Early gastric cancer with three gastric gastrointestinal stromal tumors combined with synchronous colon cancer: a case report.

BACKGROUND: There have been very few reports of patients with early gastric cancer (EGC) and colorectal cancer combined with gastric gastrointestinal stromal tumors (GISTs). CASE PRESENTATION: We report the case of a patient with multiple tumors that were found at the same time in the abdomen. The patient was a 77-year-old man who was referred for a gastric GIST. Esophagogastroduodenoscopy showed the known lesion (a gastric GIST) on the lesser curvature of the upper body and a new lesion on the lesser curvature of the lower body of the stomach with suspicion of EGC. Computed tomography findings confirmed the presence of a GIST in the stomach and revealed two new lesions. One of these lesions was suspected to be a 4-cm submucosal tumor on the anterior wall of the upper body of the stomach. The other was a wall thickening of the descending colon that demonstrated the possibility of malignancy. Synchronous colon cancer was confirmed on colonoscopy. Laparoscopic near-total gastrectomy with D1+ lymph node dissection and left hemicolectomy were performed sequentially without significant events. The patient was discharged without any postoperative complications. CONCLUSIONS: We reported a rare case of EGC with multiple gastric GISTs combined with synchronous colon cancer.

Correction to: Early gastric cancer with three gastric gastrointestinal stromal tumors combined with synchronous colon cancer: a case report.

An amendment to this paper has been published and can be accessed via the original article.

The course of headache in patients with moderate-to-severe headache due to mild traumatic brain injury: a retrospective cross-sectional study.

BACKGROUND: Little is known about the long-term course of headache in patients with moderate-to-severe headache due to traumatic brain injury (TBI). We evaluated the course of headache in patients with moderate-to-severe headache due to mild TBI. METHODS: Since September 2009, patients with TBI prospectively rated their headache using a numeric rating scale (NRS). From the database containing 935 patients with TBI between September 2009 and December 2013, 259 patients were included according to following criteria: (1) newly onset moderate-to-severe headache (NRS ≥ 4) due to head trauma; (2) age ≥ 15 years; (3) Glasgow Coma Scale ≥ 13; (4) transient loss of consciousness ≤ 30 min; and (5) radiographic evaluation, such as computed tomography or magnetic resonance image. We evaluated initial and follow-up NRS scores to determine the significance of NRS changes and identified risk factors for moderate-to-severe headache at 36-month follow-up. RESULTS: At 36-month follow-up, 225 patients (86.9%) reported improved headache (NRS ≤ 3) while 34 (13.1%) reported no improvement. The NRS scores were significantly decreased within a month (P < 0.001). The follow-up NRS scores at 12-, 24-, and 36-months were lower than those at one month (P < 0.001). Multiple logistic regression analysis showed that post-traumatic seizure (odds ratio, 2.162; 95% CI, 1.095-6.542; P = 0.041) and traumatic intracranial hemorrhage (odds ratio, 2.854; 95% CI, 1.241-10.372; P = 0.024) were independent risk factors for moderate-to-severe headache at 36-month follow-up. CONCLUSIONS: The course of headache in patients with mild TBI continuously improved until 36-month follow-up. However, 13.1% of patients still suffered from moderate-to-severe headache at 36-month follow-up, for whom post-traumatic seizure and traumatic intracranial hemorrhage might be risk factors.

Post-traumatic headache in patients with minimal traumatic intracranial hemorrhage after traumatic brain injury: a retrospective matched case-control study.

