Efficacy of Preoperative Bilateral Thoracic Paravertebral Block in Cardiac Surgery Requiring Full Heparinization: A Propensity-Matched Study.

OBJECTIVES: To assess the efficacy of preoperative bilateral paravertebral block (PVB) with general anesthesia (GA) in contributing to early extubation and decreasing opioid consumption in cardiac surgery. DESIGN: A propensity score-matched retrospective study. SETTING: A single tertiary medical center between January 2018 and December 2020. PARTICIPANTS: Adult patients undergoing isolated first-time aortic valve replacement and coronary artery bypass grafting with full sternotomy. INTERVENTIONS: A cohort of 44 patients who received PVB with GA (PVB group) was matched with 44 patients who underwent similar surgery with GA only (GA only group). MEASUREMENTS AND MAIN RESULTS: The completion rate of extubation in the operating room was significantly greater in the PVB group (65.9%) than in the GA only group (43.2%; p = 0.032). The completion rate of extubation within eight hours after surgery also was significantly greater in the PVB group (86.4%) than in the GA only group (68.2%; p = 0.042). The median amount of intraoperative fentanyl administered was significantly less in the PVB group (4.8 µg/kg; interquartile range [IQR], 3.3-7.2) than in the GA only group (8.4 µg/kg; IQR, 5.4-12.7; p < 0.001). The median amount of postoperative fentanyl administered was significantly less in the PVB group (6.8 µg/kg; IQR, 3.9-10.6) than in the GA only group (8.1 µg/kg; IQR, 6.2-15.9; p = 0.012). CONCLUSIONS: This study demonstrated that preoperative bilateral PVB combined with GA contributed to early extubation in isolated first-time aortic valve replacement and coronary artery bypass grafting and in the reduction of intraoperative and postoperative fentanyl consumption.

Effect of malnutrition and frailty status on surgical aortic valve replacement.

OBJECTIVES: To date, assessment of nutritional and frailty status in patients undergoing surgical aortic valve replacement remains unclear. This study aimed to assess the effect of geriatric nutritional risk index (GNRI) and Rockwood clinical frailty scale (CFS) on short-term and mid-term survival in patients who underwent surgical aortic valve replacement for aortic stenosis. METHODS: In total, 219 patients who underwent aortic valve replacement for aortic stenosis between Jan 1 2011 and Dec 31 2018 were retrospectively monitored in a single center. Mid-term survival was assessed using Kaplan-Meier analysis. Logistic and Cox regression analyses were performed to detect independent predictors for early and mid-term mortality. Follow-up was 97.7% complete, and a GNRI score ≤ 98 denoted malnutrition. RESULTS: In the univariable analysis, GNRI [odds ratio (OR) 0.91, 95% confidence interval (CI), 0.86-0.96, p < 0.001] and CFS (OR 2.00 95% CI 1.38-2.94, p < 0.001) were identified as significant risk factors for in-hospital mortality. Mid-term survival was significantly decreased in patients with malnutrition (3 and 5 year survival rates 83.9 and 76.9%, respectively, p < 0.001). Mid-term freedom from major cardiac and cerebrovascular events was significantly decreased in patients with malnutrition (p = 0.039). The CFS (hazard ratio 1.78) and GNRI (hazard ratio 0.95) were independent risk factors for mid-term survival in the univariable and multivariable analyses, respectively. CONCLUSIONS: A lower GNRI is associated with poor mid-term mortality and major cardiac and cerebrovascular events after surgical aortic valve replacement. A lower CFS score is associated with unfavorable mid-term outcomes.

Successful ligation of posterior tibial vein aneurysm performed according to intraoperative venography results.

A 23-year-old woman was diagnosed with a posterior tibial vein aneurysm that had resulted in deep vein thrombosis and a pulmonary embolism. The patient responded well to anticoagulation therapy, and surgical resection was planned to prevent recurrence. She was scheduled to undergo tangential aneurysmectomy and lateral venorrhaphy. However, the aneurysm could not be completely exposed because of adhesions. Therefore, venography was performed to identify the inflow and outflow vessels, which were ligated because an accessory venous communication was identified. Intraoperative venography can aid in the selection of simple ligation or reconstruction of a venous communication for the treatment of posterior tibial vein aneurysms.

