Effect of a compensated Jaffé creatinine method on the estimation of glomerular filtration rate

Background: Roche Diagnostics has issued new c-fas calibrators for its automated systems. These produce creatinine values that are more comparable with those obtained by high-performance liquid chromatography. However, this results in an underestimation of measured creatinine at concentrations below 155 μmol/L and an overestimation at concentrations above this value.

Methods: Serum and urine creatinine concentrations were prospectively determined on samples from 60 patients using the new (compensated) and old (uncompensated) c-fas calibrators, and Passing-Bablok regression analysis was performed. The regression equations thus determined were then used retrospectively to determine the compensated creatinine results (i.e. those results that would have been obtained using the new calibrator) in those serum and urine samples analysed in the previous year using the old uncompensated c-fas calibrator. The compensated creatinine results were then used to estimate the glomerular filtration rate (GFR) by calculating creatinine clearance. This was done by using the formula: UV/Pt, in which U represents the urinary creatinine concentration (μmol/L), V the urinary collection volume (mL), P the serum creatinine concentration (μmol/L) and t the urinary collection time (min). It was also calculated using the abbreviated Modification of Diet in Renal Disease study group (MDRD) formula.

Results: The creatinine clearance as determined using either the UV/Pt calculation or the MDRD formula overestimated GFR by ~30% and ~50%, respectively, in normal individuals with a serum creatinine concentration below 155 μmol/L. However, in patients with mild to moderate renal failure (serum creatinine from 155 to 500 μmol/L), changes in creatinine clearances determined by the two procedures were minimal.

Conclusion: When laboratories introduce this new, compensated calibrator into practice, it may be appropriate to discuss its potential impact with clinical staff who monitor patients using creatinine clearance.

Reduction of intubation rate during newborn resuscitation after transition from self-inflating bag to T-piece resuscitator

INTRODUCTION

T-piece resuscitator (TPR) has many advantages compared to self-inflating bag (SIB). Early Continuous Positive Airway Pressure (CPAP) during newborn resuscitation (NR) with TPR at delivery can reduce intubation rate.

METHODS

We speculated that the intubation rate at delivery room was high because SIB had always been used during NR and this can be improved with TPR. Intubation rate of newborn <24 hours of life was deemed high if >50%. An audit was carried out in June 2010 to verify this problem using a check sheet.

RESULTS

25 neonates without major congenital anomalies who required NR with SIB at delivery were included. Intubation rate of babies <24 hours of life when SIB was used was 68%. Post-intervention audit (August to November 2010) on 25 newborns showed that the intubation rate within 24 hours dropped to 8% when TPR was used. Proportion of intubated babies reduced from 48.3% (2008-2009) to 35.1% (2011-2012), odds ratio 0.58 (95% CI 0.49-0.68). Proportion of neonates on CPAP increased from 63.5% (2008-2009) to 81.0% (2011-2012), odds ratio 2.44 (95% CI 2.03-2.93). Mean ventilation days fell to below 4 days after 2010. Since then, all delivery standbys were accompanied by TPR and it was used for all NR regardless of settings. There was decline in intubation rate secondary to early provision of CPAP with TPR during NR. Mean ventilation days, mortality and length of NICU stay were reduced.

CONCLUSION

This practice should be adopted by all hospitals in the country to achieve Millennium Development Goal 4 (2/3 decline of under 5 mortality rate) by 2015.

Prostatic stromal sarcoma in a young adult: a case report

Prostate stromal sarcoma is quite rare, comprising only 0.1-0.2% of all prostate cancers. Here, we report one case of prostate stromal sarcoma in a 38-year-old man. Initially, the patient suffered from lower urinary tract symptoms, and intravenous pyelography showed a larger filling defect in the bladder. Transrectal ultrasound showed a huge heterogenous mass between the bladder and rectum. Abdominal computed tomography revealed prostate tumor with local invasion. Radical cystoprostatectomy with ileal conduit was performed; pathology revealed high-grade prostate stromal sarcoma with invasion to the right seminal vesicle and urethra. This article describes the pathology and immunohistrochemical features of this case and briefly reviews the literature.

The importance of the interpretation of urine catecholamines is essential for the diagnosis and management of patient with dopamine-secreting paraganglioma

Phaeochromocytoma or paraganglioma that exclusively secretes dopamine is very rare. This case illustrates its atypical presentation and the importance of interpretative reporting for urine catecholamines leading to the diagnosis and subsequent management of a patient with this condition. We report a 71-year-old Chinese woman with a large dopamine-secreting paraganglioma. She presented with low back pain for six months. On examination, a right abdominal mass was palpable incidentally. Her blood pressure was normal throughout. Serial 24-h urine collections for catecholamines showed enormous elevation of urine dopamine excretion to 80.7 micromol/day (normotensive:<2.6 m mol/day). However, the daily excretions of urine adrenaline and noradrenaline, as well as their metabolites were within their respective reference intervals. Good communication between chemical pathologists and physicians prompted the arrangement of the whole body 131I-meta-iodobenzylguanidine (MIBG) scintigraphy, which showed a large signal in the right upper quadrant of the abdomen corresponding to a large extra-adrenal tumour detected by both ultrasonography and computerized tomography (CT) of the abdomen. Histological section of the tumour tissue revealed paraganglioma, which stained positive for chromogranin and neuron-specific enolase. After four months, the patient presented with chest symptoms and CT of the thorax revealed multiple nodules. Lung metastases were suspected. However, follow-up urine catechola- mine and dopamine excretions were again within their respective normotensive reference intervals. A second MIBG scintigraphy was performed, but no specific uptake at either the thorax or the abdomen could be demonstrated. Fine-needle aspiration cytology using the thoracoscopic technique was performed and immunochemical staining of the biopsy specimen showed the presence of non- small-cell carcinoma of the lung.