BACKGROUND: No evidence is available on the risks of neurologically asymptomatic minimal traumatic intracranial hemorrhage (mTIH) in patients with traumatic brain injury (TBI) for post-traumatic headache (PTH). The purpose of this study was to investigate whether mTIH in patients with TBI was associated with PTH and to evaluate its risk factors. METHODS: Between September 2009 and December 2014, 1484 patients with TBI were treated at our institution, 57 of whom had mTIH after TBI and were include in this study. We performed propensity score matching to establish a control group among the 823 patients with TBI treated during the same period. Patients with TBI rated their headaches prospectively using a numeric rating scale (NRS). We compared NRS scores between mTIH group (n = 57) and non-mTIH group (n = 57) and evaluated risk factors of moderate-to-severe PTH (NRS ≥ 4) at the 12-month follow-up. RESULTS: Moderate-to-severe PTH was reported by 21.9% of patients (29.8% in mTIH group and 14.0% in non-mTIH group B, p = 0.012) at the 12-month follow-up. The mean NRS was higher in mTIH group than in non-mTIH group throughout the follow-up period (95% confidence interval [CI], 0.11 to 1.14; p < 0.05, ANCOVA). Logistic regression analysis showed that post-traumatic seizure (odds ratio, 1.520; 95% CI, 1.128-6.785; p = 0.047) and mTIH (odds ratio, 2.194; 95% CI, 1.285-8.475; p = 0.039) were independently associated with moderate-to-severe PTH at the 12-month follow-up. CONCLUSIONS: Moderate-to-severe PTH can be expected after TBI in patients with mTIH and post-traumatic seizure. PTH occurs more frequently in patients with mTIH than in those without mTIH.

Effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory: a prospective cohort study.

BACKGROUND: We prospectively evaluated the effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory. METHODS: Between March 2012 and June 2013, 56 patients were recruited for this study. Fifty-one patients met the inclusion criteria and were enrolled. Inclusion criteria were as follows: (1) age ≤65 years and (2) planned microsurgery or endovascular surgery for unruptured intracranial aneurysm. Exclusion criteria were as follows: (1) preoperative intelligence quotient <80 (n = 3); (2) initial modified Rankin scale ≥1 (n = 1); (3) loss to follow-up (n = 1). An auditory controlled continuous performance test (ACCPT), word-color test (WCT) and verbal learning test (VLT) were performed before and after (6 months) preventive surgery. RESULTS: ACCPT (attention), WCT (executive function) and VLT (learning and memory) scores did not change significantly between the pre- and postoperative evaluations. The ACCPT, WCT, total VLT scores (verbal learning) and delayed VLT scores (memory) did not differ significantly between patients undergoing microsurgery and those undergoing endovascular surgery. However, ACCPT, WCT and delayed VLT scores decreased postoperatively in patients with leukoaraiosis on preoperative FLAIR images (OR 9.899, p = 0.041; OR 11.421, p = 0.006; OR 2.952, p = 0.024, respectively). CONCLUSIONS: Preventive surgery for unruptured intracranial aneurysms did not affect attention, executive function, learning or memory. However, patients with leukoaraiosis on FLAIR images might be prone to deficits in attention, executive function and memory postoperatively, whereas learning might not be affected.

Atmospheric vs. anaerobic processing of metabolome samples for the metabolite profiling of a strict anaerobic bacterium, Clostridium acetobutylicum.

Well-established metabolome sample preparation is a prerequisite for reliable metabolomic data. For metabolome sampling of a Gram-positive strict anaerobe, Clostridium acetobutylicum, fast filtration and metabolite extraction with acetonitrile/methanol/water (2:2:1, v/v) at -20°C under anaerobic conditions has been commonly used. This anaerobic metabolite processing method is laborious and time-consuming since it is conducted in an anaerobic chamber. Also, there have not been any systematic method evaluation and development of metabolome sample preparation for strict anaerobes and Gram-positive bacteria. In this study, metabolome sampling and extraction methods were rigorously evaluated and optimized for C. acetobutylicum by using gas chromatography/time-of-flight mass spectrometry-based metabolomics, in which a total of 116 metabolites were identified. When comparing the atmospheric (i.e., in air) and anaerobic (i.e., in an anaerobic chamber) processing of metabolome sample preparation, there was no significant difference in the quality and quantity of the metabolomic data. For metabolite extraction, pure methanol at -20°C was a better solvent than acetonitrile/methanol/water (2:2:1, v/v/v) at -20°C that is frequently used for C. acetobutylicum, and metabolite profiles were significantly different depending on extraction solvents. This is the first evaluation of metabolite sample preparation under aerobic processing conditions for an anaerobe. This method could be applied conveniently, efficiently, and reliably to metabolome analysis for strict anaerobes in air.