Endoscopic placement of covered versus uncovered self-expandable metal stents for palliation of malignant gastric outlet obstruction.

OBJECTIVE: Stenting is an established endoscopic therapy for malignant gastric outlet obstruction (mGOO). The choice of stent (covered vs uncovered) has been examined in prior randomised studies without clear results. DESIGN: In a multicentre randomised prospective study, we compared covered (CSEMS) with uncovered self-expandable metal stents (UCSEMS) in patients with mGOO; main outcomes were stent dysfunction and patient survival, with subgroup analyses of patients with extrinsic and intrinsic tumours. RESULTS: Overall survival was poor with no difference between groups (probability at 3 months 49.7% for covered vs 48.4% for uncovered stents; log-rank for overall survival p=0.26). Within that setting of short survival, the proportion of stent dysfunction was significantly higher for uncovered stents (35.2% vs 23.4%, p=0.01) with significantly shorter time to stent dysfunction. This was mainly relevant for patients with extrinsic tumours (stent dysfunction rates for uncovered stents 35.6% vs 17.5%, p<0.01). Subgrouping was also relevant with respect to tumour ingrowth (lower with covered stents for intrinsic tumours; 1.6% vs 27.7%, p<0.01) and stent migration (higher with covered stents for extrinsic tumours: 15.3% vs 2.5%, p<0.01). CONCLUSIONS: Due to poor patient survival, minor differences between covered and uncovered stents may be less relevant even if statistically significant; however, subgroup analysis would suggest to use covered stents for intrinsic and uncovered stents for extrinsic malignancies.

Mechanism of aspirin-induced inhibition on the secondary hyperalgesia in osteoarthritis model rats.

AIMS: The daily activity of osteoarthritis (OA) patients is limited by chronic pain and central sensitization. Although non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are the first-line drugs for the treatment of OA-related pain, their efficacy on central sensitization remains unclear. In the present study, we evaluated the effect of acetylsalicylic acid (ASA, Aspirin) using an OA model induced by monosodium iodoacetate (MIA), which has a similar disease progression to human OA. MAIN METHODS: Secondary hyperalgesia was assessed at the plantar surface of the hind paw by Von Frey test. We evaluated the expression of acid-sensing ion channel 3 (ASIC3) in dorsal root ganglia and that of tumor necrosis factor-α (TNF-α) and interleukin-1ß (IL-1ß) in the spinal cord, which may cause secondary hyperalgesia in OA, by immunohistochemical analysis and real-time qPCR. KEY FINDINGS: The administration of ASA attenuated secondary hyperalgesia at 1-3 weeks after MIA, while celecoxib, a selective cyclooxygenase (COX)-2 inhibitor, failed to attenuate secondary hyperalgesia at week 2 after MIA injection, suggesting that ASA exerts its analgesic effect through a COX-2-independent pathway. Immunohistochemical analysis of the dorsal root ganglia indicated that ASA reduced the expression of ASIC3 during OA progression. Expression of TNF-α mRNA, but not IL-1ß mRNA, in the spinal cord following MIA injection was suppressed by ASA administration. SIGNIFICANCE: These findings suggest that ASA may have the ability to attenuate secondary hyperalgesia through suppression of ASIC3 and/or TNF-α expression. ASA is therefore a clinically useful analgesic drug for treatment of secondary hyperalgesia in OA.

Usefulness of immunohistochemical staining for MUC5AC in differentiating primary pancreatic cancer from pancreatic metastasis of breast cancer.

Diagnosis of pancreatic ductal adenocarcinoma (PDAC) and its differentiation from metastases to the pancreas from other organs remains challenging. We report a case in which immunohistochemical staining for MUC5AC was useful in distinguishing primary pancreatic cancer from breast cancer metastasis. A 51-year-old Japanese woman who underwent curative resection of her breast cancer was referred to our hospital with a pancreatic head tumor. Although we surmised her pancreatic tumor to be metastatic breast cancer based on her past history and imaging studies, she was subsequently diagnosed with PDAC on the basis of immunohistochemical staining for MUC5AC using specimens obtained by endoscopic ultrasound-fine-needle aspiration. Thus, MUC5AC may be a useful diagnostic marker for discriminating PDAC from a secondary malignancy.

Comparison between a rotatable sphincterotome and a conventional sphincterotome for selective bile duct cannulation.