Electrospray ionisation mass spectrometry: principles and clinical applications

This mini-review provides a general understanding of electrospray ionisation mass spectrometry (ESI-MS) which has become an increasingly important technique in the clinical laboratory for structural study or quantitative measurement of metabolites in a complex biological sample. The first part of the review explains the electrospray ionisation process, design of mass spectrometers with separation capability, characteristics of the mass spectrum, and practical considerations in quantitative analysis. The second part then focuses on some clinical applications. The capability of ESI-tandem-MS in measuring bio-molecules sharing similar molecular structures makes it particularly useful in screening for inborn errors of amino acid, fatty acid, purine, pyrimidine metabolism and diagnosis of galactosaemia and peroxisomal disorders. Electrospray ionisation is also efficient in generating cluster ions for structural elucidation of macromolecules. This has fostered a new and improved approach (vs electrophoresis) for identification and quantification of haemoglobin variants. With the understanding of glycohaemoglobin structure, an IFCC reference method for glycohaemoglobin assay has been established using ESI-MS. It represents a significant advancement for the standardisation of HbA1c in diabetic monitoring. With its other applications such as in therapeutic drug monitoring, ESI-MS will continue to exert an important influence in the future development and organisation of the clinical laboratory service.

Evaluation of a new handheld biosensor for point-of-care testing of whole blood beta-hydroxybutyrate concentration

OBJECTIVES

To evaluate performance characteristics of the newly available handheld combined glucose and ketone meter for beta-hydroxybutyrate measurement.

DESIGN

Laboratory method evaluation.

MAIN OUTCOME MEASURES

Accuracy of beta-hydroxybutyrate measurement and effect of acetoacetate interference at clinically important beta-hydroxybutyrate levels.

RESULTS

Deming regression analysis of beta-hydroxybutyrate measurements assessed by the ketone sensor and a laboratory enzymatic method revealed a coefficient of determination of 0.989 (P<0.001). Passing-Bablok regression analysis showed a linear relationship between the two methods, ie Y= -0.32+1.13X. The 95% confidence interval of the slope and y-intercept were: slope=1.13 (95% confidence interval, 1.04 to 1.22); intercept= -0.32 (95% confidence interval, -0.59 to -0.06). The Bland-Altman plot showed a small proportional bias between the two methods. The mean bias +/-2 standard deviations was between -0.53 and 0.67 mmol/L. Beta-hydroxybutyrate measurements made by the sensor were linear up to 6 mmol/L. Replicate analysis of two samples spiked with 3.6 mmol/L and 0.8 mmol/L of beta-hydroxybutyrate resulted in coefficients of variation of 3.3% and 13%, respectively. The presence of acetoacetate caused a negative interference in beta-hydroxybutyrate measurement. Beta-hydroxybutyrate recovery was 97.0% and 90.7% when the ketone body ratios were 6:1 and 3:1, respectively.

CONCLUSION

The analytical performance of the sensor, when operated according to manufacturer's instructions, could meet the needs of point-of-care beta-hydroxybutyrate measurement. Additional clinical studies are needed to assess the benefits of introducing such an assay in a clinical setting.

Nuclear beta-catenin expression is closely related to ulcerative growth of colorectal carcinoma

Although most colorectal cancer develops based on the adenoma-adenocarcinoma sequence, morphologically, colorectal cancer is not a homogeneous disease entity. Generally, there are two distinct morphological types: polypoid and ulcerative colorectal tumours. Previous studies have demonstrated that K-ras codon 12 mutations are preferentially associated with polypoid growth of colorectal cancer; however, little is known about the molecular mechanism that determines ulcerative growth of colorectal cancer. beta-catenin complex plays a critical role both in tumorigenesis and morphogenesis. We examined the differential expression of beta-catenin and its related factors among different types of colorectal cancer in order to determine any relationship with gross tumour morphology. Immunohistochemical staining of beta-catenin, E-cadherin and MMP-7 was performed on 51 tumours, including 26 polypoid tumours and 25 ulcerative tumours. Protein truncation tests and single-strand conformational polymorphism for mutation of the adenomatous polyposis coli tumour suppressor gene, as well as single-strand conformational polymorphism for the mutation of beta-catenin exon 3 were also done. Nuclear expression of beta-catenin was observed in 18 out of 25 (72%) cases of ulcerative colorectal cancer and seven out of 26 (26.9%) cases of polypoid colorectal cancer. A significant relationship of nuclear beta-catenin expression with ulcerative colorectal cancer was found (P<0.001). However, this finding was independent of adenomatous polyposis coli tumour suppressor gene mutation and E-cadherin expression. Together with previous data, we propose that different combinations of genetic alterations may underlie different morphological types of colorectal cancer. These findings should be taken into consideration whenever developing a new genetic diagnosis or therapy for colorectal cancer.

Risk factors for pneumothorax and bleeding after CT-guided percutaneous coaxial cutting needle biopsy of lung lesions

PURPOSE

To evaluate risk factors for pneumothorax and bleeding after computed tomography (CT)-guided percutaneous coaxial cutting needle biopsy of lung lesions.

MATERIALS AND METHODS

This study involved 117 consecutive patients with 117 intrapulmonary lesions. Statistical analysis of factors related to patient characteristics, lung lesions, and biopsy technique was performed to determine possible contribution to the occurrence of pneumothorax and bleeding. Interactions between related factors were considered to prevent colinearity.

RESULTS

Pneumothorax occurred in 12% (14 of 117) of patients. Needle aspiration of two moderate asymptomatic pneumothoraces were performed; there was no chest tube insertion. Lesion depth (P =.0097), measured from the pleural puncture site to the edge of the intrapulmonary lesion along the needle path, was the single significant predictor of pneumothorax. The highest risk of pneumothorax occurred in subpleural lesions 2 cm or shorter in depth (this represented 33% of lung lesions but caused 71% of all pneumothoraces; OR = 7.1; 95% CI, 1.3-50.8). Bleeding presented as lung parenchyma hemorrhage and hemoptysis in 30 patients (26%). Hemoptysis occurred in four patients (3%). Univariate analysis identified lesion depth (P <.0001), lesion size (P <.015), and pathology type (P =.007) as risk factors for bleeding. Multivariate logistic regression analysis identified lesion depth as the most important risk factor, with the highest bleeding risk for lesions more than 2 cm deep (14% of lesions caused 46% of all bleeding; OR = 17.3; 95% CI, 3.3-121.4).

