Navigation programs, are they helpful for perioperative care with thyroid cancer patients?

The purpose of this study was to develop and evaluate a navigation program for patients with thyroid cancer. The navigation program was developed following an analysis of the unmet needs of patients who underwent surgery for thyroid cancer. Ninety-nine patients in the control group received usual care, and 95 in the navigation group were managed with a navigation program during the perioperative period. The effectiveness of the navigation program was assessed by administering a questionnaire to both groups. Overall satisfaction scores were significantly higher in the navigation than in the control group (p = .025), as were satisfaction scores on the continuity of information (p < .001), the continuity of management (p = .002), the continuity of relationships with healthcare providers (p<.001), and patient empowerment (p < .001). The newly developed navigation program for patients with thyroid cancer was effective in raising satisfaction levels and in actively managing the disease during the perioperative period.

Risk factors for peri-anaesthetic dental injury.

In this retrospective case-control study, we evaluated peri-operative dental injury risk factors following tracheal intubation. Ninety-four of 290,415 patients experienced dental injury following tracheal intubation over a 10-y period. A control group was matched for surgery type and intubating anaesthetist. The incidence of dental injury was 0.03%. Univariate analysis revealed that previous and current difficult intubation, male gender, hepatitis, neurological disease, anticonvulsant use, pre-existing poor dentition and the use of airway devices (other than a laryngoscope) were associated with dental injury. Multivariate analysis revealed that predictors of dental injury were: history of hepatitis, odds ratio (95% CI) 10.1 (1.02-100.3); poor dentition, 8.8 (3.9-20.0); alternative airway device use, 3.1 (1.2-8.0); and intubation difficulty, 3.7 (1.0-13.3). As well as confirming previously reported risk factors for dental injury during tracheal intubation, this study also suggests hepatitis and the use of alternative airway devices as additional risk factors.

Proteolytic degradation and potential role of onconeural protein cdr2 in neurodegeneration.

Cerebellar degeneration-related protein 2 (cdr2) is expressed in the central nervous system, and its ectopic expression in tumor cells of patients with gynecological malignancies elicits immune responses by cdr2-specific autoantibodies and T lymphocytes, leading to neurological symptoms. However, little is known about the regulation and function of cdr2 in neurodegenerative diseases. Because we found that cdr2 is highly expressed in the midbrain, we investigated the role of cdr2 in experimental models of Parkinson's disease (PD). We found that cdr2 levels were significantly reduced after stereotaxic injection of 1-methyl-4-phenylpyridinium (MPP(+)) into the striatum. cdr2 levels were also decreased in the brains of post-mortem PD patients. Using primary cultures of mesencephalic neurons and MN9D cells, we confirmed that MPP(+) reduces cdr2 in tyrosine hydroxylase-positive dopaminergic neuronal cells. The MPP(+)-induced decrease of cdr2 was primarily caused by calpain- and ubiquitin proteasome system-mediated degradation, and cotreatment with pharmacological inhibitors of these enzymes or overexpression of calcium-binding protein rendered cells less vulnerable to MPP(+)-mediated cytotoxicity. Consequently, overexpression of cdr2 rescued cells from MPP(+)-induced cytotoxicity, whereas knockdown of cdr2 accelerated toxicity. Collectively, our findings provide insights into the novel regulatory mechanism and potentially protective role of onconeural protein during dopaminergic neurodegeneration.

FV-162 is a novel, orally bioavailable, irreversible proteasome inhibitor with improved pharmacokinetics displaying preclinical efficacy with continuous daily dosing.