BACKGROUND: Selective biliary cannulation (SBC) is the first challenge of endoscopic retrograde cholangiopancreatography (ERCP), especially for trainees, and a rotatable sphincterotome may be useful to guide the directional axis of the scope and SBC. METHODS: We performed a prospective randomized single-center trial, enrolling 200 patients with a native papilla who required therapeutic biliary ERCP. Patients were randomly assigned to the rotatable sphincterotome group (n = 100) or the conventional sphincterotome group (n = 100). The primary endpoint was successful SBC by the trainees within 10 minutes. RESULTS: The early and late cannulation success rates did not differ significantly between the groups (P = 0.46 and P > 0.99, respectively). For the patients in whom trainees failed to achieve SBC, the rotatable sphincterotome was used as a rescue cannulation technique in four patients from the conventional group; in no patients in the rotatable group was the conventional sphincterotome used for SBC. Post-ERCP pancreatitis (PEP) occurred in 11 patients (5.5 %; 6 mild, 5 moderate); the incidence did not differ significantly between the two groups (rotatable group 3 %, conventional group 8 %; P = 0.21). The two groups were thus combined for evaluation of the factors relating to cannulation difficulty for trainees, which revealed that orientation of the papilla was a significant factor (P < 0.001). CONCLUSIONS: The type of sphincterotome used did not affect the success of SBC by trainees. However, orientation of the papilla was revealed to be a significant factor relating to cannulation difficulty for trainees overall.

Management of Pancreatolithiasis: A Nationwide Survey in Japan.

OBJECTIVES: The aim of this study was to assess prevailing treatment of pancreatolithiasis in Japan. METHODS: We surveyed clinical data from 1834 patients (1479 men and 355 women) at 125 hospitals. RESULTS: Extracorporeal shock-wave lithotripsy (ESWL) was performed alone in 103 patients (5.6%), ESWL plus an endoscopic procedure in 446 (24.3%), endoscopic treatment alone in 261 (14.2%), and surgery in 167 (9.1%). Other treatments were given to 358 (19.5%), whereas 499 (27.2%) received no treatment. Symptoms were relieved in 85.7% after ESWL, 80.8% after endoscopic treatment alone, and 92.8% after surgery. Early complication rates within 3 months after ESWL, endoscopic treatment alone, and surgery were 8%, 4.5%, and 27.1%, respectively. Late complications after ESWL, endoscopic procedures alone, and surgery were 1.7%, 2.5%, and 8.2%, respectively. Symptom relief but also early and late complications were greater after surgery than after ESWL and endoscopic treatment. Among 417 patients undergoing ESWL, 61 (14.6%) required surgery, as did 32 (16%) of 200 patients treated endoscopically. Surgery was required less frequently following initial operative treatment (11/164 patients [6.7%]). Nonsurgical initial treatments were chosen more frequently. CONCLUSIONS: First-line treatment of pancreatolithiasis should be ESWL with or without endoscopy because of minimal invasiveness and fewer complications.

High Fractional Occupancy of a Tandem Maf Recognition Element and Its Role in Long-Range ß-Globin Gene Regulation.

Enhancers and promoters assemble protein complexes that ultimately regulate the recruitment and activity of RNA polymerases. Previous work has shown that at least some enhancers form stable protein complexes, leading to the formation of enhanceosomes. We analyzed protein-DNA interactions in the murine ß-globin gene locus using the methyltransferase accessibility protocol for individual templates (MAPit). The data show that a tandem Maf recognition element (MARE) in locus control region (LCR) hypersensitive site 2 (HS2) reveals a remarkably high degree of occupancy during differentiation of mouse erythroleukemia cells. Most of the other transcription factor binding sites in LCR HS2 or in the adult ß-globin gene promoter regions exhibit low fractional occupancy, suggesting highly dynamic protein-DNA interactions. Targeting of an artificial zinc finger DNA-binding domain (ZF-DBD) to the HS2 tandem MARE caused a reduction in the association of MARE-binding proteins and transcription complexes at LCR HS2 and the adult ßmajor-globin gene promoter but did not affect expression of the ßminor-globin gene. The data demonstrate that a stable MARE-associated footprint in LCR HS2 is important for the recruitment of transcription complexes to the adult ßmajor-globin gene promoter during erythroid cell differentiation.