CONCLUSIONS

In CT-guided coaxial cutting needle biopsy, lesion depth is the single predictor for risk of pneumothorax, which occurs at the highest rate in subpleural lesions. Increased risk of bleeding occurs in lesions deeper than 2 cm.

Effect of American ginseng extract (Panax quinquefolius) on formalin-induced nociception in mice

Twenty-three ICR mice were force fed orally with American ginseng extract, Panax quinquefolius, (Cold FX) for 4 days. Another 20 mice were fed with water as placebo in a similar fashion. Formalin tests which yield typically two phases of pain behavior were done in both groups. Although there was no difference in the first phase between groups, mice treated with Cold FX spent significantly less time in licking and biting of the injured paws in the second phase. The data indicate that American ginseng may have analgesic effect in this chronic pain model.

Solid variant of papillary renal cell carcinoma

Solid variant of papillary renal cell carcinoma is a newly recognized renal epithelial neoplasm. We encounter a case of a 36-year-old male patient with a solitary right renal tumor. The tumor is composed of solid sheets of small uniform cell with intervening micronodules, resembling the glomeruloid bodies in a metanephric adenoma. Abortive papillae rather than typical papillary formations are found in the micronodules. Furthermore, the cells in these micronodules demonstrate more cellular atypia with abundant eosinophilic cytoplasm comparing to the intervening cells. Both types of neoplastic cells are immunoreactive for epithelial membrane antigen, cytokeratins 7 and 17, but not vimentin and 34 beta E12. The features of the tumor are consistent with solid variant of papillary renal cell carcinoma. Solid variant of papillary renal cell carcinoma is similar in certain morphological and genetic features to metanephric adenoma, suggesting that they might be related.

Intrahepatic cholangiocarcinoma with lymphoepithelioma-like component

We present two cases of intrahepatic cholangiocarcinoma with lymphoepithelioma-like component. The patients included one woman and one man, aged 67 and 41 years, respectively. They presented with right upper quadrant pain and epigastralgia. Histologically, both tumors showed two distinct histological patterns with dense lymphoplasma cell infiltration. The first pattern was a well to moderately differentiated adenocarcinoma; the second component showed a feature similar to lymphoepithelioma-like carcinoma. Granulomatous reaction was noted in one case. Immunohistochemical study revealed that both tumors were immunoreactive with AE1/AE3, cytokeratin 7, and cytokeratin 19 but negative for carcinoembryonic antigen and cytokeratin 20. The stromal lymphocytes were composed of predominantly CD3(+) T cells. In situ hybridization for Epstein-Barr virus (EBV)-encoded RNA (EBER) showed positive nuclear signal in tumor cells but not in inflammatory cells in one case. The presence or absence of EBV genome was confirmed by polymerase chain reaction of LMP-1 gene in both cases. The LMP-1 gene also had a 30-bp deletion in Exon 3 as compared with the products from B95-8 cells. We further sequenced the PCR product and confirmed a 30-bp deletion between Nucleotide (nt) 168,282 and nt 168,253 corresponding to the B95-8 sequence. The clinical significance of 30-bp deletion in Exon 3 of the LMP-1 gene in lymphoepithelioma-like carcinoma of the liver warrants further investigation.

Hepatocellular carcinoma associated with focal nodular hyperplasia. Report of a case with clonal analysis

We describe a hepatocellular carcinoma partially surrounded by focal nodular hyperplasia in a 65-year-old female patient. In order to clarify the relationship of the hepatocellular carcinoma and the adjacent focal nodular hyperplasia, clonal analysis was conducted. The clonal analysis was based on the methylation pattern of the polymorphic X-chromosome-linked androgen receptor gene (HUMARA). The allelic bands from the amplification of the focal nodular hyperplasia and of the hepatocellular carcinoma showed a significant reduction in the intensity of one of the two alleles as compared with two alleles of equal intensity in the buff coat after HhaI digestion, which indicated that these two parts were monoclonal. However, the inactivated allele in the focal nodular hyperplasia and that in the hepatocellular carcinoma were not identical. Therefore, the focal nodular hyperplasia and hepatocellular carcinoma probably derived from the clonal expansion of two different clones.

Follicular dendritic cell tumor of the liver: a clinicopathologic and Epstein-Barr virus study of two cases

Two cases of hepatic follicular dendritic cell (FDC) tumor are described. Both patients were female, aged 57 and 51 years. They presented with epigastralgia or abdominal fullness and weight loss. The first patient refused surgical resection. She developed progressive polyclonal gammopathy and then bilateral purpura over the legs. Skin biopsy revealed leukocytoclastic vasculitis with granular vascular deposits of IgA and C3. The second patient had marked peripheral blood and tissue eosinophilia. The histological diagnosis was confirmed by positive staining for CD21 and CD23. The stromal lymphocytes were predominantly composed of CD3(+)and CD8(+) cells. In situ hybridization for EBER showed a positive nuclear signal in tumor cells but not in inflammatory cells. Polymerase chain reaction amplification for Exon 3 of the latent membrane protein-1 (LMP-1) gene showed a characteristic 30-bp deletion between nucleotides 168282 and 168253, corresponding to the B95-8 sequence. The unique clinicopathological features of our cases have not been reported for FDC tumors before. The clinical significance of the 30-bp deletion in Exon 3 of the LMP-1 gene in FDC tumor of the liver warrants further investigation.

