A RARE CASE OF GRAVES' THYROTOXICOSIS WITH CONCOMITANT PULMONARY ALVEOLAR PROTEINOSIS.

Background: Graves' disease results in various clinical cardio-pulmonary manifestations such as tachycardia, atrial fibrillation, and pulmonary edema. Clinical Case: A 62-year-old woman presented with palpitations and dyspnea. Laboratory and radiologic examination revealed markedly elevated free T4 (4.79 ng/dL), T3 (4.42 ng/mL), lowered TSH (0.01 uIU/mL), atrial fibrillation and multifocal lung haziness. She was initially diagnosed with atrial fibrillation with pulmonary edema, which subsequently changed to pulmonary alveolar proteinosis by further evaluations such as computed tomography and bronchoscopic biopsy. Conclusion: Pulmonary alveolar proteinosis is a rare lung disease. Clinicians should carefully assess lung lesions in thyrotoxicosis patients as they can be easily mistaken for pulmonary edema in clinical practice.

Randomized, Open-Label, Phase IV, Korean Study of Kidney Transplant Patients Converting From Cyclosporine to Prolonged-Release Tacrolimus Plus Standard- or Reduced-Dose Corticosteroids.

BACKGROUND: This 24-week, multicenter, randomized, exploratory, comparative, open-label, phase-IV study assessed the safety and efficacy of prolonged-release tacrolimus (PR-T) with reduced-dose versus standard-dose corticosteroids in stable kidney transplant recipients in Korea after converting from cyclosporine-based therapy. METHODS: At baseline, patients were converted from cyclosporine-based to PR-T-based immunosuppression and randomized (1:1) to receive either corticosteroids maintained at prestudy dose (standard-dose group) or tapered from week 4 to 50% of the prestudy dose by week 12 (reduced-dose group). Patients were seen at baseline and weeks 1, 4, 12, and 24. The primary endpoint was change in estimated glomerular filtration rate (Modification-of-Diet-in-Renal-Disease-4) between baseline and week 24. Secondary endpoints included either acute rejection or patient-reported satisfaction with PR-T. Adverse events (AEs) were recorded. RESULTS: Overall, 150 patients were randomized into a reduced-dose group (n = 73) and a standard-dose group (n = 77). At week 24, mean ± standard deviation for corticosteroid dose was 2.5 ± 0.9 mg and 5.0 ± 1.3 mg, respectively. Mean change in estimated glomerular filtration rate from baseline to week 24 was +1.5 ± 9.1 mL/min/1.73 m2 (P = .1567) and +3.4 ± 10.6 mL/min/1.73 m2 (P = .0065), respectively, and not significantly different between groups. There were no acute rejection episodes. Most respondents (>70%) considered PR-T more convenient than cyclosporine. AE incidence was similar between groups. The most common AEs experienced by ≥3% of patients in either treatment group were gastrointestinal events (20.8% and 28.6% of patients receiving reduced- and standard-dose corticosteroids, respectively). Most AEs in both treatment groups were mild or moderate in severity. CONCLUSION: Renal function was maintained following conversion from cyclosporine to PR-T, irrespective of corticosteroid regimen; PR-T enables reduced corticosteroid dosage.

A Case Series of Asymptomatic Hemodialysis Catheter-Related Right Atrial Thrombi That Are Incidentally Detected Prior to Kidney Transplantation.

A hemodialysis (HD) catheter-related right atrial thrombus (RAT) is rarely encountered prior to kidney transplantation (KT) but necessitates a decision about whether to anticoagulate and/or delay the surgery. There is controversy surrounding the clinical implications of a RAT in this situation. It is sometimes considered fatal but other opinions consider it to be benign, especially when incidentally detected. We reviewed the clinical characteristics, management, and outcomes of a patient series with HD catheter-related RAT detected prior to KT and speculated on its clinical significance. Among 3677 cases of KT performed on 3607 patients between January 1997 and September 2015 in our single tertiary center, 11 cases of HD catheter-related RAT detected on transthoracic echocardiography (TTE) prior to KT were included for analysis. The average maximal diameter of the RAT was 23.2 ± 16.3 (SD in mm) and 9 (81.8%) of these 11 patients had no symptoms associated with the RAT. Four patients (36.3%) had their catheters replaced, 5 patients (45.5%) had their catheters removed, and the catheters were maintained in the remaining 2 patients (18.2%). Six patients (54.5%) were anticoagulated with either heparin or warfarin. However all 11 patients had a successful KT suggesting that a HD catheter-related RAT incidentally detected prior to this surgery may not be as serious as previously considered and should not be a reason for delaying the transplantation.

Computational study on the effect of malalignment of the tibial component on the biomechanics of total knee arthroplasty: A Finite Element Analysis.

OBJECTIVES: Malalignment of the tibial component could influence the long-term survival of a total knee arthroplasty (TKA). The object of this study was to investigate the biomechanical effect of varus and valgus malalignment on the tibial component under stance-phase gait cycle loading conditions. METHODS: Validated finite element models for varus and valgus malalignment by 3° and 5° were developed to evaluate the effect of malalignment on the tibial component in TKA. Maximum contact stress and contact area on a polyethylene insert, maximum contact stress on patellar button and the collateral ligament force were investigated. RESULTS: There was greater total contact stress in the varus alignment than in the valgus, with more marked difference on the medial side. An increase in ligament force was clearly demonstrated, especially in the valgus alignment and force exerted on the medial collateral ligament also increased. CONCLUSION: These results highlight the importance of accurate surgical reconstruction of the coronal tibial alignment of the knee joint. Varus and valgus alignments will influence wear and ligament stability, respectively in TKA.Cite this article: D-S. Suh, K-T. Kang, J. Son, O-R. Kwon, C. Baek, Y-G. Koh. Computational study on the effect of malalignment of the tibial component on the biomechanics of total knee arthroplasty: A Finite Element Analysis. Bone Joint Res 2017;6:623-630. DOI: 10.1302/2046-3758.611.BJR-2016-0088.R2.

