Accuracy of CT Colonography for Detection of Polypoid and Nonpolypoid Neoplasia by Gastroenterologists and Radiologists: A Nationwide Multicenter Study in Japan.

OBJECTIVES: The objective of this study was to assess prospectively the diagnostic accuracy of computer-assisted computed tomographic colonography (CTC) in the detection of polypoid (pedunculated or sessile) and nonpolypoid neoplasms and compare the accuracy between gastroenterologists and radiologists. METHODS: This nationwide multicenter prospective controlled trial recruited 1,257 participants with average or high risk of colorectal cancer at 14 Japanese institutions. Participants had CTC and colonoscopy on the same day. CTC images were interpreted independently by trained gastroenterologists and radiologists. The main outcome was the accuracy of CTC in the detection of neoplasms ≥6 mm in diameter, with colonoscopy results as the reference standard. Detection sensitivities of polypoid vs. nonpolypoid lesions were also evaluated. RESULTS: Of the 1,257 participants, 1,177 were included in the final analysis: 42 (3.6%) were at average risk of colorectal cancer, 456 (38.7%) were at elevated risk, and 679 (57.7%) had recent positive immunochemical fecal occult blood tests. The overall per-participant sensitivity, specificity, and positive and negative predictive values for neoplasms ≥6 mm in diameter were 0.90, 0.93, 0.83, and 0.96, respectively, among gastroenterologists and 0.86, 0.90, 0.76, and 0.95 among radiologists (P<0.05 for gastroenterologists vs. radiologists). The sensitivity and specificity for neoplasms ≥10 mm in diameter were 0.93 and 0.99 among gastroenterologists and 0.91 and 0.98 among radiologists (not significant for gastroenterologists vs. radiologists). The CTC interpretation time by radiologists was shorter than that by gastroenterologists (9.97 vs. 15.8 min, P<0.05). Sensitivities for pedunculated and sessile lesions exceeded those for flat elevated lesions ≥10 mm in diameter in both groups (gastroenterologists 0.95, 0.92, and 0.68; radiologists: 0.94, 0.87, and 0.61; P<0.05 for polypoid vs. nonpolypoid), although not significant (P>0.05) for gastroenterologists vs. radiologists. CONCLUSIONS: CTC interpretation by gastroenterologists and radiologists was accurate for detection of polypoid neoplasms, but less so for nonpolypoid neoplasms. Gastroenterologists had a higher accuracy in the detection of neoplasms ≥6 mm than did radiologists, although their interpretation time was longer than that of radiologists.

Effect of head position on the success rate of blind intubation using intubating supraglottic airway devices.

BACKGROUND: To evaluate the effect of head position on the performance of intubating supraglottic airway devices, we compared the success rate of blind intubation in the head-elevated and the pillowless head positions with the LMA Fastrach and the air-Q, and the change of glottic visualization through the air-Q. METHODS: We assigned 193 patients to two groups according to the device used and subgrouped by head position used for intubation: Fastrach/pillowless, Fastrach/head-elevated, air-Q/pillowless, and air-Q/head-elevated. Blind intubation through the Fastrach or the air-Q was attempted up to twice after induction of general anesthesia. Before the attempt at blind intubation with the air-Q, the percentage of glottic opening (POGO) score was also fiberscopically evaluated at the outlet of the device in both head positions in a cross-over fashion. RESULTS: The Fastrach significantly facilitated blind intubation compared with the air-Q in both the pillowless and head-elevated positions: 87.2% in Fastrach/pillowless vs 65.9% in air-Q/pillowless (P=.048), 90% in Fastrach/head-elevated vs 53.7% in air-Q/head-elevated (P<.001). The head-elevated position did not significantly affect the success rate of blind intubation for either device (P=.97 in Fastrach, P=.37 in air-Q). Although the head-elevated position significantly improved the POGO score from the median (10-90 percentile) 60% (0-100%) in the pillowless position to 80% (0-100%) (P=.008), it did not contribute to successful blind intubation with the air-Q. CONCLUSION: Although the head-elevated position improved glottic visualization in the air-Q, the head position had minimal influence on the success rate of blind intubation with either the Fastrach or the air-Q.

Effects of gas composition on the delivered tidal volume of the Avance Carestation.