Comparison of coagulation and blood loss during anaesthesia with inhaled isoflurane or intravenous propofol

Propofol has been reported to affect blood coagulation. This prospective, randomized study compared coagulation and blood loss during anaesthetic maintenance with target-controlled intravenous propofol infusion vs. inhaled isoflurane. Thirty-eight ASA I-III patients undergoing head and neck surgery were allocated randomly to receive either inhaled isoflurane at end-tidal concentration 1-1.5% (group I, n=20) or target-controlled infusion (TCI) of propofol at target concentration 2-5 microg ml(-1) (group P, n=18). Thrombelastography on recalcified whole blood was performed pre-induction, and at 15, 30, 60, 90, 120 min post-induction and 30 min after anaesthesia in both groups. Blood loss was estimated from weighing swabs and the volume in suction bottles. Induced hypotension was not used, and perioperative body temperature was similar between groups. There were no significant differences in thrombelastographic coagulation (R-time, K-time, maximum amplitude and angle) or fibrinolytic variables (lysis index at 30 and 60 min) at all times between groups. Total blood loss was also not significantly different (median group I: 350 ml, range 20-1200 ml; group P: 200 ml, range 50-800 ml). Shortening of R-time and widening of angle developed over time in both groups (P<0.05 groups I and P, repeated measures ANOVA). We conclude that maintenance of anaesthesia with propofol TCI at 2-5 microg ml(-1) does not cause detectable coagulation changes on thrombelastography nor increase surgical blood loss when compared to inhaled isoflurane.

Preoperative Multidimensional Affect and Pain Survey (MAPS) scores predict postcolectomy analgesia requirement

OBJECTIVES

One aim of this study was to evaluate the relation of scores on the Multidimensional Affect and Pain Survey (MAPS) that was administered before surgery to postoperative morphine consumption and patient-controlled analgesia. A second aim of the study was to compare the ability of MAPS administered postsurgery with the commonly used Numerical Pain Rating Scale to predict patient-controlled analgesia behavior.

DESIGN

The MAPS questionnaire measures pain, suffering, and well-being. It was administered to patients 1 day before and 1 day after left hemicolectomy for colon cancer. The relations of the two scores to postoperative pain control were determined.

PATIENTS

Thirty-four patients in the surgical ward of a general hospital admitted for colorectal cancer surgery participated in this study.

RESULTS

High preoperative MAPS scores on sensory and emotional words predicted postoperative morphine dosage, dose presses, and lockout presses. Greater morphine consumption was correlated positively with high presurgery MAPS scores in four of the eight "Suffering" subclusters (Depressed Mood, Anger, Anxiety, and Fear). High presurgery MAPS scores in 13 of the 17 "Sensory Qualities" subclusters (e.g., Bothersome, Intense Pain, Pain Extent, Incisive Pressure, Traction/Abrasion) were correlated positively with lockout presses. Neither the postsurgery MAPS nor the postsurgery Numerical Pain Rating Scale predicted patient-controlled analgesia behavior.

CONCLUSION

The emotional states and attitudes of the patients toward pain before surgery are important factors in determining patient-controlled analgesia pressing behavior and postoperative demand for analgesics.

Effect of pre-incision skin infiltration on post-hysterectomy pain--a double-blind randomized controlled trial

In this double-blind placebo-controlled randomized trial, we compared the analgesic effect of preoperative 0.25% bupivacaine (n = 21) skin infiltration with normal saline (n = 19) in patients undergoing abdominal hysterectomy through a lower midline incision. All patients received postoperative patient-controlled analgesia with morphine and were followed for 72 hours. The main outcome measures were morphine consumption and pain score at rest, and the contribution of different components of pain was also assessed prospectively. No statistically significant differences were found. All except one patient (n = 39) could distinguish the different characteristics of somatic and visceral pain. Visceral pain predominated in the first 48 hours. We concluded that local anaesthetic infiltration is not effective in reducing pain after abdominal hysterectomy. Effective postoperative analgesia should aim to eliminate the visceral pain component.

Biliary hamartomas associated with biliary stones presenting as multiple microabscesses: case report

A 63-year-old men suffered from fever, jaundice, and right upper quadrant pain for 1 week. Biliary stones with biliary tract infection were diagnosed. He was treated with parenteral antibiotics. However, abdominal ultrasonography showed multiple hyperechoic lesions in both lobes, and infiltrating hepatocellular carcinoma was suspected initially. Numerous hypervascular nodular-enhancing lesions were revealed by computed tomography. Magnetic resonance imaging further disclosed numerous tiny cystic lesions with peripheral enhancement. Exploratory laparotomy was performed for biliary calculi and probable underlying malignancy. Cholecystectomy, choledocholithotomy, and liver wedge biopsy were done. The pathology revealed bile duct hamartomas with microabscess formation. The past literature about biliary hamartomas is reviewed.

Adrenal ganglioneuroma: report of five cases

Adrenal ganglioneuromas are rare tumors originating from the neural crest tissue of the sympathetic nervous system. The clinical presentation of most patients is asymptomatic, and most of these tumors are hormone silent. Usually the tumor is detected incidentally by abdominal imaging studies for unrelated reasons. Herein, we review our cases of adrenal ganglioneuroma over the past 20 years. All patients diagnosed with primary adrenal ganglioneuroma between 1979 and 1999 were reviewed. There were 5 cases of pathologically confirmed adrenal ganglioneuroma. All patients underwent surgical excision of the adrenal tumors. The mean age of the 5 patients (3 women and 2 men) was 27 years (range, 11 to 45 years). The average diameter of the tumor was 8.2 cm (range, 6 to 10 cm). The mean follow-up period was 33.6 months (range, 3 to 92 months). One case involved mesenteric lymph nodes. This patient had persistent hypertension following the operation, but no evidence of tumor recurrence was noted over the 7-year follow-up period. The prognosis was excellent after surgical excision in our series. Awareness of this rare entity may add to the differential diagnoses of adrenal masses preoperatively.

Combined effect of isoflurane and esmolol on sympathetic responses to tracheal intubation

BACKGROUND

Influences of isoflurane and esmolol on endotracheal intubation induced sympathetic changes could be different. The effect of isoflurane and its combination with esmolol on catecholamine, blood pressure and pulse during endotracheal intubation were investigated.

