Impact of various anesthetic regimens on motor-evoked potentials in infants undergoing spinal surgery: A case series.

Motor-evoked potential (MEP) monitoring is commonly used in children. MEP monitoring in infants is difficult due to smaller signals requiring higher stimulation voltages. There is limited information on the effect of different anesthetics on MEP monitoring in this age group. This case series describes the effect of different anesthetic regimens on MEP monitoring in infants. Patients <1 year of age who underwent spinal surgery with MEP monitoring between February 2022 and July 2023 at a single tertiary care children hospital were reviewed. The motor-evoked potential amplitudes were classified into 4 levels based on the voltage in the upper and lower limbs (none, responded, acceptable, sufficient). "Acceptable" or "sufficient" levels were defined as successful monitoring. A total of 19 infants were identified, involving 3 anesthesia regimens: 4/19 (21.1%) cases were anesthetized with propofol/remifentanil total intravenous anesthesia (TIVA), 3/19 (15.8%) with propofol/remifentanil/low-dose sevoflurane and another 12/19 (63.2%) cases who initially received propofol/remifentanil/sevoflurane and were converted to propofol/remifentanil anesthesia intraoperatively. The 4 cases with propofol/remifentanil showed 20/32 (62.5%) successful monitoring points. In contrast, 6/24 (25%) successful points were achieved with propofol/remifentanil intravenous anesthesia/0.5 age-adjusted minimum alveolar concentration sevoflurane. In 12 cases converted from propofol/remifentanil/low-dose inhalational anesthetics to TIVA alone, successful MEP monitoring points increased from 46/96 (47.9%) to 81/96 (84.4%). Adding low-dose inhalation anesthetic to propofol-based TIVA suppresses MEP amplitudes in infants. The optimal anesthetic regimen for infants requires further investigation.

Early mortality of emergency surgery for acute type A aortic dissection in octogenarians and nonagenarians: A multi-center retrospective study.

OBJECTIVES: The clinical data on postoperative mortality and central nervous system (CNS) complications in older adults who underwent acute type A aortic dissection are limited. Thus, in this study we aimed to evaluate the association between age and early postoperative mortality and occurrence of CNS complications. METHODS: This multicentric retrospective cohort study included 5 tertiary hospitals in Japan. All patients who underwent emergency surgery for acute type A aortic dissection between October 1998 and December 2019 were enrolled. The multilevel Cox proportional hazards model, which considered years as level 1, institutions as level 2, and surgeons as level 3, was used to evaluate the association between age and early postoperative hospital mortality and occurrence of CNS complications. RESULTS: Of the 1037 patients, 227 (21.9%) were ≥80 years old and 810 (78.1%) were <80 years old. Overall, 134 patients (12.9%) died within 30 days postoperatively; among them, 42/227 (18.5%) and 92/810 (11.4%) were aged ≥80 and <80 years, respectively (hazard ratio [HR], 1.63; P = .0046). CNS complications within 30 days postoperatively occurred in 140/1037 (13.5%) patients; among them, 42/227 (18.5%) and 98/810 (12.1%) were aged ≥80 and <80 years, respectively (HR, 1.63; P = .011). In multivariate analysis, age ≥80 years was associated with mortality within 30 days postoperatively (adjusted HR, 2.37; 95% CI, 1.23-4.57; P = .01) but not with CNS complications (adjusted HR, 1.58; 95% CI, 0.93-2.69; P = .091). CONCLUSIONS: The early postoperative mortality in older patients was approximately 50% higher than in the younger population. A thorough discussion regarding the surgical indications should be done.

Association Between Plasma Fibrinogen Concentration After Cardiopulmonary Bypass and Postoperative Blood Loss in Children Undergoing Cardiac Surgery: A Retrospective Cohort Study.

