External Validation of the Graded Prognostic Assessment for Patients with Non-Small Cell Lung Cancer and Brain Metastases Using Molecular Markers (Lung-molGPA)

PURPOSE/OBJECTIVE(S)

Patients with non-small cell lung cancer (NSCLC) and brain metastases represent a markedly heterogeneous population. The original diagnosis-specific graded prognostic assessment is a prognostic index based on data from patients diagnosed between 1985 and 2005 and includes patients age, performance status, extracranial disease, and number of brain metastases. An updated prognostic index (Lung-molGPA) that incorporates molecular features (EGFR and ALK alterations) was created in 2016 based on the North American retrospective database analysis of 2186 patients with NSCLC and newly diagnosed brain metastases between 2006 and 2014. The aim of this study is to validate the Lung-molGPA model in an independent Asian patient population.

MATERIALS/METHODS

Four hundred thirty-three patients (368 adenocarcinoma and 65 nonadenocarcinoma) with NSCLC with newly diagnosed brain metastasis between 2005 and 2017 were reviewed retrospectively and scored using the Lung-molGPA model.

RESULTS

The overall median survival for the cohort in the present study was 14 months (16.5 months in the adenocarcinoma and 8.0 months in the nonadenocarcinoma, respectively; p = 0.003). For patients with adenocarcinoma, the median survival for patients with a Lung-molGPA score of 3.5 to 4.0 was 44.7 months, while the median survival was only 8.9 months in patients scoring 0-1.0, 17.0 months in patients scoring 1.5-2.0, and 30.2 months for scores of 2.5-3.0 (p <0.0001). For patients with nonadenocarcinoma, the median survival for scores 0-1.0, 1.5-2.0, and 2.5-3.0 were 6.7, 10.3, and 13.2 months, respectively (p = 0.038).

CONCLUSION

Survival for patients with NSCLC and brain metastases varies widely. This study provides an independent validation of the 2016 Lung-molGPA in Asian patients.

Slow advancement of the endotracheal tube during fiberoptic-guided tracheal intubation reduces the severity of postoperative sore throat

Although fiberoptic-guided tracheal intubation is a gentler method than using a direct laryngoscope, injury may occur owing to impingement between the distal edge of the endotracheal tube and the glottis. This study aimed to investigate the effects of endotracheal tube advancement speed during fiberoptic-guided intubation on airway symptoms postoperatively. We randomized patients scheduled for laparoscopic gynecological surgery to either Group C or S. When advancing the tube over the bronchoscope, the operator advanced the tube at a normal speed in Group C and at a slower speed in Group S. The speed in Group S was approximately half that in Group C. The target outcomes were the severity of postoperative sore throat, hoarseness, and cough. Patients in Group C experienced a more severe sore throat than those in Group S at 3 and 24 h postoperatively (p = 0.001 and p = 0.012, respectively). However, the severity of hoarseness and cough postoperatively were not significantly different between the groups. In conclusion, the slow advancement of the endotracheal tube during fiberoptic-guided intubation can reduce sore throat severity.

Effects of bevel direction of endotracheal tube on the postoperative sore throat when performing fiberoptic-guided tracheal intubation: A randomized controlled trial

BACKGROUND

During fiberoptic-guided tracheal intubation, impingement between the distal tip of the endotracheal tube and the airway tissue can cause difficulties in tube insertion or tissue damage during the tube advancement over the bronchoscope. This randomized controlled study aimed to investigate the effects of the endotracheal tube's bevel direction on the complications associated with airway injury when performing fiberoptic-guided tracheal intubation.

METHODS

The study subjects were divided into 2 groups: L (control) and D (study). When advancing the tube over the bronchoscope, the tube's bevel was facing the patients' left in Group L and the dorsal direction in Group D. According to the degree of resistance at the time of tube advancement, the insertion score was graded in 3 stages; the severity of the patients' sore throat and hoarseness was evaluated and recorded postoperatively.

RESULTS

The severity of postoperative sore throat was higher in Group L than in Group D 3 hours and 24 hours after surgery. (P = .008, P = .023, respectively). The tube insertion score was comparable between the groups. The severity of postoperative hoarseness did not vary significantly between the groups.

CONCLUSION

Endotracheal tube insertion with the bevel facing the dorsal direction of the patient during fiberoptic-guided tracheal intubation reduced the severity of postoperative sore throat in patients undergoing laparoscopic gynecologic surgery.

Sudden arrhythmia in the prone position during spinal surgery: A case report

RATIONALE

The prone position is the most commonly required position during spinal surgery. Decreasing lumbar lordosis is necessary to facilitate the accessibility of the surgical field. And this can affect the hemodynamic circulation of the patients. The Jackson spine table is one of the most preferred methods, known to have minimal effects on cardiac function.

PATIENT CONCERNS

We report a case of sudden arrhythmia that developed during the prone position using a Jackson spine table. It occurred 30 minutes after the positional change.

DIAGNOSES

Arrhythmia showed bizarre P and QRS waves. Ectopic P, bundle branch block, or both was suspected.

INTERVENTIONS

Because it was difficult to define the exact type or cause of this sudden arrhythmia and considering that other vital signs remained stable, we decided to keep close observation during the operation rather than applying uncertain antiarrhythmic medication.

OUTCOMES

Arrhythmia spontaneously developed and subsided repeatedly. And it recovered to normal sinus rhythm immediately after the positional change to the supine position. Therefore, increased intrathoracic pressure caused by the prone position was highly suspected to be the cause of this event.

LESSONS

Although the Jackson spine table is known to have the least effect on cardiac function, the patient experienced arrhythmia in our case. Hence, to achieve better clinical outcomes, an understanding of physiological alterations and possible complications caused by the prone position is necessary for earlier diagnosis and management.