METHODS

Thirty patients were anesthetized with 3.0% isoflurane and tracheal intubation was carried out at the 5th min following the exposure to isoflurane. Half of them received intravenous saline and the other half received esmolol 2 mg/kg at the 4th min. Cardiovascular parameters were recorded and venous blood samples were taken for measurement of catecholamines every min.

RESULTS

One min after administration of isoflurane, there was increase of heart rate (P < 0.05), while at the same time the epinephrine level fell (P < 0.05) and norepinephrine level remained unaltered. Both catecholamines raised after intubation (P < 0.05). The sympathetic responses to and the beta-antagonistic effect of esmolol on intubation were not significantly changed in the presence of isoflurane.

CONCLUSIONS

Isoflurane increased heart rate while paradoxically decreased epinephrine. Norepinephrine was more specifically related to endotracheal intubation, for its serum level had little change before the event. Based on catecholamine findings, the mechanism of isoflurane effect on the sympathetic system is probably different from that of endotracheal intubation.

Morphine and methadone have different effects on calcium channel currents in neuroblastoma cells

Using patch-clamp technique, cellular calcium channel currents were studied on nine mouse neuroblastoma N1E115 cells. Both morphine and methadone decreased the T-type calcium currents in dose-dependent fashion. These effects were partially blocked by naloxane. On L-type calcium currents, morphine showed no effect. However, methadone inhibited the L-calcium currents in dose-dependent fashion. This effect was not antagonised by naloxone. Hence, the action of methadone on L-calcium channel is probably not associated with mu receptors.

Coagulation and cytokine profile after major hepatobiliary surgery in Chinese patients

BACKGROUND/AIMS

Hypercoagulability and increased circulating cytokine levels have been separately reported after surgical operations. We investigated whether the cytokine level and postoperative coagulation profile would change similarly in Chinese patients undergoing major hepatobiliary surgery.

METHODOLOGY

Serial serum levels of IL-6, IL-1 beta and TNF-alpha were measured by colorimetric ELISA. Serial coagulation profile was measured by thrombelastography. Hemoglobin and white cell counts were also measured serially.

RESULTS

Only mild hypercoagulability was found at the 12th and 144th hours, evidenced by shortening of r-time and k-time on thrombelastography (P < 0.05). IL-6 and IL-1 beta levels were significantly raised from the 12th hour (P < 0.01) while TNF-alpha level was unchanged. From the 3rd hour to the 48th hour, there was negative correlation between IL-6 levels and various thrombelastographic parameters such as coagulation index (r = -0.777, P < 0.001); k-time (r = 0.478, P < 0.05); maximum amplitude (r = -0.688, P < 0.01) and angle (r = -0.665, P < 0.01).

CONCLUSIONS

We observed a much milder degree of hypercoagulability in Chinese patients after major hepatobiliary surgery as compared to those reported in other operations in non-Chinese patients. Unlike in sepsis where a close link between increased cytokine levels and hypercoagulability has been reported, increase in IL-6 was associated with less hypercoagulability in Chinese patients after major hepatobiliary surgery.

Mutational analysis of the p27(kip1) gene in hepatocellular carcinoma

p27(Kip1) is an inhibitor of cyclin-dependent kinase. It has been reported that reduced p27(Kip1) expression is present in human hepatocellular carcinoma. To determine the role of p27(Kip1) in hepatocarcinogenesis, 46 cases with hepatocellular carcinomas were studied. p27(Kip1) mutation was first screened by single strand conformation polymorphism, and direct DNA sequencing was then performed on those cases with mobility shifts. Two polymorphism sites were found. One is a previously described polymorphism at codon 109 (GTC-->GGC) which was found in two cases. The second polymorphism was identified at codon 55 (GCG-->GCA) in six of the 46 cases. However, the polymorphism at codon 55 was also present in seven of 93 healthy controls (7.5%), indicating that it is not associated with a predisposition for development of hepatocellular carcinoma (Fisher's exact test, 0.05). These results show that p27(Kip1) mutation is not a frequent event in human hepatocellular carcinoma, and suggest that it may be inactivated predominantly by transcriptional and/or posttranscriptional regulation rather than genomic aberrations.

p16INK4 gene mutation and allelic loss of chromosome 9p21-22 in Taiwanese hepatocellular carcinoma

BACKGROUND

The p16INK4 (MTS1/CDNK2A) gene, located on chromosome 9p21, is an inhibitor of cyclin-dependent kinase 4. Various data have shown that it is frequently inactivated in several types of cell lines and primary human cancers.

MATERIALS AND METHODS

Thirty cases with hepatocellular carcinoma were studied for possible p16INK4 gene mutation in Taiwan. Homozygous deletion was determined using polymerase chain reaction (PCR). The p16INK4 gene mutation was first screened by single strand conformation polymorphism, then direct DNA sequencing was performed on the cases with mobility shifts. Deletion mapping of chromosome 9p21-22 was also carried out with two polymorphic microsatellite markers (D9S925 and D9S168) using PCR.

RESULTS

One of the 30 cases had homozygous deletion at exon 3 of the p16INK4 gene. Another tumor had altered electrophoresed mobility in exon 2 with G to T transversion in the first nucleotide of codon 61 by direct sequencing causing a stop codon (GAG-->TAG). At the D9S925 and D9S168 loci, six out of 24 (25%) and three out of 19 (16%) informative cases showed loss of heterozygosity, respectively.

CONCLUSION

Point mutation and homozygous deletion of the p16INK4 gene are present in a subset of hepatocellular carcinomas in Taiwan. The patterns of the p16INK4 gene alteration are, however, different from those from other regions. In addition, allelic loss on chromosome 9p21-22 is not an uncommon event in hepatocellular carcinomas. Therefore, the significance of chromosome 9p loss deserves to be extensively investigated.