Revolutionizing trauma care: advancing coagulation management and damage control anesthesia.

Despite advances in emergency transfer systems and trauma medicine, the incidence of preventable deaths due to massive hemorrhage remains high. Recent immunological research has elucidated key mechanisms underlying trauma-induced coagulopathy in the early stages of trauma, including sympathoadrenal stimulation, shedding of the glycocalyx, and endotheliopathy. Consequently, the condition progresses to fibrinogen depletion, hyperfibrinolysis, and platelet dysfunction. Coexisting factors such as uncorrected acidosis, hypothermia, excessive crystalloid administration, and a history of anticoagulant use exacerbate coagulopathy. This study introduces damage-control anesthetic management based on recent insights into damage-control resuscitation, emphasizing the importance of rapid transport, timely bleeding control, early administration of antifibrinolytics and fibrinogen concentrates, and maintenance of calcium levels and body temperature. Additionally, this study discusses brain-protective strategies for trauma patients with brain injuries and the utilization of cartridge-based viscoelastic assays for goal-directed coagulation management in trauma settings. This comprehensive approach may provide potential insights for anesthetic management in the fast-paced field of trauma medicine.

Korean clinical practice guidelines for diagnostic and procedural sedation.

Safe and effective sedation depends on various factors, such as the choice of sedatives, sedation techniques used, experience of the sedation provider, degree of sedation-related education and training, equipment and healthcare worker availability, the patient's underlying diseases, and the procedure being performed. The purpose of these evidence-based multidisciplinary clinical practice guidelines is to ensure the safety and efficacy of sedation, thereby contributing to patient safety and ultimately improving public health. These clinical practice guidelines comprise 15 key questions covering various topics related to the following: the sedation providers; medications and equipment available; appropriate patient selection; anesthesiologist referrals for high-risk patients; pre-sedation fasting; comparison of representative drugs used in adult and pediatric patients; respiratory system, cardiovascular system, and sedation depth monitoring during sedation; management of respiratory complications during pediatric sedation; and discharge criteria. The recommendations in these clinical practice guidelines were systematically developed to assist providers and patients in sedation-related decision making for diagnostic and therapeutic examinations or procedures. Depending on the characteristics of primary, secondary, and tertiary care institutions as well as the clinical needs and limitations, sedation providers at each medical institution may choose to apply the recommendations as they are, modify them appropriately, or reject them completely.

Isolation and characterization of a metagenome-derived thermoalkaliphilic esterase with high stability over a broad pH range.

A novel alkaliphilic esterase (EstJ) was identified from a soil metagenome of Jeju Island, Korea, using a 96-well plate-based functional assay for determination of pH dependence of activity. The amino acid sequence of EstJ showed low similarity (32-45 %) to putative α/ß hydrolases derived from whole-genome sequencing studies. EstJ, although not belonging to any of the known families of bacterial lipolytic enzymes, however, it showed closest sequence identity to the family IV enzymes that are related to the mammalian hormone-sensitive lipases. The highly conserved motifs of family IV enzymes were found in EstJ, but the corresponding sequences of each motif in EstJ were unique; most particularly the -(F/Y)(F/Y/L)HGGG- motif was represented by -WMVSGG-. The purified EstJ was highly active from pH 8.5 to 10.5. More than 90 % of maximum activity was also retained over a wide pH range of 5.5-0.5 after prolonged incubation. EstJ was also moderately thermophilic with an optimum temperature of 55 °C. Therefore, EstJ is the first metagenome-derived bacterial family IV esterase possessing both highly alkaliphilic and moderately thermophilic properties.