Background Intraoperative hypofibrinogenemia is a major factor associated with increased postoperative blood loss in adult cardiac surgery. However, previous pediatric studies on this topic did not sufficiently adjust for potential confounders and variations in surgeons' techniques. Therefore, evidence for the association between hypofibrinogenemia and postoperative blood loss after cardiac surgery in children remains insufficient. In this study, we aimed to evaluate the association between postoperative blood loss and hypofibrinogenemia by adjusting for potential confounders and the effects of differences in surgeons' techniques. Methodology This single-center, retrospective, cohort study included children who underwent cardiac surgery with cardiopulmonary bypass from April 2019 to March 2022. Multilevel logistic regression models with mixed effects were used to evaluate the association of major blood loss in the first six hours postoperatively with fibrinogen concentration at the end of cardiopulmonary bypass. The difference in the surgeon's techniques was adjusted as a random effect for the model. The model included potential confounders identified as risk factors in previous studies. Results A total of 401 patients were included. A fibrinogen concentration ≤150 mg/dL (adjusted odds ratio (aOR) = 2.08; 95% confidence interval (CI) = 1.18-3.67; p = 0.011) and the presence of cyanotic disease (aOR = 2.34; 95% CI = 1.10-4.97; p = 0.027) were associated with major blood loss in the first six postoperative hours. Conclusions A fibrinogen concentration ≤150 mg/dL and the presence of cyanotic disease were associated with postoperative blood loss in pediatric cardiac surgery. Maintaining a fibrinogen concentration >150 mg/dL is recommended, especially for patients with cyanotic diseases.

Optimal dose of normal saline for confirming correct peripheral venous access with precordial Doppler ultrasonography in children.

Precordial Doppler ultrasound technology can be utilized to confirm correct peripheral intravenous vascular (PIV) access in children during surgery. This study aimed to determine the minimally required dose of normal saline (NS) for confirming correct PIV access. Healthy children were randomly allocated to receive a 0.1 mL/kg, 0.3 mL/kg, or 0.5 mL/kg dose of NS injected via PIV access. Two independent raters judged the change in the recorded precordial Doppler sound test (S-test) before and after NS injection. Typically, rapid injection of NS increased the pitch of the heartbeat as the injection volume increased. Changes in blood flow velocity test (V-test) results were evaluated using a cut-off value of 1 cm/s. Both in the S- and V-tests, the detection rate of correct PIV access was lower with 0.1 mL/kg NS than with 0.3 mL/kg or 0.5 mL/kg. Logistic regression analysis showed that the positive results in both the S- and V-tests were significantly decreased with a 0.1 mL/kg NS; no significant difference was observed with a 0.3 mL/kg NS (reference dose: 0.5 mL/kg). These results suggest 0.3 mL/kg is the minimally required dose of NS for confirming correct PIV access. This study is registered with the University Hospital Medical Information Network (UMIN000041330).

Precordial Doppler to assess vascular access in children: A preliminary report.

BACKGROUND: Delayed identification and dysfunction of peripheral intravenous (PIV) infiltration can lead to serious injury in children. This preliminary study aimed to describe the application of precordial Doppler ultrasound to detect and confirm the correct PIV access in children with congenital heart disease (CHD). METHODS: This study was conducted on children (<18 years) diagnosed with CHD and admitted to the pediatric intensive care unit (PICU) of a single center after cardiac surgery or cardiac catheterization between February 2020 and May 2021. Three raters judged the precordial Doppler sound change (S test) after injection of 0.5 mL/kg of normal saline (NS) through the PIV access. Blood-flow velocities before and after the NS injection were recorded and the accuracy of detecting PIV catheter infiltration and dysfunction was analyzed (V test). RESULTS: The overall incidence of PIV infiltration and dysfunction was in 3 out of 103 patients (2.9%). The sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver operating characteristic curve were 3 out of 3 [100%, 95% confidence interval (CI): 29.2-100], 86 out of 100 (86%, 95% CI: 77.6%-92.1), 7.1, 0.0, and 0.93, respectively, in the S test and they were 2 out of 3 (66.7%, 95% CI: 9.4%-99.2), 94 out of 100 (94.0%, 95% CI: 87.4%-7.8%), 11.1, 0.36, and 0.80, respectively in the V test. CONCLUSIONS: Precordial Doppler ultrasound was a feasible and accurate technique for confirming correct PIV access in children with CHD; however, a larger, prospective investigation is necessary to examine its diagnostic accuracy.