Cardiac Perforation Caused by Bone Cements as a Complication of Cement Augmented Pedicle Screw Fixation Using the Fenestrated Pedicle Screw: A Case Report

Cement-augmented fenestrated pedicle screw fixation is becoming more popular for osteoporotic patients. Although several reports have been published on leakage-related problems with bone cement, no cases of cardiac perforation after cement-augmented pedicle screw fixation have been reported. We present a case of cardiac perforation after cement-augmented fenestrated pedicle screw fixation. A 67-year-old female was admitted to our hospital with complaints of dyspnea and chest pain after lumbar surgery. She had been treated with L4-5 lumbar interbody fusion and percutaneous pedicle screw fixation with bone cement augmentation seven days earlier for degenerative spondylolisthesis. The right chest pain was observed a day after the surgery; she was treated conservatively but it did not improve for 7 days after surgery. Chest computed tomography (CT) revealed a hemothorax and a large sharp bone cement fragment that perforated the right atrium. Bone cement can be removed with thoracotomy surgery. We have to be aware of cement leakage through the normal venous drain system around the vertebral body. We also have to consider a detailed cardiac workup, which may include chest CT or echocardiography, if a patient complains of chest pain or dyspnea after cement augmentation.

Role of Remote Ischemic Preconditioning in Hepatic Ischemic Reperfusion Injury

The effect of remote ischemic preconditioning (RIPC) has been proposed that mediates the protective response in ischemia reperfusion injury (IRI) of various organs. In this study, we investigated the effect of RIPC in hepatic IRI, by assessing biomarker of oxidative stress and inflammatory cytokines. Moreover, we intended to demonstrate any such protective effect through nitric oxide (NO). Twenty-five rats were divided into the 5 groups: (1) Sham; (2) RIPC; (3) hepatic IRI; (4) RIPC + hepatic IRI; (5) C-PTIO, 2-(4-carboxyphenyl)-4,5dihydro-4,4,5,5-tetramethyl-1H-imidazolyl-1-oxy-3oxide, + RIPC + hepatic IRI. RIPC downregulated the level of aspartate aminotransferase (AST), alanine aminotransferase (ALT), histologic damage, and activity of Malondialdehyde (MDA). However, there was no significant reduction in the level of tumor necrosis factor-alpha (TNF-α) and nuclear factor kappa B (NF-κB). AST and ALT levels, and hepatic tissue morphology in the C-PTIO group showed a significant improvement compared to those of the RIPC + hepatic IRI group. The application of RIPC before hepatic ischemia downregulated the oxidative stress, not the inflammatory cytokines. Moreover, these protective effect of RIPC would be mediated through the activation of NO as well as anti-oxidant effect.

Failure to awaken from general anesthesia due to infratentorial hemorrhage after cervical spine surgery: A case report

RATIONALE

Emergence is not simply the reverse process of induction. Many dynamic situations could occur in this period by distinct neurobiology as recent studies indicated. Herein we report a rare case of failure of emergence from general anesthesia after cervical spine surgery.

PATIENT CONCERNS

Despite the perioperative vital signs and laboratory results were unremarkable, the patient could not recover his mental status and spontaneous breathing during emergence. 20 minutes after cessation of anesthetic drug administration, his blood pressure suddenly began to decrease requiring transfusion and vasopressor.

DIAGNOSIS

After thorough inspection of intraoperative alterations of hemodynamic and metabolic values, which showed no significant changes except possible signs of delayed volume loss, cerebrovascular bleeding was most suspected as the cause of the event. Computed tomography was performed and infratentorial hemorrhage after cervical spine surgery was checked.

INTERVENTIONS

Decompression operation was required for removing the hemorrhage. However, the patient's family refused further management considering his limited life expectancy.

OUTCOMES

The patient expired on postoperative day 5.

LESSONS

Failure to awaken is a relatively rare event. It could be confused with simple delayed emergence, which is often caused by residual drug effect. However, when it occurs, the result could be devastating. Therefore, appropriate recognition and prompt response are required to decrease the mortality and morbidity of the patient.

Traumatic severe tricuspid regurgitation diagnosis after the progression of right ventricle function deterioration

Traumatic tricuspid regurgitation is a rare complication of blunt cardiac injury and frequently misdiagnosed during the initial assessment. Unfortunately, it may be diagnosed after deterioration of right ventricle function, which may be fatal to the patient. Here, we report a case of a patient with blunt chest injury complicated by a diagnosis of traumatic severe tricuspid regurgitation after deterioration of the right ventricle function even after the patient was subjected to serum cardiac enzyme normalization. The patient was a driver and admitted to the hospital owing to multiple traumatic injuries. Echocardiography was performed suspicious of blunt cardiac injury, which revealed no abnormal findings. Initial cardiac enzyme levels were high, but after serial follow-up, the levels improved. However, on day 4 of hospitalization, hemodynamic deterioration occurred owing to severe tricuspid regurgitation and delayed right ventricle dysfunction. Immediate tricuspid valve replacement was performed, however, the patient had a pronged recovery period. We believe that it is important to take into account the nature of the accident and the presentation of clinical signs and symptoms and not be blinded by laboratory test results alone; it is also important to consider performing repeated serial echocardiographic examinations for blunt cardiac injury patients.

Beneficial Role of Hydrogen Sulfide in Renal Ischemia Reperfusion Injury in Rats

PURPOSE

Hydrogen sulfide (H₂S) is an endogenous gaseous molecule with important physiological roles. It is synthesized from cysteine by cystathionine γ-lyase (CGL) and cystathionine β-synthase (CBS). The present study examined the benefits of exogenous H₂S on renal ischemia reperfusion (IR) injury, as well as the effects of CGL or CBS inhibition. Furthermore, we elucidated the mechanism underlying the action of H₂S in the kidneys.