BACK GROUND: Measurements with various flowmeters are affected by changes in gas mixture density. The Avance Carestation incorporates ventilator feedback controlled by a built-in flowmeter with a variable orifice sensor. We hypothesised that changes in the composition of delivered gas may cause changes in the delivered tidal volume by affecting the flow measurement unless appropriate corrections are made. METHODS: We used 100 % O2, 40 % O2 in N2 and 40 % O2 in N2O as carrier gases with/without sevoflurane and desflurane. We measured delivered tidal volume using the FlowAnalyzer™ PF 300 calibrated with the corresponding gas mixtures during volume control ventilation with 500-ml tidal volume using the Avance Carestation connected to a test lung. RESULTS: Change of carrier gas and addition of sevoflurane and desflurane significantly altered delivered tidal volume. Desflurane 6 % reduced delivered tidal volume by 7.6, 3.6 and 16 % of the pre-set volume at 100 % O2, 40 % O2 in N2 and 40 % O2 in N2O, respectively. Importantly, the Carestation panel indicator did not register these changes in measured expired tidal volume. Ratios of delivered tidal volume to 500 ml correlated inversely with the square root of the delivered gas density. CONCLUSIONS: These results support our hypothesis and suggest that changing gas composition may alter delivered tidal volume of anesthesia machines with built-in ventilators that are feedback-controlled by uncorrected flowmeters due to changes in gas mixture density.

[Airway Management Using McGrath MAC in a Pediatric Patient with a Laryngeal Saccular Cyst].

An 18-month-old female infant was scheduled for resection of a laryngeal saccular cyst inducing narrow airway. Since the cyst protruded from the left side of the epiglottis and the vocal cord was compressed to the right side, a difficult airway was anticipated. In addition, there was a risk of tracheal occlusion by rupture of the cyst Awake intubation was considered to be dangerous. Slow induction with sevoflurane and neuromusclar blockade was attempted, preparing reversal of the neuromusclar blockade. Fortunately, mask ventilation was achieved without difficulty. It was necessary to insert a tracheal tube avoiding the cyst We used McGrath MAC (Aircraft Medical Co., UK), which enabled us to manipulate the tracheal tube. A tracheal tube was successfully inserted under McGrath monitor guidance.

Comparison of intubation performance between the King Vision and Macintosh laryngoscopes in novice personnel: a randomized, crossover manikin study.

PURPOSE: The King Vision laryngoscope is a newly developed video laryngoscope. We conducted a simulation study to evaluate the efficacy of the King Vision in novice personnel. METHODS: Thirty-one registered nurses with no previous experience with tracheal intubation were enrolled. Participants made 6 consecutive attempts at intubation of the manikin's trachea with a Macintosh laryngoscope (MAC) and the King Vision with channeled blade (KVC) and non-channeled blade (KVNC) in a randomized cross-over fashion. The Grading Scale of Intubation Difficulty (GSID) was rated on a 5-point scale. RESULTS: Overall median (range) intubation times (sec) were 16.9 (8.0-60.0) with the MAC, 20.5 (7.2-60.0) with the KVC, and 60.0 (11.0-60.0) with the KVNC. The KVNC required significantly longer intubation time compared with the MAC or the KVC (p < 0.001). Success rate with the KVNC was 47.3 %, which was significantly inferior to that with the MAC (91.4 %) or KVC (86.6 %). Median GSID was 2 (range 1-5) with the KVC and 3 (1-4) with the MAC, which were both significantly lower than the 4 (2-5) with the KVNC (p < 0.001). Esophageal intubation with the MAC occurred in 18 of 186 attempts, whereas no incidents of esophageal intubation occurred with the KVC or KVNC. CONCLUSION: The KVC facilitated intubation by novice personnel without incidence of esophageal intubation. However, intubation times, success rates, and GSID scores were similar to the values obtained with the MAC. These findings suggest that the KVC, but not the KVNC, could be used as an alternative device for intubation by novice personnel.

[Usefulness of epidural anesthesia for percutaneous endoscopic lumbar discectomy (PELD)].

BACKGROUND AND METHODS: To study feasibility of epidural anesthesia for percutaneous endoscopic lumbar discectomy (PELD), we made a retrospective comparison of three anesthetic groups (28 cases with epidural anesthesia, 19 cases with local anesthesia, and 28 cases with general anesthesia) undergoing PELD. RESULTS: Three groups matched each other in age, the surgical site, and the duration of surgery; however, the frequency of male patients was significantly greater in the local anesthesia (LA) group. In the epidural anesthesia (EA) group, there was no patient who required a change of the anesthetic technique or analgesics administration during surgery. In EA group, patients received smaller amount of local anesthetic but spent longer time in the operating room compared with those in LA group. EA and GA groups included several cases staying long time in the hospital and presented wide statistical dispersion of the duration of hospitalization. There was no difference in the dose of local anesthetics, the duration of total procedure, or time to discharge between EA and GA groups. CONCLUSIONS: Epidural anesthesia is suggested to be a useful option for anesthetic techniques in patients undergoing PELD.

A new staging system for colorectal carcinoma with liver metastasis.