Volar RIM Plate Rarely Causes Flexor Tendon Complications in a Short Period Despite Its Plate Prominence over the Watershed Line: A Descriptive Study.

Background: The DePuy Synthes variable angle LCP® Volar RIM Plate has been designed with its contour to overhang volar rim fragments of the distal radius to prevent secondary displacement after fracture fixation. Therefore, RIM potentially contributes to a risk of flexor tendon rupture due to its plate prominence over the watershed line. This is a retrospective cross-sectional study that aims at describing the occurrence of complications by utilizing RIM as well as three standards VLPs to evaluate the impact of plate design on flexor tendons. Methods: A total of 84 patients with a volar locking plate fixation were analyzed retrospectively (Far-distal; RIM: 14 cases, Juxta-articular; AcuLoc2 (ACUMED): 20 cases, Dual-Loc V7 (MEIRA): 25 cases, Extra-articular; VA-TCP (DePuy Synthes): 25 cases). Tendinous problems were evaluated with a reported adverse event and flexor tendon appearance examined by utilizing ultrasonography and direct observation during hardware removal. Plate prominence was graded according to Soong's classification and the distance to flexor tendons was measured to describe the risk that each plate damage the flexor tendons. Results: The mean follow-up period was 13.0 months. All RIM plates were placed in grade 2 (85.7%) and grade 1 (14.3%). Symptomatic and asymptomatic tendinous problems were barely reported in RIM. The examination of ultrasonography and direct observation during hardware removal showed that tendons smoothly slid without attrition on the curved plate surface of RIM despite their adjacent appositions came from its high and distal plate prominence. Conclusions: Smooth profile of RIM showed an ability to decrease the potential risk of flexor tendon damage regardless of its prominence over the watershed line. RIM can be applied more to challenging far distal fractures when used judiciously and surgeons need to be even more vigilant for symptoms of tendon irritation as usually recommended without being coward more than necessary.

Validity of the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) for Japanese patients with labral tear.

The Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) was created for patient-reported outcome measures (PROMs) and to evaluate the conditions of patients with hip disease. Nevertheless, the validity of the JHEQ for patients with hip labral tears remains unclear. Therefore, we validated the JHEQ in patients with labral tears. There were 51 patients (mean age 44.5, range 18-60 years; 31 women). Thirty-two patients had right-sided tears, 29 underwent hip arthroscopy, 32 had femoroacetabular impingement and 15 had developmental hip dysplasia. Five PROMs included in the JHEQ were evaluated using test-retest methods. Statistical analysis was performed using SPSS software according to the COnsensus-based Standards for the selection of health status Measurement Instruments checklist. The intra-class correlation coefficient (1, 2) of all JHEQ scores (84 points) was 0.88 and Cronbach's α was 0.94. Bland-Altman analysis revealed good test-retest reliability for the JHEQ. The Spearman's rank test, including the SF-36 subscale, showed a high correlation with physical functioning [1, 0.67 (P < 0.01); 2, 0.65 (P < 0.01)], body pain [1, 0.54 (P < 0.01); 2, 0.53 (P < 0.01)] and physical component summary [1, 0.55 (P < 0.01); 2, 0.55 (P < 0.01)]. The value of minimal important change (22.9) was higher than that of smallest detectable change (3.21), suggesting that the JHEQ has adequate responsiveness. We demonstrated the reliability, validity and responsiveness of the JHEQ in Japanese patients with hip labral tears. JHEQ is a valid assessment tool not only for patients with hip osteoarthritis or osteonecrosis but also for those with hip labral tears.