MATERIALS AND METHODS

Thirty male Sprague-Dawley rats were randomly assigned to five groups: a sham, renal IR control, sodium hydrosulfide (NaHS) treatment, H₂S donor, and CGL or CBS inhibitor administration group. Levels of blood urea nitrogen (BUN), serum creatinine (Cr), renal tissue malondialdehyde (MDA), and superoxide dismutase (SOD) were estimated. Histological changes, apoptosis, and expression of mitogen-activated protein kinase (MAPK) family members (extracellular signal-regulated kinase, c-Jun N-terminal kinase, and p38) were also evaluated.

RESULTS

NaHS attenuated serum BUN and Cr levels, as well as histological damage caused by renal IR injury. Administration of NaHS also reduced oxidative stress as evident from decreased MDA, preserved SOD, and reduced apoptotic cells. Additionally, NaHS prevented renal IR-induced MAPK phosphorylation. The CGL or CBS group showed increased MAPK family activity; however, there was no significant difference in the IR control group.

CONCLUSION

Exogenous H₂S can mitigate IR injury-led renal damage. The proposed beneficial effect of H₂S is, in part, because of the anti-oxidative stress associated with modulation of the MAPK signaling pathways.

Treatment of radiation-induced cystitis and vulvodynia via a ganglion impar block using a lateral approach under computed tomography guidance: a case report

Adjuvant radiation therapy (RT) after colorectal cancer surgery can prevent local recurrence, but has several side effects. Precise injection of drugs into the affected areas is complicated by radiation-induced fibrosis of soft or connective tissue. A 48-year-old woman experienced severe intractable perineal pain, dysuria, urinary urgency, and frequent urination after rectal cancer surgery and adjuvant RT, and was diagnosed with radiation-induced cystitis and vulvodynia. Her symptoms persisted despite two fluoroscopy-guided ganglion impar blocks. Fluoroscopy revealed atypical needle tip positioning and radiolucent dye distribution, presumably due to radiation-induced fibrosis in the target region. We performed two computed tomography (CT)-guided ganglion impar blocks by using a lateral approach, which allowed more accurate po-sitioning of the needle tip. Her pain visual analog score decreased from 9 to 3, and she recently resumed sexual intimacy. CT guidance is a viable alternative to fluoroscopy guidance when performing ganglion impar blocks in fibrotic areas.

Non-Anastomotic Rupture of a Woven Dacron Graft in the Descending Thoracic Aorta Treated with Endovascular Stent Grafting

The intrinsic structural failure of a Dacron graft resulting from the loss of structural integrity of the graft fabric can cause late graft complications. Late non-anastomotic rupture has traditionally been treated surgically via open thoracotomy. We report a case of the successful use of thoracic endovascular repair to treat a Dacron graft rupture in the descending aorta. The rupture occurred 20 years after the graft had been placed. Two stent grafts were placed at the proximal portion of the surgical graft, covering almost its entire length.

Inhibition of reactive oxygen species downregulates the MAPK pathway in rat spinal cord after limb ischemia reperfusion injury

INTRODUCTION

We examined the activity of mitogen-activated protein kinase (MAPK) family members, extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), and p38, in rats pinal cord after hind limb ischemia reperfusion (IR) and analyzed the role of reactive oxygen species (ROS) as mediators of MAPK signaling under these conditions.

METHODS

In experiment 1, hind limb IR rats were treated intraperitoneally with one of following agents at 30 min before reperfusion: allopurinol (4, 40 mg/kg), superoxide dismutase (SOD, 4000 U/kg), N-nitro-l-arginine methyl ester (l-NAME, 10 mg/kg), or SOD (4000 U/kg) + l-NAME (10 mg/kg). In experiment 2, 5,10,15,20-tetrakis (N-methyl-4'-pyridyl) porphyrinato iron (III) (FeTMPyP) was administered intraperitoneally (1, 3, or 10 mg/kg) 30 min before reperfusion. After 3 d reperfusion period, the spinal cord (L4-6) was harvested to investigate MAPK signaling activity.

RESULTS

In experiment 1, p-ERK and p-JNK levels were significantly higher in the IR group than sham group. Administration of allopurinol, SOD, l-NAME, or SOD + l-NAME significantly reduced the IR-induced increase in p-ERK and p-JNK levels. There were no significant differences in p-p38 levels. In experiment 2, FeTMPyP significantly reduced the IR-induced increase in p-ERK and p-JNK levels in a dose-dependent manner.

CONCLUSIONS

Activation of ERK and JNK in the spinal cord was induced by hind limb IR and was not accompanied by p38 activation. IR-induced MAPK phosphorylation was reduced by inhibition of superoxide, nitric oxide, and peroxynitrite, indicating that ROS produced by hind limb IR mediate the activation of these signaling pathways in the spinal cord, potentially affecting distant organs.

An insight into the heat and mass transfer mechanisms of eggshells hatching broiler chicks and its effects to the hatcher environment

Thermodynamic study of incubated eggs is an important component in the optimisation of incubation processes. However, research on the interaction of heat and moisture transfer mechanisms in eggs is rather limited and does not focus on the hatching stage of incubation. During hatch, both the recently hatched chick and the broken eggshell add extra heat and moisture contents to the hatcher environment. In this study, we have proposed a novel way to estimate thermodynamically the amount of water evaporated from a broken eggshell during hatch. The hypothesis of this study considers that previously reported drops in eggshell temperature during hatching of chicks is the result remaining water content evaporating from the eggshell, released on the inner membrane by the recently hatched wet chick, just before hatch. To reproduce this process, water was sprayed on eggshells to mimic the water-fluid from the wet body of a chick. For each sample of eggshell, the shell geometry and weight, surface area and eggshell temperature were measured. Water evaporation losses and convection coefficient were calculated using a novel model approach considering the simultaneous heat and mass transfer profiles in an eggshell. The calculated average convective coefficient was 23.9 ± 7.5 W/m(2) °C, similar to previously reported coefficients in literature as a function of 0.5-1m/s air speed range. Comparison between measured and calculated values for the water evaporation showed 68% probability accuracy, associated to the use of an experimentally derived single heat transfer coefficient. The results support our proposed modelling approach of heat and mass transfer mechanisms. Furthermore, by estimating the amount of evaporated water in an eggshell post-hatch, air humidity levels inside the hatcher can be optimised to ensure wet chicks dry properly while not dehydrating early hatching chicks.