Approved proteasome inhibitors have advanced the treatment of multiple myeloma but are associated with serious toxicities, poor pharmacokinetics, and most with the inconvenience of intravenous administration. We therefore sought to identify novel orally bioavailable proteasome inhibitors with a continuous daily dosing schedule and improved therapeutic window using a unique drug discovery platform. We employed a fluorine-based medicinal chemistry technology to synthesize 14 novel analogs of epoxyketone-based proteasome inhibitors and screened them for their stability, ability to inhibit the chymotrypsin-like proteasome, and antimyeloma activity in vitro. The tolerability, pharmacokinetics, pharmacodynamic activity, and antimyeloma efficacy of our lead candidate were examined in NOD/SCID mice. We identified a tripeptide epoxyketone, FV-162, as a metabolically stable, potent proteasome inhibitor cytotoxic to human myeloma cell lines and primary myeloma cells. FV-162 had limited toxicity and was well tolerated on a continuous daily dosing schedule. Compared with the benchmark oral irreversible proteasome inhibitor, ONX-0192, FV-162 had a lower peak plasma concentration and longer half-life, resulting in a larger area under the curve (AUC). Oral FV-162 treatment induced rapid, irreversible inhibition of chymotrypsin-like proteasome activity in murine red blood cells and inhibited tumor growth in a myeloma xenograft model. Our data suggest that oral FV-162 with continuous daily dosing schedule displays a favorable safety, efficacy, and pharmacokinetic profile in vivo, identifying it as a promising lead for clinical evaluation in myeloma therapy.

Nefopam as an adjunct to intravenous patient-controlled analgesia after renal transplantation: a randomised trial.

BACKGROUND: Nefopam has been used as an adjuvant to opioid analgesia after operation. We investigated the efficacy of nefopam as an adjunct to fentanyl-based intravenous patient-controlled analgesia (IV PCA) on post-operative pain relief in patients undergoing renal transplantation. METHODS: Ninety-eight patients undergoing elective renal transplantation were randomised into two groups: nefopam or control groups. The former received nefopam (160 mg in 200 ml at a rate of 4 ml/h) whereas the latter received normal saline during the first 48 h after reperfusion of grafted kidney. Pain intensity scores, cumulative dose of fentanyl, and the incidence of adverse events were assessed at 1, 6, 12, 24, and 48 h post-operatively. Serum creatinine and estimated glomerular filtration rate were evaluated on post-operative days 1, 2, 4, and 7. RESULTS: The cumulative fentanyl consumption during the first 48 h after operation was 19% less in the nefopam group than that in the control group (1005 ± 344 µg vs. 1246 ± 486 µg, mean ± SD; P = 0.006). Pain intensity scores at rest and on coughing were significantly lower in the nefopam group throughout the first 12 and 48 h after operation, respectively. Adverse events and early graft function were comparable between the groups, except a significantly lower incidence of drowsiness observed in the nefopam group (4% vs. 21%, P = 0.027). CONCLUSION: In combination with fentanyl PCA, nefopam reduced post-operative fentanyl consumption with superior analgesia after renal transplantation.

Heart rate variability dynamics during controlled hypotension with nicardipine, remifentanil and dexmedetomidine.

BACKGROUND: This study was done to investigate how nicardipine, remifentanil and dexmedetomidine affect the balance of the autonomic nervous system in patients receiving controlled hypotension under general anaesthesia by evaluating heart rate variability indices. METHODS: Sixty-two patients were randomly allocated to either the nicardipine-sevoflurane (Group N, n = 21), remifentanil-sevoflurane (Group R, n = 21) or dexmedetomidine-sevoflurane (Group D, n = 20) group for controlled hypotension during orthognathic surgery. Electrocardiogram data acquisition was done after vital sign stabilization following anaesthesia induction (T1) and 30 min after controlled hypotension was induced (T2). RESULTS: Total power and low frequency (LF) power was significantly decreased at T2 compared with T1 in all groups, while a decrease in high frequency (HF) power was only observed in Group N (P < 0.001). LF/HF ratios of Group R and D were significantly suppressed at T2 compared with T1 (P = 0.001 and P < 0.001, respectively), but was increased Group N (P = 0.009). The LF/HF ratio of Group N was significantly higher than Group R and D at T2 (P < 0.001 in both), with Group D showing a significantly lower LF/HF ratio compared with Group R (P < 0.001). CONCLUSIONS: Remifentanil and dexmedetomidine did not have sympathetic nervous system-stimulating effects during controlled hypotension, while remifentanil seemed to be superior in preserving the overall balance in autonomic nervous system activity. Nicardipine was found to stimulate the sympathetic nervous system, which may be problematic in patients vulnerable to disturbances in the autonomic nervous system.