Exploring the validation of a Japanese version of the International Hip Outcome Tool 12: Reliability, validity, and responsiveness.

BACKGROUNDS: The International Hip Outcome Tool 12 (iHOT12) was authorized by the Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN). iHOT12 is increasingly being adopted in orthopedic studies to report patient outcomes. This study aimed to develop a Japanese version of the International Hip Outcome Tools "iHOT12J", and to establish its reliability, validity, and responsiveness. METHODS: To assess test-retest reliability, an identical set of patients reported outcome measures with five qualitative scoring measures including iHOT12; these were filled out by each patient twice. Reliability was explored using Cronbachss alpha and intraclass correlation coefficient. The Bland-Altman plot was used to explore the absolute agreement. To evaluate validity, we examined the relationships between SF36 and iHOT12. Responsiveness was assessed by comparing the smallest detectable change to the minimal important change by applying an anchor-based approach. RESULTS: Fifty patients (51 joints) were analyzed from March 2016 to October 2017 in Japanese four facility. The Cronbach α coefficient was 0.90 and the average value of intraclass coefficient (ICC) was 0.89. Bland-Altman plot analysis showed a solid agreement. Regarding the validity, the Spearman rank correlation coefficients were strong with PF (r = 0.69, p < 0.01), BP (r = 0.71, p < 0.01) and PCS (r = 0.69, p < 0.01). The smallest detectable change (3.19) was smaller than the minimum important change (12.40). CONCLUSIONS: We developed iHOT12J, which seems to show sufficient reliability, validity, and responsiveness. We believe that this patient reported outcome measure is beneficial in studying Japanese patients with femoroacetabular impingement.

Japanese version of the international PROMs "Vail Hip Score": Reliability, validity, and responsiveness according to the COSMIN checklist.

BACKGROUND: This study aimed to develop a Japanese version of the international PROMs "Vail Hip Score (Vail10)" and to establish its reliability, validity, and responsiveness with COSMIN check-list. METHODS: The study was conducted from March 2016 to October 2017 and included 46 patients totaling 47 joints. Disorders included 30 cases of FAI (55%), 13 cases of DDH (28%), and 4 others (8%). We administered an identical set of PROMs (5 measures: Japanese-version iHOT12 (pilot draft), Japanese-version Vail10, Japanese-version Oxford Hip Score, JHEQ, and SF36) twice in these subjects. We determined interclass correlation coefficients for the first and second round [ICC(1,2)], as well as the Cronbach α coefficient for patient responses to each of the 10 items in Vail10. In addition, we determined Spearman rank correlation coefficients of Vail10, OHS, JHEQ, satisfaction VAS, the 8 subscales of SF36, and the 3 QOL summary scores. RESULTS: ICC for the total score of all 10 items in Vail10 was 0.96. Cronbach α coefficient was 0.96. Bland-Altman plot analysis showed a solid agreement. Regarding the validity, Spearman rank correlation coefficients, only satisfaction VAS, and SF36 subscales of PF and BP had r > 0.45 (p < 0.01 in both administration rounds). The SDC (1.32) was smaller than the MIC (8.14). CONCLUSIONS: After developing the Japanese version of Vail10, we examined its Reliability, validity, and responsiveness by administering the measure to patients with acetabular labral tear. Correlations were strong and demonstrated the efficacy of the Japanese version of Vail10.

Sudden Airway Collapse After Pneumoperitoneum With Undiagnosed Tracheomalacia in a Morbidly Obese 12-Year-Old Boy Undergoing Laparoscopic Cholecystectomy: A Case Report.