Differential profiles of salivary proteins with affinity to Streptococcus mutans lipoteichoic acid in caries-free and caries-positive human subjects

Streptococcus mutans is a representative oral pathogen that causes dental caries and pulpal inflammation. Its lipoteichoic acid (Sm.LTA) is known to be an important cell-wall virulence factor involved in bacterial adhesion and induction of inflammation. Since Sm.LTA-binding proteins (Sm.LTA-BPs) might play an important role in pathogenesis and host immunity, we identified the Sm.LTA-BPs in the saliva of caries-free and caries-positive human subjects using Sm.LTA-conjugated beads and LTQ-Orbitrap hybrid Fourier transform mass spectrometry. Sm.LTA was conjugated to N-hydroxysuccinimidyl-Sepharose(®) 4 Fast Flow beads (Sm.LTA-beads). Sm.LTA retained its biological properties during conjugation, as determined by the expression of nitric oxide and interferon-γ-inducible protein 10 in a murine macrophage cell line and activation of Toll-like receptor 2 (TLR2) in CHO/CD14/TLR2 cells. Sm.LTA-BPs were isolated from pooled saliva prepared from 10 caries-free or caries-positive human subjects each, electrophoresed to see their differential expression in each group, and further identified by high-resolution mass spectrometry. A total of 8 and 12 Sm.LTA-BPs were identified with statistical significance in the pooled saliva from the caries-free and caries-positive human subjects, respectively. Unique Sm.LTA-BPs found in caries-free saliva included histone H4, profilin-1 and neutrophil defensin-1, and those in caries-positive saliva included cystatin-C, cystatin-SN, cystatin-S, cystatin-D, lysozyme C, calmodulin-like protein 3 and β-actin. The Sm.LTA-BPs found in both groups were hemoglobin subunits α and β, prolactin-inducible protein, protein S100-A9, and SPLUNC2. Collectively, we identified Sm.LTA-BPs in the saliva of caries-free and caries-positive subjects, which exhibit differential protein profiles.

Treatment of large arteriovenous malformation in right lower limb

A 10-year-old boy with arteriovenous malformation (AVM) of the right lower limb was scheduled for an amputation of the affected limb. Limb amputation was necessary because of the ineffectiveness of previous sclerotherapy and the rapid progression of AVM causing pain and heart failure. Right hip disarticulation was considered the best option to improve his quality of life. To prevent congestive heart failure and uncontrollable hemorrhage during surgery, the disarticulation was done under a partial cardiopulmonary bypass. The patient underwent surgery successfully without complications.

Abnormal origin of the left subclavian artery from the left pulmonary artery in a patient with double outlet right ventricle

Anomalous aortic origin of the left subclavian artery (LSCA) from the left pulmonary artery (LPA) is a rare congenital cardiac malformation. We describe a case of LSCA from the LPA via ductus arteriosus in association with a double-outlet right ventricle, which never has been reported previously in Korea.

INCB018424 induces apoptotic cell death through the suppression of pJAK1 in human colon cancer cells

Janus kinase (JAK) is one of the main upstream activators of signal transducers and activators of transcription (STAT) that are constitutively activated in various malignancies and are associated with cell growth, survival, and carcinogenesis. Here, we investigated the role of JAKs in colorectal cancer in order to develop effective therapeutic targets for INCB018424, which is the first JAK1/2 inhibitor to be approved by FDA. After examining the basal expression levels of phospho-JAK1 and phospho-JAK2, we measured the effects of INCB018424 on the phosphorylation of JAK1/2 using western blot analysis. Cell viability was determined using the trypan blue exclusion assay. The cell death mechanism was identified by the activation of caspase 3 using western blot and annexin V staining. The basal levels of phospho-JAK1 and phospho-JAK2 were cancer cell type dependent. Colorectal cancer cell lines that phosphorylate both JAK1 and JAK2 include DLD-1 and RKO. INCB018424 inactivates both JAK1 and JAK2 in DLD-1 cells but inactivates only JAK1 in RKO cells. Cell death was proportional to the inactivation of JAK1 but not JAK2. INCB018424 causes caspase-dependent cell death, which is prevented by treatment with z-VAD. The inhibition of JAK1 phosphorylation seemed sufficient to allow INCB018424-mediated apoptosis. JAK1 is a key molecule that is involved in colon cancer cell survival and the inhibition of JAK1 by INCB01424 results in caspase-dependent apoptosis in colorectal cancer cells. The use of selective JAK1 inhibitors could be an attractive therapy against colorectal cancer, but further clinical investigations are needed to test this possibility.

Antiallodynic effects of vitamin C and vitamin E in chronic post-ischemia pain rat model

Background

Recent research has shown that reactive oxygen species (ROS) play a significant role in the development and persistence of neuropathic pain through central sensitization via N-methyl-D-aspartate (NMDA) receptor activation. In the present study, we examined whether the intraperitoneal administration of vitamins C and E alone or together could alleviate mechanical allodynia in a chronic post-ischemia pain (CPIP) rat model.

Methods

Vitamins C and E were administered intraperitoneally to 48 male Sprague Dawley rats once per day for 3 days before hindpaw ischemia-reperfusion (I/R) injury was induced. On the third day, the CPIP rat model was produced by inducing ischemia in the left hindpaw by applying an O-ring for 3 h, followed by reperfusion. Three days after reperfusion, hindpaw mechanical allodynia was assessed by measuring the withdrawal response to von Frey filament stimulation. The rats were sacrificed immediately after behavioral testing to determine the phosphorylated NMDA receptor subunit 1 (pNR1) and extracellular-signal-regulated kinases (pERK) levels in the spinal cord.

