted laparoscopic right hemicolectomy because of colon cancer. The patient was placed supine with Trendelenburg position at an angle about 5 degrees and tilted left about 15 degrees. The operation is uneventful, but he developed common peroneal nerve palsy on the first postoperative day. The patient was fully recovered with conservative treatment after 2 months. We consider that nerve palsy as a result of compression of common peroneal nerve related to patient positioning. So we should be careful not to develop common peroneal nerve palsy even if the patient was placed in the supine position during robotic assisted surgery.

Human amnion-derived mesenchymal stem cells are a potential source for uterine stem cell therapy

OBJECTIVES

Human amnion is an easy-to-obtain novel source of human mesenchymal stem cells, which poses little or no ethical dilemmas. We have previously shown that human amnion-derived mesenchymal (HAM) cells exhibit certain mesenchymal stem cell-like characteristics with respect to expression of stem cell markers and differentiation potentials.

MATERIALS AND METHODS

In this study, we further characterized HAM cells' potential for in vivo therapeutic application.

RESULTS

Flow cytometric analyses of HAM cells show that they express several stem cell-related cell surface markers, including CD90, CD105, CD59, CD49d, CD44 and HLA-ABC, but not CD45, CD34, CD31, CD106 or HLA-DR. HAM cells at the 10th passage showed normal karyotype. More interestingly, the AbdB-like HOXA genes HOXA9, HOXA10 and HOXA11 that are expressed in the mesenchyme of the developing female reproductive tract and pregnant uteri are also expressed in HAM cells, suggesting similarities between these two mesenchymal cell types. Progesterone receptor is also highly expressed in HAM cells and expression of genes or proteins in HAM cells could be manipulated with the aid of lentivirus technology or cell-permeable peptides. To test potentials of HAM cells for in vivo application, we introduced enhanced green fluorescence protein (EGFP)-expressing HAM cells to mice by intrauterine infusion (into uteri) or by intravenous injection (into the circulation). Presence of EGFP-expressing cells within the uterine mesenchyme after intrauterine infusion or in lungs after intravenous injection was noted within 1-4 weeks.

CONCLUSIONS

Collectively, these results suggest that HAM cells are a potential source of mesenchymal stem cells with therapeutic potential.

A comparison of intra-operative cell-saving strategies upon immediate post-operative outcomes after CPB-assisted cardiac procedures

Cardiotomy suction has been associated with adverse outcomes under routine conditions in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). We hypothesized that the routine use of a cell saver (CS) in place of the cardiotomy sucker would have no negative impact on transfusion rate (TR), chest tube drainage (CTD), ventilation time (VT) or intensive care unit length of stay (ICULOS) while avoiding the detrimental effects of cardiotomy suction. Retrospective data were collected from 69 patients where a cell saver was not used (NCS). Prospective data were collected from 219 patients who were followed after the implementation of an intra-operative cell saver. No significant increase in transfusion rate, chest tube drainage or ventilation time was found between the NCS group and the CS group. However, post-operative hemoglobin concentrations were significantly higher in the CS group (0.0001) and the CS group spent significantly less time in the ICU (p=0.018).

Target-controlled propofol infusion for sedation in patients undergoing transrectal ultrasound-guided prostate biopsy

The efficacy and safety of the routine use of target-controlled infusion of propofol for the sedation of patients undergoing transrectal ultrasound-guided prostate biopsy were assessed. The optimal level of sedation was also evaluated. A total of 250 patients were randomized into five groups according to sedation level determined by the Observer's Assessment of Alertness/Sedation (OAA/S) scale. As the level of sedation was increased, the overall pain and discomfort score decreased and the satisfaction rate tended to increase, although hypoxia meant that intervention occurred more frequently at higher sedation levels. Target-controlled infusion of propofol provided safe and effective sedation during transrectal ultrasound-guided prostate biopsy, particularly if moderate sedation (OAA/S score of 3) was achieved. The effect-site concentration of propofol for this level of sedation was about 1.5 microg/ml.

The Effects of Propofol on Cardiac Function After 4 Hours of Cold Cardioplegia and Reperfusion

OBJECTIVE

To examine whether propofol protects against postischemic myocardial dysfunction and apoptosis during reperfusion after prolonged cold ischemia in isolated rat hearts.

DESIGN

A prospective, randomized, controlled study.

SETTING

A university laboratory.

PARTICIPANTS

Animals.

INTERVENTIONS

The isolated hearts of 40 Sprague-Dawley male rats were perfused with modified Krebs-Hennseleit solution for 15 minutes for a stabilization period and 15 minutes for a perfusion period and then underwent 4 hours of global cold ischemia followed by 60 minutes of reperfusion. Four groups were studied (n = 10 for each group). Ten hearts served as an untreated control group. Propofol (2 micromol/L) treatment was performed only before ischemia in the PRE group, only during reperfusion in the POST group, and both before and after ischemia in the ALL group.

MEASUREMENTS AND MAIN RESULTS

Infusion of propofol during reperfusion improved recovery of left ventricular-developed pressure (LVDP) from 61.2% +/- 8.5% (control) to 86.3% +/- 12.1% (POST) and 74.9% +/- 13.2% (ALL, both p < 0.05), whereas preischemic infusion of propofol (64.3% +/- 9.7%, PRE) did not improve recovery of LVDP. Infusion of propofol during reperfusion significantly reduced the number of apoptotic cells and led to a smaller infarct size than control and PRE groups (p < 0.05, respectively).

CONCLUSIONS

Propofol infusion during the reperfusion period produced a cardioprotective effect and inhibited apoptosis of cardiomyocytes in the ischemia-reperfusion model, with prolonged cold ischemia, in isolated rat hearts.

Tau overexpression in transgenic mice induces glycogen synthase kinase 3β and β-catenin phosphorylation

The abnormal phosphorylations of tau, GSK3beta, and beta-catenin have been shown to perform a crucial function in the neuropathology of Alzheimer's disease (AD). The primary objective of the current study was to determine the manner in which overexpressed htau23 interacts and regulates the behavior and phosphorylation characteristics of tau, GSK3beta, and beta-catenin. In order to accomplish this, transgenic mice expressing neuron-specific enolase (NSE)-controlled human wild-type tau (NSE/htau23) were created. Transgenic mice evidenced the following: (i) tendency toward memory impairments at later stages, (ii) dramatic overexpression of the tau transgene, coupled with increased tau phosphorylation and paired helical filaments (PHFs), (iii) high levels of GSK3beta phosphorylation with advanced age, resulting in increases in the phosphorylations of tau and beta-catenin, (iv) an inhibitory effect of lithium on the phosphorylations of tau, GSK3beta, and beta-catenin, but not in the non-transgenic littermate group. Therefore, the overexpression of NSE/htau23 in the brains of transgenic mice induces abnormal phosphorylations of tau, GSK3beta, and beta-catenin, which are ultimately linked to neuronal degeneration in cases of AD. These transgenic mice are expected to prove useful for the development of new drugs for the treatment of AD.