Tracheomalacia is characterized by the collapse of the tracheal wall due to the softening of the tracheal cartilage and myoelastic tissues. We describe the case of a 12-year-old morbidly obese boy, without previous medical issues, scheduled for elective laparoscopic cholecystectomy. Immediately after pneumoperitoneum was established, mechanical ventilation could not be performed. Intraoperative exploration with flexible bronchoscopy showed that the tip of the endotracheal tube was nearly occluded by the posterior tracheal wall bulging anteriorly. Anesthesiologists should be aware of undiagnosed tracheomalacia as a cause of sudden airway collapse, even after the airway is secured with an endotracheal tube.

Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National Emergency Airway Registry for Children.

OBJECTIVES: Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU. DESIGN: A retrospective cohort study of a multicenter pediatric airway quality improvement registry. SETTINGS: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Children (< 18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036). CONCLUSIONS: Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.

Downward Trend in Pediatric Resident Laryngoscopy Participation in PICUs.

OBJECTIVES: As of July 2013, pediatric resident trainee guidelines in the United States no longer require proficiency in nonneonatal tracheal intubation. We hypothesized that laryngoscopy by pediatric residents has decreased over time, with a more pronounced decrease after this guideline change. DESIGN: Prospective cohort study. SETTING: Twenty-five PICUs at various children's hospitals across the United States. PATIENTS: Tracheal intubations performed in PICUs from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Prospective cohort study in which all primary tracheal intubations occurring in the United States from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children) were analyzed. Participating PICU leaders were also asked to describe their local airway management training for residents. Resident participation trends over time, stratified by presence of a Pediatric Critical Care Medicine fellowship and airway training curriculum for residents, were described. A total of 9,203 tracheal intubations from 25 PICUs were reported. Pediatric residents participated in 16% of tracheal intubations as first laryngoscopists: 14% in PICUs with a Pediatric Critical Care Medicine fellowship and 34% in PICUs without one (p < 0.001). Resident participation decreased significantly over time (3.4% per year; p < 0.001). The decrease was significant in ICUs with a Pediatric Critical Care Medicine fellowship (p < 0.001) but not in ICUs without one (p = 0.73). After adjusting for site-level clustering, patient characteristics, and Pediatric Critical Care Medicine fellowship presence, the Accreditation Council for Graduate Medical Education guideline change was not associated with lower participation by residents (odds ratio, 0.86; 95% CI, 0.59-1.24; p = 0.43). The downward trend of resident participation was similar regardless of the presence of an airway curriculum for residents. CONCLUSION: Laryngoscopy by pediatric residents has substantially decreased over time. This downward trend was not associated with the 2013 Accreditation Council for Graduate Medical Education change in residency requirements.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children.

OBJECTIVES: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. DESIGN: A retrospective observational study using a multicenter emergency airway quality improvement registry. SETTING: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. MEASUREMENTS AND MAIN RESULTS: Propensity score-matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62-0.75; p < 0.001). In propensity score-matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90-0.95; p < 0.001). CONCLUSIONS: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Estimation of the success rate of anesthetic management for thymectomy in patients with myasthenia gravis treated without muscle relaxants: a retrospective observational cohort study.

Although maintaining anesthesia for myasthenia gravis (MG) with minimal muscle relaxants (MR) is common, the success rate of anesthetic management for MG without MR is not clear. We therefore retrospectively examined the success rate of anesthetic management for MG without MR among 66 consecutive cases of thymectomy for MG performed at our hospital between January 2004 and April 2010, before approval of using sugammadex. A total of 60 patients (90.9 %) were treated without MR (N group). Among the 60 cases, 17 (28.3 %) patients were not extubated in the operating room due to postoperative respiratory depression or other reasons. Therefore, the success rate of anesthetic management for thymectomy in patients with MG without treating MR was 71.7 % (43/60) [95 % confident interval (CI): 65.9-77.5 %]. The reasons for using MR included coughing at intubation in one case, bucking during surgery in two cases, and MR was considered to be safer by the attending anesthesiologist in three cases. The number of cases of impossible extubation requiring ventilation on that day was three in the N group and none in the R group. Finally, the success rate of anesthetic management for MG without MR was estimated to be 71.1 % (95 % CI: 65.9-77.5 %).