Results

When the antioxidant vitamins C and E were administered intraperitoneally to CPIP rats, I/R injury-induced mechanical allodynia was attenuated, and pNR1 and pERK levels were decreased in the rat spinal cord. Additionally, the co-administration of both vitamins had an increased antiallodynic effect.

Conclusions

The reduced phosphorylated NR1 and ERK levels indicate that vitamins C and E inhibit the modulation of spinal cord neuropathic pain processing. Co-administration of vitamins C and E had a greater antiallodynic effect.

Computed tomography-guided cervical selective transforaminal epidural block for a patient with bilateral anatomical variations of vertebral artery -a case report-

A 56-year-old woman complained of radiating pain to the left arm. She was diagnosed with left-sided foraminal stenosis at the C5-6 level. The neurosurgeon requested a left C6 cervical selective transforaminal epidural block (CSTE). Cervical MRI showed a left-sided large tortuous vertebral artery (VA) at the C5-6 level. Before performing CSTE, a CT angiogram was carried out and showed bilateral tortuous VAs. To minimize adverse events, CSTE was performed with non-particulated steroids and under CT guidance. Following the procedure, the patient's symptoms were relieved completely. Although complication rates of CSTE are generally low, if it occurs, disastrous situation could be. Additionally, if the patient has anatomical variations, the possibility of a complication occurring is greatly increased. It is therefore important to determine whether the patient has any anatomical variations of the VA before performing procedures such as CSTE, and to ensure that needle placement is correct during the procedure and an appropriate drug, such as a non-particulated steroid, is selected.

New polymorphic microsatellite loci of threadsail filefish, Stephanolepis cirrhifer (Teleostei, Monacanthidae), from Korean waters

The threadsail filefish, Stephanolepis cirrhifer (Monacanthidae), is found mainly in the western Pacific. It is intensively caught in Korea and is a highly appreciated seafood delicacy. Consequently, the natural population of this species has drastically decreased, despite introductions from hatcheries. To provide information necessary for its conservation and management, we developed 24 polymorphic microsatellite markers using a combination of a total enriched genomic library and a small-scale 454 pyrosequencing. A total of 90,847 raw reads were obtained, and 75,128 unique sequences were generated, with an average length of 477 bp; 5350 (7.12%) sequences contained a minimum of 5 di- to tetranucleotide repeat motifs. Seventy-four sequences were used for microsatellite primer design. They all amplified successfully; 24 were polymorphic, with 8 containing trinucleotide repeats and 3 containing tetranucleotide repeats. The genetic variations based on 15 primer sets were investigated using 45 wild individuals from the coastal waters of Geomun Island. The number of alleles per locus varied from 4 to 15, with an average of 7.47. The observed and expected heterozygosities ranged from 0.333 to 0.956 and from 0.316 to 0.870, with averages of 0.692 and 0.701, respectively. No linkage disequilibrium was found between any pair of loci, indicating their independence. One locus significantly deviated from Hardy-Weinberg equilibrium after Bonferroni's correction; this may be due to the existence of a null allele. Cross-amplification was also tested for all 24 polymorphic loci in another monacanthid species, Thamnaconus modestus; 7 loci were effectively amplified. The high degree of polymorphism that was exhibited by the 15 newly developed microsatellites will be useful for assessing genetic variation and for conservation genetic studies of these 2 monacanthid species.

The effect of the intravenous phenylephrine on the level of spinal anesthesia

Background

Spinal anesthesia causes hypotension and bradycardia due to sympathetic nerve block and it is difficult to predict the level of sensory block and the duration of blockade. Recent studies have reported that intravenous phenylephrine can reduce the rostral spread of spinal anesthesia in pregnant women. We think a phenylephrine infusion will be useful for maintaining the baseline blood pressure by reducing the rostral spread of spinal anesthesia during the elective surgery of non-obstetric patients.

Methods

Sixty patients who were undergoing urologic surgery were randomized into two groups: Group C (the control group without phenylephrine) and Group P (with the addition of phenylephrine). After a bolus infusion of 50 µg phenylephrine following the spinal injection, phenylephrine was continuously infused at the rate of 200 µg/hr. We compared the dermatomal spreads of spinal anesthesia, the hemodynamic parameters (blood pressure, heart rate) and the incidences of hypotension between the two groups.

Results

At 20 minutes, the level of the upper dermatome blocked against cold sensation was a median of T8 (interquartile range: T8-T10) for the phenylephrine group, as compared with T4 (interquartile range: T4-T6) for the control group (P < 0.001).

Conclusions

Intravenous phenylephrine can decrease the rostral spread of spinal anesthesia during urologic surgery.

Target-controlled infusion of remifentanil for conscious sedation during spinal anesthesia

Background

The aim of this study was to define the optimal target concentration of remifentanil which effectively achieves conscious sedation without significant vital sign changes and side effects during spinal anesthesia.

Methods

Sixty patients underwent spinal anesthesia with 0.5% hyperbaric bupivacaine (8-16 mg), and were infused with a target controlled infusion (TCI) of remifentanil at 1.0 ng/ml (group R10, n = 15), 2.0 ng/ml (group R20, n = 15), 3.0 ng/ml (group R30, n = 15), and 3.5 ng/ml (group R35, n = 15). Observer's assessment of alertness/sedation (OAA/S) scale, the bispectral index (BIS), anxiety levels and infusion rate of remifentanil were monitored during the operation.

Results

OAA/S scale was significantly lower in groups R30 (3.96) and R35 (3.34) than groups R10 (4.31) and R20 (4.26). Incidence of intraoperative respiratory depression events, post operative nausea and vomiting were significantly higher in group R35 than the other groups. There were no significant differences in BIS, anxiety level and incidences of recall of the operative procedure among the groups.