Analgesic effects of ultrasound-guided fourquadrant transversus abdominis plane in patients with cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective, randomized, controlled study.

BACKGROUND: Postoperative pain occurring after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is difficult to control because of extensive surgical injuries and long incisions. We assessed whether the addition of a four-quadrant transabdominal plane (4Q-TAP) block could help in analgesic control. METHODS: Seventy-two patients scheduled to undergo elective CRS with HIPEC and intravenous patient-controlled analgesia (IV PCA) were enrolled. The patients received 4Q-TAP blocks in a 10 ml mixture of 2% lidocaine and 0.75% ropivacaine per site (4Q-TAP group, n = 36) or normal saline (control group, n = 33). Oxycodone in the post-anesthesia care unit (PACU) and pethidine or tramadol in the ward were used as rescue analgesics. The primary outcome was less than 3 times of rescue analgesic administration (%) in the ward for 5 postoperative days. Secondary endpoints included oxycodone requirement in PACU, fentanyl doses of IV PCA, morphine milligram equivalent (MME) of total opioid use, hospital stay, and postoperative complications. RESULTS: During 5 postoperative days, there was no difference in pain scores and total rescue analgesic administration between two groups. However, the use of oxycodone in PACU (P = 0.011), fentanyl requirement in IV PCA (P = 0.029), and MME/kg of total opioid use (median, 2.35 vs. 3.21 mg/kg, P = 0.009) were significantly smaller in the 4Q-TAP group. Hospital stay and incidence of postoperative morbidity were similar in both groups. CONCLUSIONS: The 4Q-TAP block enhanced multimodal analgesia and decreased opioid requirements in patients with CRS with HIPEC, but did not change postoperative recovery outcomes.

Isolation and characterization of cold-active family VIII esterases from an arctic soil metagenome.

Functional screening for lipolytic enzymes at low temperatures resulted in the isolation of the novel cold-active esterases, EstM-N1 and EstM-N2, from a metagenomic DNA library of arctic soil samples. EstM-N1 and EstM-N2 were 395 and 407 amino acids in length, respectively, and showed the highest similarity to class C ß-lactamases. However, they shared a relatively low level of sequence similarity (30%) with each other. Phylogenetic analysis of bacterial lipolytic enzymes confirmed that EstM-N1 and EstM-N2 belonged to family VIII of bacterial esterases/lipases. The (His)(6)-tagged esterases were purified to about 99% homogeneity from the soluble fraction of recombinant Escherichia coli cultures. The purified EstM-N1 and EstM-N2 retained more than 50% of maximal activity in the temperature range of 0-35 °C, with optimal temperatures of 20 °C and 30 °C, respectively. Both enzymes preferred the short acyl chains of p-nitrophenyl esters and exhibited very narrow substrate specificity, indicating that they are typical esterases. The ß-lactamase activity of EstM-N1 and EstM-N2 was also detected and reached about 31% and 13% of the positive control enzyme, Bacillus cereus ß-lactamase, respectively. These first cold-active esterases belonging to family VIII are expected to be useful for potential biotechnological applications as interesting biocatalysts.

Synthesis activity-based zymography for detection of lipases and esterases.

A new zymography method for lipases and esterases was developed on the basis of the esterification reaction between fatty acids and alcohols. The enzymes were separated by SDS-PAGE and native PAGE. The gel was washed and then incubated in an aqueous solution containing fatty acids (oleic acid 18:1 or caprylic acid 8:0) and dodecanol. Synthesis was visualized by in situ precipitation of water-insoluble and non-diffusible fatty acid esters, such as dodecyl oleate and dodecyl octanoate. The synthesis activity-based zymography was confirmed with different enzyme samples, including commercial lipase preparations, purified recombinant lipase and cutinase, and crude culture supernatants of lipolytic enzyme-producing soil bacteria.

Airway Management Failure after Delayed Extubation in a Patient with Oral Malignant Melanoma Who Underwent Partial Mandibulectomy and Reconstruction with a Free Flap.