Determination of interactions between human thrombopoietin and its receptor MPL by yeast two-hybrid system and affinity biosensor

The binding of human thrombopoietin to the extracellular domain of its receptor MPL prompts a cascade transduction of intracellular signals, leading to the development of megakaryocyte precursors and the production of circulating platelets. We have used a yeast two-hybrid system to reveal, via in vivo interactions between different deletion constructs of MPL and thrombopoietin, that the extracellular subunit 1 of MPL is the ligand binding site and the N-terminal domain of thrombopoietin alone is sufficient for the binding. The extracellular portion of MPL was heterologously expressed in E. coli and its specific affinity with thrombopoietin was visualized in vitro by resonance mirror biosensor technique.

Adult Wilms' tumor presenting as acute abdomen with elevated serum lactate dehydrogenase-4 and -5 isoenzymes: case report

Wilms' tumor, an embryonic neoplasm, is the most frequent renal tumor in childhood but is rare in adults. The prognosis of adult Wilms' tumor is worse than pediatric Wilms' tumor. The preoperative diagnosis of adult Wilms' tumor is extremely difficult to make because diagnostic imaging techniques, such as intravenous pyelography, computed tomography, ultrasound, renal angiography, and nuclear magnetic resonance imaging, only confirm the presence of a renal mass. Diagnosis usually depends on histological characteristics, such as the presence of blastemic, epithelial, and mesenchymal components. A 27-year-old female presented with acute abdomen and with elevated serum lactate dehydrogenase (LDH) at 212 U/l (normal range: 47-140), and 2 of 5 LDH isoenzymes, namely LDH-4 at 13.6% (normal range: 6.8%-10.2%) and LDH-5 at 20% (normal range: 6.5%-9.7%). In this patient, stage I Wilms' tumor was managed by radical nephrectomy. The levels of LDH returned to its normal range. In conclusion, in cases of acute abdomen with a renal mass in young adults, the possibility of Wilms' tumor should be considered. Serum LDH and its isoenzymes, LDH-4 and LDH-5, could be used as tumor markers for either differential diagnosis or monitoring the response of treatment.

Prevention of postoperative nausea and vomiting in gynaecological laparotomies: a comparison of tropisetron and ondansetron

In a randomized, double-blind study, the antiemetic efficacy of a single bolus of tropisetron 5 mg (group T, 37 patients), ondansetron 4 mg (group O, 39 patients) or saline (group C, 45 patients) given at induction was compared in a homogeneous group of 121 patients undergoing gynaecological laparotomy and receiving postoperative patient-controlled intravenous morphine for 24 to 48 hours. Fewer group T and group O patients developed severe nausea compared to group C (P < 0.01, log rank test in Kaplan-Meier analysis). Group T patients also had lower nausea scores than group O at 8 to 16h (P < 0.05). The overall incidences of severe nausea in groups T, O, and C were 5.4%, 17.9%, and 44.4% respectively (P < 0.001, group T vs group C; P < 0.05 group O vs group C). In conclusion, the 5-hydroxytryptamine 3 receptor antagonists tropisetron and ondansetron were superior to placebo in preventing PONV.

Partial nephrectomy for incidental primary renal neuroendocrine carcinoma: case report

Here we present an 83-year-old woman who was referred to our hospital and had had left flank pain and oligouria for 3 days. Plain abdominal film and ultrasonography revealed left ureteropelvic junction stone with obstructive uropathy. The serum level of creatinine fell to 3.1 mg/dl from 7.6 mg/dl after ureteral catheter drainage was given 5 days after admission. Then a left pyelolithotomy was performed and a tumor of 2 x 1 x 1 cm over the lower pole of the left kidney was found incidentally. Partial nephrectomy was performed in consideration of her age and poor renal function although the biopsy result showed it to be carcinoma. The final pathological report and immunohistochemical study results proved that it was neuroendocrine carcinoma. To our knowledge, this is the first case of primary renal neuroendocrine carcinoma to be treated using conservative surgery. The clinical course was acceptable, since she had been found to be free of disease during regular follow-up of 2.5 years with the creatinine level of about 2.5 mg/dl.

Control of shivering under regional anesthesia in obstetric patients with tramadol

PURPOSE

Tramadol in a dose of 1 mg x kg(-1) iv is effective in the treatment of shivering after general anesthesia. The current study aimed to investigate (1) whether tramadol was equally effective for shivering under regional anesthesia in obstetric patients and (2) whether effective treatment could be achieved with lower doses.

METHODS

In a randomised, double-blind study, 36 obstetric patients who shivered during Cesarean section under regional anesthesia and who requested anti-shivering treatment were allocated to one of three groups for iv treatment: Group T0.5 received tramadol 0.5 mg x kg(-1) (n = 12), Group T0.25 tramadol 0.25 mg x kg(-1) (n = 13) and Group NS normal saline 0.05 ml x kg(-1) (n = 11). Treatment efficacy was evaluated subjectively by the parturient as no improvement, slight improvement, or marked improvement. The attending anesthesiologist who was blinded also independently noted the time elapsed from treatment to the time shivering subsided. Side effects such as nausea, vomiting or sedation and Apgar scores of the newborn were also noted.

RESULTS

Eighty percent of parturients in Group T0.5 and 92% in Group T0.25 were judged by observers to have shivering controlled compared with 27% in Group NS (P < 0.001). The response rates of Group T0.5 and Group T0.25 were not different. There was no increased incidence of side effects in the treatment groups.

CONCLUSION

We conclude that tramadol iv was effective in the treatment of intraoperative shivering during regional anesthesia for Cesarean section. There was no demonstrable difference in response rate or incidence of side effects between the two doses of 0.5 mg x kg(-1) and 0.25 mg x kg(-1).

Thrombelastographic patterns during cryotherapy for recurrent hepatocellular carcinoma

A cirrhotic patient with recurrent hepatocellular carcinoma and thrombocytopenia undergoing cryotherapy showed: 1) transient hyperfibrinolysis shortly after platelet transfusion, and 2) evidence of activation of coagulation after freezing and thawing of tumor as measured on the thrombelastography. No anti-fibrinolytic treatment was required for the hyperfibrinolysis which subsided spontaneously in this patient. This case report highlights that: 1) in patients with chronic liver disease, platelet transfusion might potentially worsen rather than improve the hemostatic function by activation of fibrinolysis, and 2) activation of coagulation may underlie the perioperative coagulation changes seen in cryotherapy.