Conclusions

We conclude that the TCI of remifentanil at 3.0 ng/ml produces an effective sedation and anti-anxiety effects without significant side effects during spinal anesthesia.

Development of adsorbent for the simultaneous removal of organic and inorganic contaminants from aqueous solution

In this study, a modified adsorbent, alginate complex beads, was prepared and applied to the removal of mixed contaminants from wastewater. The alginate complex beads were generated by the immobilization of powdered activated carbon and synthetic zeolites onto alginate gel beads, which were then dried at 110 °C for 20 h until the diameter had been reduced to 1 mm. This dry technique increased the hardness of the adsorbent to assure its durability and application. The adsorption onto the alginate complex beads of organic and inorganic compounds, as target contaminants, was investigated by performing both equilibrium and kinetic batch experiments. From the adsorption isotherms, according to the Langmuir equation, the alginate complex bead was capable of effectively removing benzene, toluene, zinc and cadmium. From kinetic batch experiments, the removal efficiencies of benzene, toluene, zinc and cadmium were found to be 66.5, 92.4, 74.1 and 76.7%, respectively, for initial solution concentrations of 100 mg L(-1). The results indicated that the adsorbent developed in this study has the potential to be a promising material for the removal of mixed pollutants from industrial wastewater or contaminated groundwater.

Comparing the effects of 5% albumin and 6% hydroxyethyl starch 130/0.4 on coagulation and inflammatory response when used as priming solutions for cardiopulmonary bypass

AIM

This prospective, randomized and controlled trial compares the use of human albumin (HA) and hydroxyethyl starch (HES) 130/0.4 in the priming solution for a non-biocompatible cardiopulmonary bypass (CPB) circuit. The effects of each substance on coagulation, postoperative blood loss and pro-inflammatory activities were examined.

METHODS

Thirty-six adult patients undergoing mitral valvular heart surgery were randomly assigned to either the HA or HES group; 500 mL of 5% HA or 6% HES 130/0.4 were added to the priming solution of the CPB circuit for each group, respectively. Coagulation variables were measured perioperatively; these variables included thromboelastographic (TEG) parameters and pro-inflammatory markers such as interleukin (IL)-6, IL-8 and tumor necrotic factor (TNF)-a. Postoperative blood loss and transfusion requirements were also assessed.

RESULTS

There were no significant intergroup differences in the coagulation variables (including TEG parameters), serum concentrations of IL-6, IL-8 and TNF-a, and blood loss or transfusion requirements. TEG parameters, which indicate the speed of solid clot formation and the strength of the fibrin clot, decreased up to 4 hours after CPB in both groups. Serum concentrations of IL-6, IL-8 and TNF-a were higher up to 12 hours after surgery compared to baseline values in both groups. Hemoglobin levels and platelet counts were lower up to 12 hours after surgery compared to baseline values in both groups.

CONCLUSION

HES 130/0.4 was comparable to albumin as a component of the priming solution for a non-biocompatible CPB circuit. The two substances showed similar effects on coagulation variables, blood loss and pro-inflammatory activities in adult patients undergoing mitral valvular heart surgery.

Sildenafil and beraprost combination therapy in patients with pulmonary hypertension undergoing valvular heart surgery

BACKGROUND AND AIM OF THE STUDY

Sildenafil and beraprost, as orally available pulmonary vasodilators, are used increasingly to treat pulmonary hypertension (PH). An evaluation was made, in patients with PH undergoing valvular heart surgery, as to whether preoperative combined oral sildenafil and beraprost treatment could induce synergistic and prolonged pulmonary vasodilation, or result in a loss of pulmonary selectivity.

METHODS

Fifty patients scheduled for valvular heart surgery with a mean pulmonary arterial pressure (PAP) > 30 mmHg were randomly assigned to receive either 50 mg oral sildenafil + 40 microg beraprost, or a placebo, 15 min before the induction of anesthesia. Hemodynamic variables were measured intraoperatively.

RESULTS

The treatment group had a significantly lower systemic vascular resistance index at 60 min after medication. No other significant intergroup differences in hemodynamic variables were observed. In addition, significantly more patients in the treatment group required vasopressor therapy. In both groups, the PAP was significantly reduced by general anesthesia, and almost normalized after valvular heart surgery.

CONCLUSION

Preoperative oral sildenafil and beraprost treatment resulted in a loss of pulmonary selectivity, and did not provide any additional pulmonary vasodilation or favorable perioperative hemodynamics in patients with PH undergoing valvular heart surgery.

Value of specimen radiographs in diagnosing multifocality of thyroid cancer

BACKGROUND

Specimen radiography has been used widely to evaluate the complete excision of calcified breast lesions but has not been evaluated for thyroid cancer.

METHODS

Specimen radiographs were evaluated retrospectively to identify additional cancers that were demonstrated only as calcifications. Receiver operating characteristic curve analysis was performed to compare the combination of specimen radiography and ultrasonography versus ultrasonography alone for detecting multifocality.

RESULTS

Some 122 thyroid cancer specimens were obtained from 122 patients between January and April 2008. Specimen radiography detected 27 cancers (18.5 per cent) not detected by ultrasonography. Diagnoses were changed after evaluation of specimen radiographs in three of these patients. The area under the curve of the combination of specimen radiography and ultrasonography was significantly higher than that of ultrasonography alone (P = 0.005).

CONCLUSION

Specimen radiography is a potentially useful tool for diagnosing cancer type and predicting the extent of thyroid cancer.