Randomized controlled comparison of combined general and epidural anesthesia versus general anesthesia on diaphragmatic function after laparoscopic prostatectomy.

BACKGROUND: Little is known about the effect of anesthetic technique on postoperative diaphragmatic function, which is associated with postoperative morbidity and recovery in patients undergoing laparoscopic pelvic surgery. The aim of this trial was to study the effect of combined general and epidural anesthesia versus general anesthesia on postoperative diaphragmatic function measured by ultrasonography in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALRP). METHODS: Fifty-four patients undergoing RALRP were enrolled prospectively. Study population was randomized to receive general (group G, N.=27) or combined general and epidural (group GE, N.=27) anesthesia. Diaphragmatic inspiratory amplitude (DIA), and inspiration and expiration time (Ti and Te, respectively) were measured by M-mode ultrasonography during quiet/deep breathing and sniffing before the surgery and on postoperative days (POD) 1 and 2. Diaphragmatic inspiratory and expiratory velocities (DIV and DEV) were also calculated (DIA/Ti and DIA/Te, respectively). Spirometry was performed in addition to ultrasonography. RESULTS: DIA during deep breathing and sniffing was significantly decreased on POD 1 in group G, while it was preserved in group GE. These reductions in diaphragmatic function were restored to preoperative values on POD 2 in both groups. Vital capacity and peak expiratory flow were diminished in group G on POD 1 and 2. However, spirometry revealed no impairment in group GE except for vital capacity on POD 1. The correlation coefficients (R2) between diaphragmatic function and spirometry variables ranged from 0.231 to 0.286. Postoperaitve pain was comparable. CONCLUSION: Combined general and epidural anesthesia may attenuate the severity of postoperative diaphragmatic dysfunction after RALRP compared to conventional general anesthesia.

Effects of single-dose dexmedetomidine on the quality of recovery after modified radical mastectomy: a randomised controlled trial.

BACKGROUND: Dexmedetomidine is a highly selective α2 agonist with analgesic, anxiolytic, and anti-inflammatory properties. We investigated the effect of a single dose of dexmedetomidine on patient-perceived quality of recovery and clinical recovery variables after modified radical mastectomy under general anesthesia in this randomized, double-blind, placebo-controlled study. METHODS: After Institutional Review Board approval, ninety two female patients were randomly allocated to receive intravenously either saline (Group C, N.=46) or 0.5 µg/kg of dexmedetomidine (Group D, N.=46) five min before the end of surgery. The quality of recovery was assessed using a 40-item quality-of-recovery scoring system (QoR-40) preoperatively and 24 h after surgery. Pain intensity, rescue analgesics, and postoperative nausea and vomiting (PONV) were assessed at postanesthesia care unit (PACU), 1-6 h, and 6-24 h after surgery. RESULTS: Postoperative global QoR-40 scores were higher in Group D compared with Group C (181 [175-187] vs. 174 [154.5-181.5], P=0.004); postoperative QoR-40 scores were improved in the dimensions of emotional state, physical comfort, and psychological support. Total amount of tramadol during 24 h after surgery was significantly lower in Group D than in Group C (54 vs. 76 mg, P=0.006). The incidence of PONV was lower in Group D than in Group C in PACU (21% vs. 43%, P=0.026) and 6-24 h period after surgery (10% vs. 41%, P=0.012). Heart rate and mean blood pressure were significantly lower in Group D as compared with Group C at 5 min after administration of dexmedetomidine, 1 min after extubation, and 20 min after arrival in PACU. CONCLUSION: The use of a single dose dexmedetomidine improved the quality of recovery and reduced analgesic requirements and the incidence of PONV in the early postoperative period after modified radical mastectomy.

Extraskeletal myxoid chondrosarcoma of the neck.

Extraskeletal myxoid chondrosarcoma is a rare malignant soft-tissue tumour that is typically in the deep soft tissues of the lower extremity. The tumour is usually a well-defined, multinodular soft-tissue mass without calcifications. A 62-year-old woman with a history of nasopharyngeal cancer presented with a palpable mass in the anterior neck. Radiologically, the lesion was a well-defined soft-tissue mass with the extensive calcifications on various imaging examinations. Although this lesion was histopathologically diagnosed as extraskeletal myxoid chondrosarcoma, the unusual imaging findings were challenging and very intriguing.