A patient with possible TRALI who developed pulmonary hypertensive crisis and acute pulmonary edema during cardiac surgery.

There are very few case reports of transfusion-related acute lung injury (TRALI) under close hemodynamic monitoring. We encountered a case of possible TRALI during on-pump coronary artery bypass grafting (CABG). A 66-year-old man who had undergone on-pump CABG was administered fresh frozen plasma (FFP). One hour after FFP transfusion, pulmonary hypertensive crisis and subsequent hypoxic decompensation occurred. A second cardiopulmonary bypass (CPB) was needed for circulatory and respiratory deterioration. Extracorporeal life support (ECLS), intraaortic balloon pumping (IABP), and nitric oxide therapy were required after the surgery. Despite the severity of the initial state, his recovery was comparatively smooth. ECLS and IABP were removed on postoperative day (POD)1; the patient was extubated and discharged from the ICU on POD7 and POD12, respectively. The diagnosis of TRALI was confirmed by human leukocyte antigen antibody detection in the administered FFP. In addition, lymphocytic immunofluorescence test showed that a cross-match of the plasma from the pooled FFP against the recipient leukocytes was positive. The clinical course of the pulmonary artery hypertension was followed by a decrease in dynamic lung compliance. The mechanism of this phenomenon is unclear. However, it might suggest the possibility of vasoconstriction or obstruction of the peripheral pulmonary artery preceding lung damage, as in the case in animal models reported previously.

Phase II clinical trial of postoperative S-1 monotherapy for gastric cancer patients with free intraperitoneal cancer cells detected by real-time RT-PCR.

BACKGROUND: We have previously reported the molecular detection of peritoneal micrometastases in patients with gastric cancer by quantifying carcinoembryonic antigen (CEA) mRNA in the peritoneal washes. Patients with CEA mRNA exceeding a cutoff value have a significant risk for developing peritoneal carcinomatosis, but optimal treatment for this population remains unknown. METHODS: CEA mRNA (+) patients with gastric cancer were treated postoperatively with S-1 monotherapy. Overall survival, the primary endpoint of this phase II trial, was compared with the historical control, which is comprised of CEA mRNA (+) patients who were not given postoperative chemotherapy. RESULTS: A total of 32 patients with CEA mRNA (+) gastric cancer were enrolled. Twelve patients (37.5%) relapsed; ten showed peritoneal relapse. Three-year survival was similar between the study population and the historical control (67.3% vs. 67.1%, respectively). CONCLUSIONS: S-1 monotherapy, which significantly reduced risk for recurrence in stage II/III gastric carcinoma in another phase III trial, seems not to be as effective in eradicating free cancer cells in the abdominal cavity.

Feasibility study of direct fentanyl patch introduction without prior opioid titration.

BACKGROUND: Opioids are key drugs for cancer pain relief, but some patients, especially those who have gastroenterological cancers, suffer from severe opioid-induced bowel dysfunction (OBD), which reduces their quality of life. In order to achieve better pain relief, efforts to minimize OBD are required. METHODS: Between September 2006 and December 2007, 18 patients were enrolled in this feasibility study. All patients had gastroenterological cancer pain. The patients received direct fentanyl patch introduction starting from 12.5 microg/h, with additional opioid treatment for the first 12 h. Adverse events, changes of medications, pain scale, and patients' satisfaction scores were recorded for 9 days after fentanyl patch introduction. RESULTS: All patients completed the protocol treatment without interruption by adverse events. Eight patients (44%) showed adverse events that were presumed to be related to the treatment. However, all events were grade 1 and had a minimal effect on patients' quality of life. According to subjective evaluation on day 9, only 4 patients (22%) mentioned that they had felt adverse events during the treatment course. Seventeen patients (94%) had pain score scale improvements evaluated on day 9. Satisfaction scores on days 9 and day 27 were excellent or good for all but one of the patients. CONCLUSION: This prospective study showed the safety and efficacy of direct fentanyl patch introduction in Japanese gastroenterological cancer patients, and the treatment had good feasibility. This model should help cancer pain management for patients with a high risk of features of OBD such as constipation, subileus, or postabdominal surgery.