Feasibility of electroflotation to separate solids and liquid in an activated sludge process

In this study, electroflotation (EF) has been applied as a secondary clarification in the activated sludge process to improve the efficiency of the solids-liquid separation, which is essential in maintaining effluent quality. The effects of sludge settleability were examined through a series of batch and semi-continuous experiments. The results of the batch experiments revealed that thickening efficiencies using EF were 2.6 to 9.2 times higher than those with gravity settling (GS). In addition, clarification efficiencies were not significantly influenced by sludge settling properties, as compared with GS as a control. In the semi-continuous EF experiments, the concentrations of solids in the float layer were maintained above 10 g L(-1) during flotation, regardless of variations in sludge settleability. Furthermore, the volumetric gas proportion in the float layer increased as the gas to solids (G/S) ratio rose. This allowed the float layer to be more stably suspended against gravity at the top of the reactor. Based on the results obtained from these batch and semi-continuous experiments, an anoxic/oxic (AO) reactor combined with EF clarifier remained in successful continuous operation for four months. In comparison with conventional AO processes using a GS clarifier, enhanced clarification and thickening efficiencies were achieved through the EF-AO system. In addition, higher mixed liquor suspended solids concentrations (averaging 5300 mg L(-1)) in the bioreactor (EF-AO) were maintained via the return of highly concentrated sludge (averaging 16,400 mg L(-1)) from the EF clarifier. These findings suggest that EF could be a promising and effective alternative for the solids-liquid separation of poorly settling sludge.

Predictors of ineffectual radial arterial pressure monitoring in valvular heart surgery

BACKGROUND AND AIM OF THE STUDY

Unexpected sustained underestimation of the central aortic pressure by the radial arterial pressure commonly develops following cardiopulmonary bypass (CPB) in valvular heart surgery (VHS), leading to an inappropriate use of vasopressors. The study aim was to identify clinical predictors leading to a sustained inappropriate difference between the radial and femoral arterial pressure (IDRF) in VHS.

METHODS

A total of 200 patients undergoing VHS was studied prospectively. Those patients who developed sustained IDRF (systolic IDRF > or =10 mmHg and/or mean IDRF > or =5 mmHg) from immediately after discontinuation of CPB until the end of the surgery were compared with patients who did not develop any IDRF.

RESULTS

Data from seven patients who required second aortic cross-clamping and re-CPB were excluded from the analysis; thus, data from 193 patients were analyzed. In total, 53 patients (27.5%) developed sustained IDRF, whereas 80 patients (41.4%) did not develop any IDRF. In multivariate analysis, female gender, the presence of atrial fibrillation and diuretic use were identified as independent preoperative predictors; longer-duration aortic cross-clamping and use of larger amounts of vasopressin during CPB were identified as independent operative risk factors of the sustained IDRF.

CONCLUSION

When an erroneously low radial arterial pressure is suspected following CPB in this subset of patients undergoing VHS, monitoring of the femoral or axillary arterial pressure should be considered to guide hemodynamic management, as there is an increased risk of persistence of this phenomenon.

Remifentanil protects myocardium through activation of anti-apoptotic pathways of survival in ischemia-reperfused rat heart

Remifentanil is a commonly used opioid in anesthesia with cardioprotective effect in ischemia-reperfused (I/R) heart. We evaluated the influence of remifentanil on myocardial infarct size and expressions of proteins involved in apoptosis in I/R rat heart following various time protocols of remifentanil administration. Artificially ventilated anesthetized Sprague-Dawley rats were subjected to a 30 min of left anterior descending coronary artery occlusion followed by 2 h of reperfusion. Rats were randomly assigned to one of five groups; Sham, I/R only, remifentanil preconditioning, postconditioning and continuous infusion group. Myocardial infarct size, the phosphorylation of ERK1/2, Bcl2, Bax and cytochrome c and the expression of genes influencing Ca2+ homeostasis were assessed. In remifentanil-administered rat hearts, regardless of the timing and duration of administration, infarct size was consistently reduced compared to I/R only rats. Remifentanil improved expression of ERK1/2 and anti-apoptotic protein Bcl2, and expression of sarcoplasmic reticulum genes which were significantly reduced in the I/R rats only. Remifentanil reduced expression of pro-apoptotic protein, Bax and cytochrome c. These suggested that remifentanil produced cardioprotective effect by preserving the expression of proteins involved in anti-apoptotic pathways, and the expression of sarcoplasmic reticulum genes in I/R rat heart, regardless of the timing of administration.

Predictive value of C-reactive protein for major postoperative complications following off-pump coronary artery bypass surgery: prospective and observational trial

BACKGROUND

To prospectively investigate the predictive value of the preoperative C-reactive protein (CRP) concentration for major postoperative complications following off-pump coronary artery bypass (OPCAB) surgery.

METHODS AND RESULTS

From January 2007 to December 2007, 185 consecutive patients scheduled for elective OPCAB surgery were allocated to a low-CRP group (n=137, CRP <0.3 mg/dl) and a high-CRP group (n=48, CRP > or = 0.3 mg/dl). The incidence of major postoperative complications, defined as postoperative myocardial infarction, and 5 major morbidity endpoints including permanent stroke, renal dysfunction, any cardiac surgery reoperation, ventilation for more than 48 h, and deep sternal wound infection were assessed and compared. Multivariate logistic regression was used to determine the predictors of major postoperative complications. Patients in the high-CRP group had a significantly higher overall incidence of major postoperative complications, particularly renal dysfunction. In the multivariate logistic regression model, adjusting all the significant univariate predictors, baseline CRP >0.3 mg/dl and preoperative chronic renal failure (CRF) remained as significant independent predictors of major postoperative complications.

CONCLUSIONS

Elevated preoperative CRP level and/or preoperative CRF indicate increased risk of developing major postoperative complications, particularly acute postoperative renal dysfunction in patients undergoing OPCAB surgery.

Relationship between echocardiographic index of ventricular filling pressure and intraoperative haemodynamic changes during off-pump coronary bypass surgery

BACKGROUND

The ratio of mitral velocity to early-diastolic velocity of the mitral annulus (E/e') is an indicator of diastolic function representing acute loading conditions of the left ventricle. We tested the efficacy of E/e' as a predictor of haemodynamic derangement during off-pump coronary artery bypass surgery (OPCAB), when heart displacement causes loading changes.