Effects of a 1:1 inspiratory to expiratory ratio on respiratory mechanics and oxygenation during one-lung ventilation in the lateral decubitus position.

Prolonged inspiratory to expiratory (I:E) ratio ventilation may have both positive and negative effects on respiratory mechanics and oxygenation during one-lung ventilation (OLV), but definitive information is currently lacking. We therefore compared the effects of volume-controlled ventilation with I:E ratios of 1:1 and 1:2 on respiratory mechanics and oxygenation during OLV. Fifty-six patients undergoing thoracoscopic lobectomy were randomly assigned volume-controlled ventilation with an I:E ratio of 1:1 (group 1:1, n=28) or 1:2 (group 1:2, n=28) during OLV. Arterial and central venous blood gas analyses and respiratory variables were recorded 15 minutes into two-lung ventilation, at 30 and 60 minutes during OLV, and 15 minutes after two-lung ventilation was re-initiated. Peak and plateau airway pressures in cmH2O [standard deviation] during OLV were significantly lower in group 1:1 than in group 1:2 (P <0.01) (19 [3] and 23 [4]; 16 [3] and 19 [5], respectively). The arterial to end-tidal carbon dioxide tension difference was significantly lower in group 1:1 than in group 1:2 (P <0.01), (0.5 [0.3] and 1.1 [0.5]). There were no significant differences in PaO2 during OLV between the two groups (OLV30, P=0.856; OLV60, P=0.473). In summary, volume-controlled ventilation with an I:E ratio of 1:1 reduced peak and plateau airway pressures improved dynamic compliance and efficiency of alveolar ventilation, but it did not improve arterial oxygenation in a substantial manner. Furthermore, the associated increase in mean airway pressure might have reduced cardiac output, resulting in a lower central venous oxygen saturation.

AFM study of the differential inhibitory effects of the green tea polyphenol (-)-epigallocatechin-3-gallate (EGCG) against Gram-positive and Gram-negative bacteria.

(-)-Epigallocatechin-3-gallate (EGCG), a main constituent of tea catechins, affects Gram-positive and Gram-negative bacteria differently; however, the underlying mechanisms are not clearly understood. Atomic force microscopy (AFM) was used to compare morphological alterations in Gram-positive and Gram-negative bacteria induced by EGCG and by H(2)O(2) at sub-minimum inhibitory concentrations (MICs). EGCG initially induced aggregates in the cell envelopes of Staphylococcus aureus and eventually caused cell lysis, which was not observed in cells treated with H(2)O(2). It initially induced nanoscale perforations or microscale grooves in the cell envelopes of Escherichia coli O157:H7 which eventually disappeared, similar to E. coli cells treated with H(2)O(2). An E. coli O157:H7 tpx mutant, with a defect in thioredoxin-dependent thiol peroxidase (Tpx), was more severely damaged by EGCG when compared with its wild type. Similar differing effects were observed in other Gram-positive and Gram-negative bacteria when exposed to EGCG; it caused aggregated in Streptococcus mutans, while it caused grooves in Pseudomonas aeruginosa. AFM results suggest that the major morphological changes of Gram-negative bacterial cell walls induced by EGCG depend on H(2)O(2) release. This is not the case for Gram-positive bacteria. Oxidative stress in Gram-negative bacteria induced by EGCG was confirmed by flow cytometry.

Effects of substrates on biofilm formation observed by atomic force microscopy.