Detection of elevated proteins in peritoneal dissemination of gastric cancer by analyzing mass spectra data of serum proteins.

BACKGROUND: Recently, several authors reported on the Protein Chip approach to analyze serum. They used SELDI-TOF-MS (surface enhanced laser desorption/ionization-time of flight-mass spectrometry) to identify patients with cancers of various origins in a highly sensitive and specific manner. In the current study, a similar approach was employed to analyze the serum of patients with various stages of gastric cancer. METHODS: Control serum specimens from patients with gastritis (n = 19) and those with gastric cancer (Stage I: n = 6, Stage II or III: n = 6, Stage IV: n = 6, total: n = 18) were collected and analyzed by the Protein Chip biomarker system (Bio-Rad, Japan), a platform for SELDI-TOF-MS, and protein profiles were obtained and compared. The cation exchange chip (CM10) and the anion exchange chip (Q10) were used for processing before TOF-MS. RESULTS: nine proteins were significantly over-expressed (P < 0.05, Student t-test) in patients with gastric cancer compared to patients with gastritis. Among them, four protein masses with 2929 m/z, 3293 m/z, 3371 m/z, and 4213 m/z were found to be differentially expressed solely in patients suffering from peritoneal dissemination. All peaks were processed on CM10 chips. Employing one data mining method, CART (classification and regression trees), gastric cancer patients with peritoneal dissemination were successfully separated from those who had no peritoneal seeding. CONCLUSION: A validation study with a larger number of samples is mandatory; however, the detected peaks here might be candidates for biomarkers of peritoneal dissemination and/or gastric cancer. Moreover, further analysis of these four proteins might be helpful in revealing the mechanism of peritoneal dissemination, which at present has no cure.

Titration of serum CEA, p53 antibodies and CEA-IgM complexes in patients with colorectal cancer.

The early detection of colorectal cancer is key to the improvement of patient survival. Although fecal occult blood testing and carcinoembryonic antigen (CEA) in serum are widely used as non-invasive screening methods, they have limited sensitivity. Forty-five patients who underwent surgery for primary colorectal cancer were enrolled in this study. Sixteen (36%) were determined to have Stage I tumors, 15 (33%) Stage II tumors and 14 (31%) Stage III tumors. Serum samples from a non-colorectal cancer group of 22 patients with no tumors were analyzed as a control. In each serum sample, CEA, p53 antibodies and CEA-IgM complexes were measured. The combination of these three tests had an overall sensitivity of 53% (24/45), and revealed 31% (5/16) of the tumors to be in Stage I, 53% (8/15) to be in Stage II and 79% (11/14) to be in Stage III, while the false positive rate was 18% (4/22). The combined use of these three tests in serum is potentially an effective screening method for the detection of colorectal cancer, at even the early stages of the disease.

[A case of recurrent gastroesophageal junction adenocarcinoma successfully treated with radiation plus chemotherapy (5-FU+CDDP, S-1, Paclitaxel, CPT-11) for long-term survival with good QOL].

We report a 63-year-old man with recurrent gastroesophageal junction adenocarcinoma. He underwent esophagogastrectomy in August 2004. After curative operation with Stage III (pT3N1M0), a recurrence was found at the anastomosis site in November 2004. Chemoradiotherapy with S-1 followed by chemotherapy (S-1) was performed from January 2005 to April 2006. Lymphnode metastasis to the left side of the main bronchus appeared in May 2006, and paclitaxel was used until December 2007 when PR was indicated by CT scan and GIF. Now he is receiving CPT-11. During these 3 years and 3 months, his performance status was maintained from 0 to 1.