Maxillofacial surgery may cause severe complications in perioperative airway management. We report a case of failed airway management in a patient who underwent segmental mandibulectomy, radical neck dissection, and reconstruction with a free flap. The patient was extubated approximately 36 hours after surgery. Approximately 7 hours after extubation, the patient complained of dyspnoea, and respiratory failure followed. Bag-mask ventilation, direct laryngoscopy, video laryngoscopy, and supraglottic airway access were ineffective. The surgical airway was secured with an emergency tracheostomy while performing cardiopulmonary resuscitation. However, the patient experienced permanent hypoxic brain damage. The airway of patients with oral cancer may be compromised postoperatively due to surgical trauma and bulky flap reconstruction. Patients should be closely monitored during the postoperative period to prevent airway failure. Early diagnosis and airway management before airway failure occurs are important. Medical staff should be aware of airway management algorithms, be trained to perform difficult airway management, and have the required equipment readily available.

Life-threatening tension pneumothorax after unsuccessful tracheostomy tube exchange in a trauma patient - A case report.

BACKGROUND: Tracheostomy tube exchange is a common and safe procedure. However, when the tracheocutaneous tract is not completely mature, cannula exchange or endotracheal tube insertion via the tracheostomy site can rarely induce life-threatening complications, including subcutaneous emphysema, loss of airway, tension pneumothorax, and pneumoperitoneum. CASE: We report a case of life-threatening tension pneumothorax developed during tracheostomy tube exchange with a reinforced endotracheal tube for a planned facial surgery after recent tracheostomy in a trauma patient. CONCLUSIONS: Understanding of the pathogenesis and the use of preventive strategies based on it are expected to provide safer and more effective anesthetic management to patients with tracheostomy.

Successful management of uncontrolled postpartum hemorrhage due to morbidly adherent placenta with Resuscitative endovascular balloon occlusion of the aorta during emergency cesarean section - A case report.

BACKGROUND: Morbidly adherent placenta (MAP) may cause life-threatening postpartum hemorrhage (PPH) requiring massive transfusions. Furthermore, it could endanger the lives of both mother and baby. Despite various efforts, such as adjuvant endovascular embolization and hysterectomy, massive PPH due to MAP still occurs and is difficult to overcome. CASE: Herein, we described the case of a 40-year-old woman with placenta previa totalis who experienced massive bleeding during a cesarean section. We used resuscitative endovascular balloon occlusion of the aorta (REBOA) and it improved the condition of the surgical field and the hemodynamic stability of the patient temporarily. The patient was successfully managed without further complications. CONCLUSIONS: REBOA can be used as a rescue procedure for uncontrolled bleeding situations in patients with MAPs. Anesthesiologists should consider and recommend REBOA as another resuscitative therapeutic option in the case of massive PPH.

High-level expression and characterization of Fusarium solani cutinase in Pichia pastoris.

High-level extracellular production of Fusarium solani cutinase was achieved using a Pichia pastoris expression system. The cutinase-encoding gene was cloned into pPICZalphaA with the Saccharomyces cerevisiae alpha-factor signal sequence and methanol-inducible alcohol oxidase promoter by two different ways. The additional sequences of the c-myc epitope and (His)6-tag of the vector were fused to the C-terminus of cutinase, while the other expression vector was constructed without any additional sequence. P. pastoris expressing the non-tagged cutinase exhibited about two- and threefold higher values of protein amount and cutinase activity in the culture supernatant, respectively. After simple purification by diafiltration process, both cutinases were much the same in the specific activity and the biochemical properties such as the substrate specificity and the effects of temperature and pH. In conclusion, the high-level secretion of F. solani cutinase in P. pastoris was demonstrated for the first time and would be a promising alternative to many expression systems previously used for the large-scale production of F. solani cutinase in Saccharomyces cerevisiae as well as Escherichia coli.

Prediction of the effect of injected ethanol on pulmonary arterial pressure during sclerotherapy of arteriovenous malformations: relationship with dose of ethanol.