Formation of biofilm is known to be strongly dependent on substrates including topography, materials, and chemical treatment. In this study, a variety of substrates are tested for understanding biofilm formation. Sheets of aluminum, steel, rubber, and polypropylene have been used to examine their effects on formation of Pseudomonas aeruginosa biofilm. In particular, the morphological variation, transition, and adhesiveness of biofilm were investigated through local measurement by atomic force microscopy (AFM). Mechanism of removing biofilm from adhering to substrate is also analyzed, thus the understanding of the mechanism can be potentially useful to prevent the biofilm formation. The results reveal that formation of biofilm can remain on rough surface regardless of substrates in hot water, which may easily induce extra-polymeric substances detachment from bacterial surface. By probing using AFM, local force-distance characterization of extra-cellular materials extracted from the bacteria can exhibit the progress of the biofilm formation and functional complexities.

Nonionic intravenous contrast agent does not cause clinically significant artifacts to 18F-FDG PET/CT in patients with lung cancer.

OBJECTIVE: This study was performed to evaluate the effects of intravenous (i.v.) contrast agent on semi-quantitative values and lymph node (LN) staging of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in patients with lung cancer. METHODS: Thirty-five patients with lung cancer were prospectively included. Whole-body PET and nonenhanced CT images were acquired 60 min following the i.v. injection of 370 MBq 18F-FDG and subsequently, enhanced-CT images were acquired with the i.v. administration of 400 mg iodinated contrast agent without positional change. PET images were reconstructed with both nonenhanced and enhanced CTs, and the maximum and average standardized uptake values (SUVmax and SUVave) calculated from lung masses, LNs, metastatic lesions, and normal structures were compared. To evaluate the effects of the i.v. contrast agent on LN staging, we compared the LN status on the basis of SUVs (cut-offs; SUVmax=3.5, SUVave=3.0). RESULTS: The mean differences of SUVmax in normal structures between enhanced and nonenhanced PET/CT were 15.23%+/-13.19% for contralateral lung, 8.53%+/-6.11% for aorta, 5.85%+/-4.99% for liver, 5.47%+/-6.81% for muscle, and 2.81%+/-3.05% for bone marrow, and those of SUVave were 10.17%+/-9.00%, 10.51%+/-7.89%, 4.95%+/-3.89%, 5.66%+/-9.12%, and 2.49%+/-2.50%, respectively. The mean differences of SUVmax between enhanced and nonenhanced PET/CT were 5.89%+/-3.92% for lung lesions (n=41), 6.27%+/-3.79% for LNs (n=76), and 3.55%+/-3.38% for metastatic lesions (n=35), and those of SUVave were 3.22%+/-3.01%, 2.86%+/-1.71%, and 2.33%+/-3.95%, respectively. Although one LN status changed from benign to malignant because of contrast-related artifact, there was no up- or down-staging in any of the patients after contrast enhancement. CONCLUSIONS: An i.v. contrast agent may be used in PET/CT without producing any clinically significant artifact.

Increased telomerase activity and human telomerase reverse transcriptase mRNA expression in the endometrium of patients with endometriosis.

BACKGROUND: Endometriosis is considered a frequent, benign disease with the ability to undergo neoplastic processes. The aim of this study was to evaluate the limitless replication potential of the endometrium in patients with endometriosis by examining human telomerase reverse transcriptase (hTERT) mRNA expression and telomerase activity. METHODS: Endometrium samples from 30 endometriosis patients and 30 patients without endometriosis were obtained via endometrial biopsy. The expression of hTERT mRNA was determined by real-time RT-PCR assay, and telomerase activity was measured by telomerase repeat amplification protocol (TRAP) assay. RESULTS: The mean normalized hTERT (N hTERT) mRNA level was significantly higher in the endometriosis than in the control group (P = 0.013). The mean hTERT mRNA levels during the proliferative phase and during the secretory phase were higher in the endometriosis group than in the control group, although the difference was only significant for the secretory phase (P = 0.036). We found a prominent difference in endometrial telomerase activity between moderate-to-severe endometriosis and the control group (P = 0.048). The levels of hTERT mRNA and telomerase activity increased as the disease became more severe (P = 0.038, P = 0.016). CONCLUSIONS: This study showed the overexpression of hTERT mRNA and telomerase activity in the endometrium of endometriosis patients. These finding suggest that replication potential of endometrial cells may have an important role in the pathogenesis of endometriosis.

Effects of chronic angiotensin II receptor antagonist and angiotensin-converting enzyme inhibitor treatments on neurohormonal levels and haemodynamics during cardiopulmonary bypass.