Absence of APC gene mutation in the mutation cluster region in hepatocellular carcinoma

APC gene mutations have been demonstrated not only in colorectal carcinoma but also in a variety of human cancers. To define the possible role of mutations of the APC gene in hepatocarcinogenesis, we examined 46 pairs of hepatocellular carcinomas and corresponding non-tumorous liver tissue by polymerase chain reaction and single strand conformation polymorphism. All 46 hepatocellular carcinomas had no altered electrophoretic mobility to suggest the presence of APC gene mutation in the mutation cluster region. We also examined the possible loss of heterozygosity of APC and MCC gene loci by fragment length polymorphism analysis and by polymerase chain reaction. None of the cases showed a loss of heterozygosity at the APC and MCC gene loci. The results suggested that the possibility of APC and MCC as the gene defect in the genesis of human hepatocellular carcinoma may be very rare.

Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraoperative loading with morphine

Thirty-eight ASA I-III patients undergoing lower abdominal operations were randomly allocated to receive either morphine (group M, patient-controlled analgesia bolus = 1 mg of morphine) or tramadol (group T, patient-controlled analgesia bolus = 10 mg of tramadol) for post-operative patient-controlled analgesia (PCA) after receiving morphine intraoperatively. There were no between-group differences in the pain, sedation or vomit scores. The nausea scores were significantly higher in group T in the initial 20 h and between 32 and 36 h (P < 0.01, 0-4 and 8-12 h; P < 0.05, 4-8, 12-16, 16-20 and 32-36 h). The incidence of dizziness was also significantly higher in group T (68.4% vs. 31.6%, group T vs. group M, P < 0.05). There was no difference in the overall satisfaction. We conclude that the use of tramadol, compared with morphine, for post-operative PCA after intraoperative loading with morphine is associated with more nausea and dizziness, but with similar sedation, quality of analgesia and patient satisfaction.

Solitary extramedullary plasmacytoma in the retroperitoneum

Solitary extramedullary plasmacytoma is an uncommon neoplasm and occurs most frequently in the upper respiratory tract. Herein, we reported a solitary extramedullary plasmacytoma in the retroperitoneum. A 28-year-old man presented with obstructive jaundice and a retroperitoneal tumor. Ultrasound-guided biopsy confirmed that the lesion was a plasma cell neoplasm. A detailed investigation showed that no other sites were involved. The tumor got a moderate reduction following local irradiation, and a complete remission was achieved after 12 courses of adjuvant chemotherapy. Therefore, the possibility of a solitary extramedullary plasmacytoma should be considered in the differential diagnosis of obstructive jaundice without a history of multiple myeloma.

An audit of the safety of an acute pain service

We audited and analysed the adverse effects and safety of postoperative pain management on 2509 consecutive patients under care of the Acute Pain Service at a tertiary referral teaching hospital over a 32-month period. Our standard respiratory monitoring consisted of continuous pulse oximetry, hourly respiratory rate counting, sedation scoring and intermittent arterial blood gas sampling. This protocol was reliable and detected six episodes of bradypnoea, 13 of hypercapnia and 23 of oxygen desaturation occurring in 39 patients (1.8% of all spontaneously breathing patients). Two patients required naloxone injection and none had long-term sequelae. Hypotension due to epidural bupivacaine 0.0625% and fentanyl 3.3 micrograms.ml-1 infusion occurred in four patients (1.2%), all with a sensory block higher than T5. They readily responded to fluid infusion and ephedrine (two patients). Postoperative nausea or vomiting occurred in 723 (28.8%) and 380 (15.1%) patients, respectively. Odds ratio analysis showed that the risk factors for postoperative nausea and vomiting were: female gender, gynaecological operations, nongeriatric patients and systemic analgesia. Postoperative nausea and vomiting decreased analgesic efficacy by discouraging the use of patient-controlled analgesia and was regarded as equally distressing as pain. Other side-effects included: pruritus in 182 patients; dizziness in 333 and lower limb weakness in 73 (21.2% of patients receiving epidural local anaesthetics). It is concluded that a standard monitoring and management protocol, an experienced nursing team and reliable Acute Pain Service coverage is mandatory for the safe use of modern analgesic techniques.

Epidural infusion of bupivacaine 0.0625% plus fentanyl 3.3 micrograms/ml provides better postoperative analgesia than patient-controlled analgesia with intravenous morphine after gynaecological laparotomy

One hundred and twenty women undergoing gynaecological abdominal operations were randomized to receive either epidural bupivacaine 0.0625% + fentanyl 3.3 micrograms/ml infusion (Group EPI, n = 57), or patient-controlled intravenous morphine analgesia (Group PCA, n = 54) for postoperative pain relief. The groups were comparable in demographic data, types and duration of operation. Group EPI achieved significantly lower verbal rating scale of pain (VRS) at rest at 0, 4, 12, 16, 20, 28 and 40th postoperative hours. The VRS during cough were also significantly lower in Group EPI at 0, 4, 8, 12, 28 and 36th postoperative hours. None of the patients had respiratory depression or hypotension. Nausea/vomiting occurred in 52.6%/33.3% of patients in Group EPI and 52.7%/37.0% in Group PCA. Most patients (84.2% in Group EPI and 72.2% in Group PCA) rated their pain management as "good". We conclude that epidural infusion of bupivacaine 0.0625% and fentanyl 3.3 micrograms/ml provide better analgesia than patient-controlled intravenous morphine after gynaecological laparotomy.

Comparison of tramadol and tramadol/droperidol mixture for patient-controlled analgesia

PURPOSE

To compare the analgesic efficacy and side effects of tramadol vs tramadol and droperidol for post-operative patient-controlled analgesia (PCA).