PURPOSE: To prospectively evaluate the effect of injected ethanol on pulmonary artery pressure during embolosclerotherapy of arteriovenous malformations (AVMs). MATERIALS AND METHODS: This prospective study was conducted in 16 male and 14 female patients (37 sessions; mean age, 34 years; age range, 17-67 years) with AVMs during a 2-year period. The authors measured pulmonary artery pressure via a pulmonary artery catheter and ethanol levels from the pulmonary and radial arteries simultaneously within 3 minutes after each ethanol injection. The authors analyzed the relationship between pulmonary artery pressure and ethanol levels obtained from pulmonary and radial arteries with respect to both single and cumulative doses of ethanol injected. Retrospectively, patients were divided into two groups-those treated with and those treated without vascular occlusion techniques. RESULTS: The radial arterial ethanol level showed good correlation with the pulmonary arterial ethanol level (r = 0.7). Single dose per injection was statistically related with pulmonary artery pressure (r = 0.5 vs 0.1 and P < .05 vs .29, respectively, in patients treated without and patients treated with vascular occlusion techniques), and the correlation coefficient between cumulative dose and pulmonary artery pressure was 0.2 and 0.3 in respective cases (P < .05 for both). The mean pulmonary artery pressure correlated with pulmonary arterial ethanol level irrespective of the use of vascular occlusion (r = 0.6 for both groups). CONCLUSIONS: Pulmonary artery pressure reflected the pulmonary arterial ethanol level and was positively related to the dose of ethanol. Single dose per injection was predictive of pulmonary artery pressure only in patients treated without vascular occlusion techniques.

Gene cloning, expression, and characterization of a new carboxylesterase from Serratia sp. SES-01: comparison with Escherichia coli BioHe enzyme.

The carboxylesterase-encoding gene (bioHs) of a newly isolated strain, Serratia sp. SES-01, was cloned from the genomic DNA library by detecting formation of transparent halo around the colony on LB-tributyrin agar plates. The amino acid sequence of BioHs was highly similar to the members of the BioH enzyme family involved in the biotin biosynthetic pathway; it showed the highest similarity (91%) with that of Serratia proteamaculans. To compare BioHs with other BioH enzymes, the relatively well-known bioHe gene of E. coli was cloned with PCR. After we achieved high-level expression of soluble BioHs and BioHe through the exploration of different culture conditions, the purified BioHs and BioHe enzymes were characterized in terms of specificity, activity, and stability. BioHe was generally more robust to a change in temperature and pH and an addition of organic solvents than BioHs. The two enzymes exhibited a strong preference for carboxylesterase rather than for thioesterase and were optimal at relatively low temperatures (20-40 degrees ) and alkaline pHs (7.5-9.0). The results in this study strongly suggested that both the BioHs and BioHe enzymes would be potential candidates for use as a carboxylesterase in many industrial applications.

Inferior turbinate outfracture for successful nasotracheal intubation in a patient undergoing maxillofacial surgery: case report.

An enlarged inferior turbinate is a predisposing factor for difficult nasotracheal intubation. We describe a case of successful nasotracheal intubation by induced outfracture of the inferior turbinate during maxillofacial surgery, and discuss the importance of adequate airway evaluation and anesthetic management for successful nasal intubation.

Unexpected extensive hemorrhage from a subcapsular hematoma of the liver during emergent laparotomy in a premature neonate.

A subcapsular hematoma of the liver is often found during autopsy in stillborn infants rather than clinically. It is usually asymptomatic unless ruptured; thus, the diagnosis is often delayed or missed. Rupture of a subcapsular hematoma in a premature neonate causes massive intraabdominal hemorrhage, which is associated with high mortality. Thus, early recognition and treatment to avoid rupture are imperative. We describe a case of life-threatening hemorrhage from a subcapsular hematoma of the liver during emergent laparotomy for mechanical obstruction in an 860 g premature neonate and discuss the appropriate preoperative preparation and anesthetic management for this case.