Prognostic model for survival based on readily available pretreatment factors in patients with advanced pancreatic cancer receiving palliative chemotherapy.

BACKGROUND: We aimed to construct a prognostic model to predict survival in patients with advanced pancreatic cancer (APC) receiving palliative chemotherapy using readily available pretreatment factors. METHODS: The model was constructed using data from 306 consecutive patients with APC who received palliative chemotherapy between January 2006 and March 2013. The predictive accuracy of the model was assessed using a concordance index (c-index) and calibration curves. RESULTS: Among the 12 potential prognostic factors investigated, multivariate analysis identified the following six independent negative prognostic factors-performance status (PS), the presence of distant metastatic disease, the status of initially unresectable disease, carcinoembryonic antigen (CEA) level, carbohydrate antigen 19-9 (CA19-9) level, and neutrophil-lymphocyte ratio (NLR). A prognostic index (PI) based on the coefficients of these factors was constructed as follows-PI = 2 (if PS 2-3) + 1 (if distant metastatic disease) + 1 (if initially unresectable disease) + 1 (if CEA level ≥5.0 ng/ml) + 1 (if CA 19-9 level ≥1,000 U/ml) + 2 (if NLR ≥5). The patients were classified into three prognostic groups-favorable (PI 0-1, n = 73), intermediate (PI 2-3, n = 145), and poor (PI 4-8, n = 88). The median overall survival times for each prognostic group were 16.5, 12.3, and 6.2 months, respectively (P < 0.001). Bootstrapping verified the good fitness of this model for predicting 1-year survival, and the c-index was 0.658. CONCLUSIONS: This simple prognostic model could help clinicians to estimate survival in patients with APC who receive palliative chemotherapy.

Safety climate and motivation toward patient safety among Japanese nurses in hospitals of fewer than 250 beds.

A questionnaire survey was done to examine the associations between the dimensions of safety climate and the nurses' motivation toward patient safety. Excluding nursing directors, a total of 371 full-time female Japanese nurses (registered nurses and licensed practical nurses) working in 6 hospitals of fewer than 250 beds were analyzed. The average age was 35.6 yr (range, 20-69). For the safety climate, factor analysis (the principal factor method and promax rotation) was performed, and factors with an eigenvalue of>or=1 were extracted. Seven dimensions were extracted by factor analysis as follows: "Opportunities for nursing education", "Reporting", "Fatigue reduction", "Superiors' attitudes", "Nursing conditions", "Communications with physicians", and "Relationships among nurses". We subsequently examined the associations between the dimensions of the safety climate and "Nurses' motivation to prevent mistakes". Multiple linear regression analysis showed that "Nurses' motivation to prevent mistakes" was significantly associated with "Reporting", "Nursing conditions", and "Communications with physicians". It is necessary to improve the reporting system in hospitals. It is also necessary to improve on reducing improper communications with physicians. And appropriate nursing conditions must be actualized and maintained.

A pilot study testing the dimensions of safety climate among Japanese nurses.

To investigate the dimensions of safety climate among Japanese nurses, an anonymous self-administered questionnaire survey was conducted. The subjects involved in the survey included 293 full-time nurses (registered nurses and licensed practical nurses) working in a public hospital, excluding directors of nursing. A total of 221 of the 293 nurses answered the questionnaires. Among 221 questionnaires, the questionnaires, which had missing values in the question items used in this study, were excluded from the analyses. Consequently, a total of 201 questionnaires were analyzed. The average age of the subjects was 34.7 yr. As a result of exploratory factor analysis, 5 factors were extracted as follows: intellectual development regarding medical safety among nurses, accumulated fatigue, nursing conditions, supervisors' attitudes, and communication with physicians. All the values of Cronback's coefficient alpha among these 5 factors were between 0.804 and 0.892. As a result of the confirmatory factor analysis of the 5 factors, the value of the GFI (Goodness of Fit Index) was 0.868. The value of the CFI (Comparative Fit Index) was 0.943. The value of the RMSEA (Root Mean Square Error of Approximation) was 0.062. The results of this study will contribute to the investigation of the dimensions of a nurses' safety climate scale in the future. The associations between the dimensions of the safety climate and the motivation to work toward improving patients' safety among Japanese nurses will need to be examined, as will those between the dimensions of the safety climate and actual clinical mistakes.