METHODS

Randomised, double-blind study. Thirty-four patients undergoing elective colorectal or head and neck surgery were allocated to Group 1 (n = 18, PCA bolus 10 mg tramadol) or Group 2 (n = 16, PCA bolus 10 mg tramadol + 0.1 mg droperidol). Anaesthesia was induced with fentanyl and thiopentone and maintained with O2, N2O plus enflurane or isoflurane with iv morphine at doses decided by the attending anaesthetists. Muscle relaxation was achieved with atracurium or vecuronium. Patients were observed four-hourly for pain using an 11-point verbal rating scale (VRS). Nausea and vomiting, and sedation were assessed using four-point scales post-operatively. Vital signs, request for rescue anti-emetic and analgesic, and overall satisfaction were recorded.

RESULTS

The mean nausea scores were lower in Group 2 (1.00 +/- 1.33 vs 0.06 +/- 0.25 at 0-8 hr, 1.22 +/- 1.93 vs 0.06 +/- 0.25 at 8-16 hr, P < 0.01; 0.81 +/- 1.68 vs 0 at 32-40 hr, P < 0.05; Group 1 vs Group 2). The vomiting scores were also lower (0.50 +/- 1.04 vs 0 at 0-8 hr, 0.67 +/- 1.50 vs 0, at 8-16 hr, P < 0.05; Group 1 vs Group 2). Seven (39%) patients in Group 1, but none in Group 2 requested rescue anti-emetic (P < 0.01). There were no differences in VRS, sedation score, overall satisfaction or vital signs.

CONCLUSION

Tramadol and droperidol combination is superior to tramadol alone for post-operative PCA. It provides a similar quality of analgesia with less nausea and vomiting and without an increase in sedation.

The efficacy, applicability and side-effects of postoperative intravenous patient-controlled morphine analgesia: an audit of 1233 Chinese patients

We analyzed data from 1233 Chinese patients of a wide age range who received patient-controlled analgesia (PCA) intravenous morphine for postoperative pain relief, during the period of January 1992 to May 1995. The analgesic regimen was standardized as follows: PCA bolus 1 to 1.5 mg; lock-out interval 5 minutes; one-hour maximum dose 0.075 to 0.1 mg.kg-1 and background infusion 0 or 0.5 mg.h-1. Most patients underwent major surgery that was broadly subclassified according to the anatomical area involved. The median verbal numerical rating scales of pain (0 to 10) at rest and while coughing for the first, second and third 24 hours were 3.0/5.0, 1.5/4.0 and 0/3.0 respectively and the corresponding demand to delivery ratios were 2.8 +/- 2.9, 2.6 +/- 2.4 and 2.4 +/- 2.6. The overall morphine consumptions in 1004 of these Chinese patients were 27.5 +/- 16.8, 17.8 +/- 16.1 and 18.1 +/- 21.0 micrograms.kg-1.h-1 during the first 16, 17 to 41 and 42 to 66 postoperative hours respectively. These figures were the same as for Caucasian patients managed in the same institution. Morphine consumption was significant higher following thoracic, upper abdominal and spinal surgery. Also it was higher in patients younger than 65 years, males, cigarette smokers and those with ASA physical status I or II. The commonest side-effects were nausea (34.5%) and vomiting (18.2%). Bradypnoea and oxygen desaturation occurred in 0.5% and 1.6% respectively. All cases were promptly detected and managed with no adverse outcomes. Most patients were satisfied (76.7% ranked "good") with their postoperative analgesia. The commonest reasons for dissatisfaction were inadequate pain relief, nausea and reluctance to self-control analgesic administration. It is concluded that PCA with intravenous morphine is effective and safe as a routine postoperative technique for Chinese surgical patients.

The bamboo skewer: airway management in a patient with penetrating injury of the floor of mouth

PURPOSE

To report a safe airway management option in patients with penetrating injury of the floor of the mouth, reinforcing the similar experience of others and illustrating the importance of proper assessment and planning before airway negotiation.

CLINICAL FEATURES

A 23-yr-old man was admitted with a penetrating injury of the floor of mouth caused by falling on bamboo and with the foreign body in situ. The extent of penetration could not be assessed clinically but computerized tomography (CT) was used to assist in preoperative evaluation of the airway. After atropine iv, fentanyl iv, topical cocaine and lidocaine spray, awake fibreoptic guided nasal intubation was performed successfully and the patients airway secured before induction of anaesthesia. Elective tracheostomy was performed postoperatively which was removed on day 5. Post-operative recovery was uneventful.

CONCLUSION

Awake fibreoptic guided nasal intubation was useful in managing the airway of a patient with a penetrating injury of the floor of mouth and foreign body in situ. Thorough previous evaluation of the patients airway by CT scan, careful topicalisation of the airway, and judicious use of iv sedation and anti-sialogue contributed to the safe and successful airway management.

Malakoplakia of urinary tract: report of two cases with emphasizing the histologic spectrum and the morphogenesis of Michaelis-Gutmann bodies

Two cases of urinary tract malakoplakia, one in right kidney and the other one in urinary bladder, were reported. Both cases affected middle-aged female patients with long-term urinary tract infection. Their clinical presentation simulated a neoplasm. The diagnosis entirely depended on pathologic examination. The former case also extensively involved the retroperitoneum, liver and duodenum. The latter case was unusually associated with Pseudomonas infection. Electron microscopy showed that the morphogenesis of Michaelis-Gutmann bodies occurred within the phagolysosomes. Initially, small myelin-like figures-containing phagolysosomes were undergoing to fuse to form a large one. Then, the membranous fragments and myelin-like figures served as nucleation sites. The nucleation sites could be multiple in the same phagolysosome. Needle shaped crystalline material began to deposit by unknown mechanism. Finally, mature Michaelis-Gutmann bodies were well formed. But no bacteria were identified. The two cases were successfully managed with surgical resection then sulfamethoxazole-trimethoprim treatment. Finally, it was emphasized that frozen section of tumor biopsy avoided unnecessary radical surgery in the latter case.