BACKGROUND: Chronic treatment with renin-angiotensin system (RAS) antagonists frequently causes deleterious hypotension during anaesthesia. We compared the effects of angiotensin II receptor antagonists (ARA) and angiotensin-converting enzyme inhibitors (ACEI) on neurohormonal levels and haemodynamics during cardiopulmonary bypass (CPB). METHODS: Forty-four patients undergoing mitral valvular surgery who were treated with either ARA (ARA group, n=14) or ACEI (ACEI group, n=15) over 12 weeks or who were not treated with any RAS antagonist (control group, n=15) were enrolled. The plasma levels of epinephrine, norepinephrine, arginine vasopressin (AVP) and angiotensin II, and haemodynamic variables were measured before (T1) and 15 min after (T2) the start of CPB, before aortic unclamping (T3) and at skin closure (T4). Mean arterial pressure (MAP) was maintained above 60 mm Hg with phenylephrine administration during CPB. RESULTS: The plasma epinephrine, norepinephrine, AVP and angiotensin II levels increased during CPB in all groups. Compared with the control group, the AVP level was lower at T1 in the ARA group and at T2 in the ARA and ACEI groups. The angiotensin II level was higher at T1, T2 and T3 in ARA group compared with ACEI and control groups. There were no significant differences in the epinephrine and norepinephrine levels among the three groups. The amount of administered phenylephrine during CPB was greater and MAP was lower in the ARA group compared with the ACEI and control groups. CONCLUSIONS: Chronic ARA treatment resulted in more profound hypotension than ACEI treatment during CPB, and this may be associated with the blockade of angiotensin II receptors by ARA.

Topical lidocaine effectively reduced the increase of systolic blood pressure after side-clamping of the aorta in off-pump cardiac surgery.

BACKGROUND: Side-clamping of the ascending aorta during off-pump coronary artery bypass surgery (OPCAB) may be associated with a significant increase in systemic blood pressure which may rarely result in aortic dissection. We evaluated whether topical application of lidocaine on the ascending aorta could reduce the rise in systemic blood pressure during side-clamping of the aorta in OPCAB. METHODS: Forty-four patients scheduled for OPCAB were randomly allocated to receive gauze soaked with 10 ml of 4% lidocaine (n = 22) or normal saline (n = 22) on the side-clamping site of the aorta. Sodium nitroprusside (SNP) was infused as necessary to maintain the systolic blood pressure at around 100 mmHg immediately prior to and during side-clamp of the aorta. The requirement and frequency of use of SNP, as well as haemodynamic variables, were recorded serially. RESULTS: The number of patients requiring an SNP infusion and the average amount of infused SNP were significantly less in the lidocaine group. Systolic blood pressure increased significantly during side-clamping in the control group, but not in the lidocaine group. CONCLUSION: Topical application of lidocaine on the surface of the aorta is a simple and effective method to reduce the risk of a sudden increase in systemic blood pressure during side-clamping of the aorta.

The addition of induction chemotherapy with etoposide, ifosfamide, and cisplatin failed to improve therapeutic outcome of concurrent chemoradiotherapy in patients with locally advanced non-small cell lung cancer -- single institution retrospective analysis.

Although chemoradiotherapy (CRT) is a standard treatment for unresectable locally advanced non-small cell lung cancer (NSCLC), the optimal sequencing remains to be determined. We retrospectively compared the treatment results of induction chemotherapy followed by concurrent CRT (induction group, 32 patients) with those of concurrent CRT alone (concurrent group, 41 patients) in unresectable stage IIIA/IIIB NSCLC patients. In induction group, 2 cycles of induction chemotherapy (etoposide/ifosfamide/cisplatin: 24 patients, others: 8 patients) were followed by concurrent CRT (60 Gy/30 fractions, 6 mg/m2 of cisplatin daily), while the same concurrent CRT was administered in concurrent group. Clinicopathologic characteristics including age, weight loss, histologic types, and clinical stage did not show significant differences between two groups except for a higher proportion of patients with ECOG performance status 2 in concurrent group (3% vs. 27%, p=0.015). Overall toxicity was generally acceptable with 1 treatment-related death from tracheoesophageal fistula in induction group. The response rates after concurrent CRT were 41% for induction group and 54% for concurrent group, which showed no significant difference (p=0.560). With median follow-up of 13 (1-92) months, there was a trend toward an advantage for concurrent group in median progression-free survival (6 months vs 8.3 months, p=0.067) and overall survival (12 months vs. 14.5 months, p=0.059). In multivariate analysis, only more than 10% weight loss within 6 months was significantly associated with poor survival (p=0.001). In conclusion, the addition of induction chemotherapy to concurrent CRT did not show any advantage over concurrent CRT alone in locally advanced NSCLC.