METHODS AND RESULTS

Fifty patients with left ventricular (LV) ejection fraction >or= 50% were divided into two groups; E/e'<8 (normal LV filling pressure, n=25) and >15 (increased LV filling pressure, n=25). Haemodynamic measurements were recorded after induction of anaesthesia, during grafting, and after sternum closure. Patients' characteristics and operative data were similar between the groups. Cardiac index and mixed venous oxygen saturation were significantly lower during grafting and after sternum closure in the E/e'>15 group, compared with E/e'<8 group and with the baseline values. The E/e'>15 group required significantly longer ventilation time and length of stay in the intensive care unit.

CONCLUSIONS

Even in patients with preserved systolic LV function, patients with E/e'>15 were more prone to undergo a significant decrease in cardiac output during OPCAB, which did not return to baseline level after completion of grafting. Whether this finding is associated with increased morbidity and mortality should be validated.

Effect of low-dose ketamine on inflammatory response in off-pump coronary artery bypass graft surgery

BACKGROUND

Off-pump coronary artery bypass graft surgery (OPCAB) is still associated with a marked systemic inflammatory response. The aim of this study was to investigate whether pre-emptive, low dose of ketamine, which has been reported to have anti-inflammatory activity in on-pump coronary artery bypass surgery, could reduce inflammatory response in low-risk patients undergoing OPCAB.

METHODS

In this prospective randomized-controlled trial, 50 patients with stable angina and preserved myocardial function undergoing OPCAB were randomly assigned to receive either 0.5 mg kg(-1) of ketamine (Ketamine group, n=25) or normal saline (Control group, n=25) during induction of anaesthesia. Inflammatory markers including C-reactive protein (CRP), interleukin (IL)-6, tumour necrosis factor-alpha (TNF-alpha), and cardiac enzymes were measured previous to induction (T1), 4 h after surgery (T2), and the first and second days after the surgery (T3 and T4).

RESULTS

There were no significant intergroup differences in the serum concentrations of the CRP, IL-6, and TNF-alpha and cardiac enzymes. Pro-inflammatory markers and cardiac enzymes, except TNF-alpha, were all increased after the surgery compared with baseline values in both groups.

CONCLUSIONS

Low-dose ketamine administered during anaesthesia induction did not exert any evident anti-inflammatory effect in terms of reducing the serum concentrations of pro-inflammatory markers in low-risk patients undergoing OPCAB.

Development of distant stereoacuity in visually normal children as measured by the Frisby-Davis distance stereotest

AIMS

To establish the range of normal distance stereoacuity and evaluate its development in visually normal children by using the Frisby-Davis distance stereotest (FD2).

METHODS

The distance stereoacuity of visually normal children aged less than 11 years and of adults was measured with FD2 using a standard testing protocol.

RESULT

This study involved 94 visually normal children aged 36-131 months and 46 visually normal adults aged 20-49 years. The distance stereoacuity of the children aged 36-59 months was 40.61 (SD 9.823) seconds of arc; that of the children aged 60-119 months, 14.18 (8.152) seconds of arc; and that of the adults, 12.50 (4.802) seconds of arc. The FD2 distance stereoacuity of the children aged 36-59 months differed significantly from that of the older subjects (p = 0.000), and the FD2 distance stereoacuity of the children aged more than 59 months did not differ significantly from that of the adults (p = 0.813).

CONCLUSION

Distance stereoacuity reaches adult levels at approximately 5 years of age. These data of the age-related normal values could represent a reference frame for the comparison of data obtained for clinical populations.

Diffuse sclerosing variant of papillary carcinoma of the thyroid: ultrasound features with histopathological correlation

AIM

To evaluate the ultrasound (US) features of the diffuse sclerosing variant of papillary carcinoma (DSVPC) of the thyroid, with histopathological correlations.

MATERIALS AND METHODS

The US and histopathological findings of six patients with surgically proven DSVPC of the thyroid were retrospectively assessed.

RESULTS

Most of cases showed diffuse, scattered microcalcifications with or without associated masses and underlying heterogeneous hypoechogenicity at the site of the DSVPC in the thyroid. At ultrasound, scattered microcalcifications and heterogeneous hypoechogenicity seen in the DSVPC correlated to psammoma bodies and lymphocytic infiltration at histopathological review.

CONCLUSION

DSVPC of the thyroid usually manifested as diffuse scattered microcalcifications and associated suspicious mass on ultrasound. These findings are not specific for the DSVPC of the thyroid. However, in relatively young patients with suspicious masses associated with underlying diffuse scattered microcalcifications on US, the possibility of DSVPC should be included in differential diagnosis.

Intraoperative examination of sentinel lymph nodes by immunohistochemical staining in patients with breast cancer

AIM

To performed a prospective investigation of the relative merits of rapid cytokeratin immunohistochemical (CK-IHC) staining of the SLN removed during the operation of breast cancer patients.

STUDY DESIGN

Between December 2002 and March 2004, 62 patients with T1 and T2 breast cancer were enrolled after undergoing successful sentinel lymph node biopsy. Eighty-nine sentinel lymph nodes (mean number, 1.44) were biopsied and first examined by hematoxylin-eosin (H&E) stained frozen section. All the tumour free sentinel lymph nodes by H&E stained frozen section were immunostained for cytokeratin using a rapid immunohistochemical assay (Cytokeratin (PAN), 1:50, Novocastra Lab., Newcastle, UK) during the operations.

RESULTS

Rapid IHC staining revealed seven positive sentinel lymph nodes that were negative for metastasis by H&E staining. This study showed a sensitivity of 92.86%, a specificity of 100%, an accuracy of 98.9%, and a negative predictive value of 98.7%.

CONCLUSIONS

The intraoperative examination of sentinel lymph nodes is an accurate and effective way of predicting the axillary lymph node status of patients with breast cancers.