PURPOSE: The prognosis of colorectal carcinoma (CRC) with liver metastasis varies from case to case. A standardized classification system for evaluation of the prognosis and the treatment is needed. Therefore, we developed a new staging system for CRC with liver metastasis (HM-stage) based on the survival data. PATIENTS AND METHODS: We evaluated 148 CRC patients with liver metastasis treated between 1985 and 1999. Prognostic factors were identified based on a multivariate analysis. According to the final prognostic factors and hazard ratios, we defined the HM- stage. RESULTS: Three factors, including extent of liver metastasis, depth of tumor invasion and peritoneal metastasis, were identified to be the final prognostic factors. These factors were then assigned points. The patients were classified as being HM-stage I to IV by the sum total. The median survival time for each HM-stage were 37 months for HM-stage I, 23 months for II, 10 months for III and 7 months for IV respectively. A significant difference among each stage was recognized (p<0.0001). CONCLUSION: This new staging system for CRC with liver metastasis is simple and should be clinically useful for both estimation of the prognosis and evaluation of the therapy in patients.

Effect of using self-etching primer for bonding orthodontic brackets.

Questions over the use of self-etching primers with composite resin adhesives in the bonding of orthodontic brackets remain unsolved. In addition, there are no previous reports on the efficacy of self-etching primers with resin-modified glass ionomer cements for bonding orthodontic brackets in orthodontic dentistry. The purpose of this study was to determine the shear bond strengths of orthodontic brackets bonded with one of four protocols: (1) a composite resin adhesive used with 40% phosphoric acid, (2) the same composite resin used with Megabond self-etching primer, (3) a resin-modified glass ionomer cement adhesive used with 10% polyacrylic acid enamel conditioner, and (4) the same resin-modified glass ionomer cement used with Megabond self-etching primer. The appearance of the tooth surfaces after acid etching or priming was observed with a field-emission scanning electron microscope (FE-SEM). When used with resin-modified glass ionomer cement, Megabond self-etching primer gave no significantly different shear bond strength compared with polyacrylic acid etching. But when used with composite resin adhesive, Megabond self-etching primer gave significantly lower shear bond strength than phosphoric acid etching. However, the shear bond strength of orthodontic brackets bonded with composite resin adhesive after Megabond priming was almost the same as that of brackets bonded with resin-modified glass ionomer cement after polyacrylic acid etching. FE-SEM observation revealed that Megabond self-etching primer produced less dissolution of enamel surface than did phosphoric acid and polyacrylic acid etching. Megabond self-etching primer may be a candidate for bonding orthodontic brackets using the resin-modified glass ionomer cement for minimizing the amount of enamel loss.

A Case of Benign Schwannoma of the Transverse Colon with Granulation Tissue.

Schwannomas occurring in the gastrointestinal tract are rare, and among them, schwannomas of the large intestine are extremely rare. In this paper, we report a case of a macroscopically atypical schwannoma of the transverse colon. The case is a female aged 67. Stool occult blood test was positive, and colonoscopy revealed a protruded lesion resembling a type 1 carcinoma measuring 4 cm with a reddish and uneven surface on the transverse colon. The surface was smooth and lobulated in observation with indigo carmine spray, and granulation tissue was revealed by biopsies. CT of the abdomen showed an irregular mass, and clinical examinations could not rule out malignancy. Therefore, partial transverse colectomy with peripheral lymph node dissection was performed. Histologically, proliferation of spindle cells was observed originating from the muscularis propria, and most of the upper part of the lesion was replaced by granulation tissue. In immunohistochemical staining, S-100 protein and NSE were positive while KIT, CD34, desmin and smooth muscle actin were negative, and the tumor was therefore diagnosed to be a schwannoma. In addition, since the MIB-1 labeling index was low and virtually no mitosis was observed, it was diagnosed as benign tumor.

Apoptotic lymphocytes induced by surgical trauma in dogs.

PURPOSE: An investigation was made of the population and function of lymphocytes in canine peripheral blood, in animals with or without laparotomy under inhalation anesthesia. METHODS: Fourteen healthy beagles were allocated to two experimental groups: laparotomy (group A) and without laparotomy (group B). Induction of anesthesia in both groups was carried out with an intravenous injection of thiopentone, and was maintained by isoflurane inhalation. Ten blood samples, consisting of 10 ml of venous blood withdrawn by venipuncture into syringes containing 200 units of preservative-free heparin, were taken, from before anesthesia to the 28th postoperative day. The blood samples were collected, and the number of lymphocytes, the lymphocyte subpopulations, the proportion of apoptotic lymphocytes, and plasma cortisol level were measured, and the blastoid transformation of lymphocytes was observed. RESULTS: Lymphopenia was observed in both groups after anesthesia. Flow cytometry indicated a greater reduction in the proportion of T lymphocytes than of B lymphocytes. Blast transformation was also depressed in both groups. Progression of apoptosis after anesthesia was demonstrated in both groups, with a higher percentage of apoptotic cells being observed in group A at 12 h after anesthesia (28.5 +/- 3.2% by TUNEL assay). Plasma levels of cortisol were elevated to a greater extent in group A at the end of anesthesia (10.3 +/- 0.8 microg/dl) than in group B (7.8 +/- 1.9 microg/dl). CONCLUSIONS: These results indicate that surgical trauma concomitant with anesthesia could impair immunocompetence by reducing the number and function of lymphocytes.