Solitary liver mass detected by transesophageal echocardiography.

UNLABELLED: Transesophageal echocardiography (TEE) has become a mainstay of cardiac surgery in the diagnosis of intracardiac and vascular lesions adjacent to the esophagus. In this case, we detected a liver mass during intraoperative TEE examination in a patient undergoing elective cardiac valve surgery. Preoperatively, the patient had normal liver function tests and no symptoms of hepatocellular carcinoma. This mass was diagnosed as hepatocellular carcinoma after the surgery and treated with transarterial chemoembolization. In conclusion, this case report outlines another potential application of intraoperative TEE extending its role outside the realm of cardiac surgery. IMPLICATIONS: A liver mass was detected during intraoperative transesophageal echocardiography (TEE) examination in a patient undergoing cardiac valve surgery. This incidental finding permitted the early diagnosis of hepatocellular carcinoma, and demonstrates another potential utility of TEE.

Changes in jugular bulb oxygen saturation during off-pump coronary artery bypass graft surgery.

BACKGROUND: The effect of haemodynamic derangement during coronary artery anastomosis in off-pump coronary artery bypass surgery on cerebral blood flow has not been elucidated. Jugular bulb oxygen saturation is a useful indicator of cerebral blood flow provided that the cerebral metabolic rate is constant. This study was designed to evaluate the changes in jugular bulb oxygen saturation during off-pump coronary artery bypass surgery. METHODS: With IRB approval, 48 patients were included. After anaesthesia, an 18-G catheter was introduced into the jugular bulb. Haemodynamic variables and oxygen profiles from gas analysis of jugular bulb blood and arterial blood were obtained: after sternotomy (baseline); at 5 min after the beginning of the anastomosis of the left anterior descending artery, obtuse marginal artery, and right coronary artery; and after sternal closure. RESULTS: Cardiac index and mixed venous oxygen saturation decreased significantly during anastomosis of all three arteries compared to the baseline value. Although the changes in jugular bulb oxygen saturation during anastomosis were statistically significant compared to its baseline value, jugular bulb oxygen saturation remained within normal limit throughout the study. CONCLUSIONS: Jugular bulb oxygen saturation, which represents the global cerebral oxygenation, was well maintained during the anastomosis of all coronary arteries despite significant haemodynamic changes during off-pump coronary artery bypass (OPCAB).

The haemodynamic effects of propranolol and atenolol medication on dobutamine infusion in patients with coronary artery obstructive disease.

We compared the haemodynamic effects of beta-blockers on dobutamine infusion in 60 patients undergoing coronary artery bypass graft surgery. All patients had been taking propranolol (n = 30) or atenolol (n = 30) pre-operatively for at least 1 month. After sternotomy, dobutamine was infused at 2 microg/kg per min, and the dose increased to 4 microg/kg per min and then 8 microg/kg per min, at 15-min intervals. In both groups, dobutamine infusion did not increase the cardiac index or the heart rate, but was associated with an increase in mean arterial pressure, systemic vascular resistance index and mean pulmonary arterial pressure in a dose-dependent manner. The haemodynamic responses to dobutamine infusion were similar in the two groups. We conclude that pre-operative medication with beta-blockers reduced the inotropic and chronotropic effects of dobutamine infusion. There was no difference between the modification produced by propranolol, a non-selective beta-blocker, and that produced by atenolol, a selective beta1-blocker, however.