Nanowire sensors monitor bacterial growth kinetics and response to antibiotics.

Miniaturized and cost-efficient methods aiming at high throughput analysis of microbes are of great importance for the surveillance and control of infectious diseases and the related issue of antimicrobial resistance. Here we demonstrate a miniature nanosensor based on a honeycomb-patterned silicon nanowire field effect transistor (FET) capable of detection of bacterial growth and antibiotic response in microbiologically relevant nutrient media. We determine the growth kinetics and metabolic state of Escherichia coli cells in undiluted media via the quantification of changes in the source-drain current caused by varying pH values. Furthermore, by measuring the time dependent profile of pH change for bacterial cultures treated with antibiotics, we demonstrate for the first time the possibility of electrically distinguishing between bacteriostatic and bactericidal drug effects. We believe that the use of such nanoscopic FET devices enables addressing parameters that are not easily accessible by conventional optical methods in a label-free format, i.e. monitoring of microbial metabolic activity or stress response.

Effects of sugammadex vs. pyridostigmine-glycopyrrolate on post-operative nausea and vomiting: propensity score matching.

BACKGROUND: Sugammadex is a new agent that reverses neuromuscular blockade by aminosteroid neuromuscular blocker. This retrospective study compared the effects of sugammadex on post-operative nausea and vomiting (PONV) with those of a pyridostigmine-glycopyrrolate mixture. METHODS: We reviewed the electronic medical records of 7179 patients who had received fentanyl-based, intravenous, patient-controlled analgesia (IV-PCA) at Chung-Ang University Hospital between January 1, 2010 and December 31, 2015. We categorized the patients into two groups on the basis of the type of reversal agent to neuromuscular blockade that was used: a traditional reversal agent (pyridostigmine-glycopyrrolate mixture; Group R; n = 7059) and sugammadex (Group S; n = 120). The propensity score matching method was then used to select 408 subjects in Group R and 115 subjects in Group S; on the basis of their covariates, these subjects were then matched with a counterpart in the other group. RESULTS: After propensity score matching, the two groups were well balanced with respect to all baseline covariates. In Group S, the numeric rating scale of nausea on day 0, as well as the number of patients who vomited on day 0, was lower than that in group R. Furthermore, Group S used fewer rescue antiemetics on day 0 and had a higher complete response on day 0. CONCLUSION: Sugammadex might be more beneficial for PONV compared to pyridostigmine-glycopyrrolate mixture for patients who have received opioid-based IV-PCA.

Development of a nomogram for predicting the probability of postoperative delirium in patients undergoing free flap reconstruction for head and neck cancer.

PURPOSE: To develop nomogram for prediction of postoperative delirium (POD) in patients undergoing ablative and reconstruction surgery for head and neck cancer. METHODS: Total 341 patients were retrospectively analyzed, and clinical variables in preoperative, intraoperative and postoperative periods were compared between delirium group (n = 89) and non-delirium group (n = 252). Multivariate logistic regression, receiver operating characteristics curve, and area under the curve (AUC) were used to generate and test a nomogram, which performance was evaluated by 10-fold cross validation (CV) procedure. RESULTS: In univariate and multivariate analysis, age, history of psychiatric disorder, marital status, preoperative numeric rating scale for pain, ASA classification, and ICU stay period were identified as significant risk factors. Using these factors, nomogram for predicting the POD was developed and it showed sensitivity of 61.8%, specificity of 75.4%, PPV of 47.0%, and NPV of 84.8% (Youden's index of 0.372). In 10-fold cross validation set, corresponding values were 44.9%, 84.1%, 50.0% and 81.2% (Youden's index of 0.337). AUC was comparable between two sets (0.7407 and 0.6898). CONCLUSIONS: Proposed nomogram showed fair discriminative power for POD risk in head and neck cancer patients undergoing major surgery.

Risk Factors for Hypertension After Living Donor Kidney Transplantation in Korea: A Multivariate Analysis.

BACKGROUND: Post-transplantation hypertension is very common and is associated with cardiovascular complications and poor graft survival in kidney transplant recipients. This study aimed to identify risk factors for hypertension after living donor kidney transplantation. METHODS: We retrospectively analyzed patients who underwent renal transplantation between January 2009 and April 2012. Hypertension was defined as the use of antihypertensive medications at 12 months post-transplantation. Student t test and chi-squared test were performed for univariate analysis. Logistic regression analysis was performed for multivariate analysis. RESULTS: Five-hundred thirty-nine patients were enrolled in the analyses. The rate of antihypertensive medication use was 67% at 12 months. In multivariate analysis, male gender (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.55-4.61), pretransplantation hypertension (OR, 4.65; 95% CI, 2.14-10.11), donor hypertension (OR, 3.23; 95% CI, 1.05-9.96), high body mass index (BMI; OR, 1.21; 95% CI, 1.12-1.29), and use of cyclosporine (OR, 2.05; 95% CI, 1.28-3.27) were associated with post-transplantation hypertension. CONCLUSION: These data show that male recipient, hypertension before transplantation, donor hypertension, high BMI, and cyclosporine use were independent factors associated with hypertension. It would be useful to predict and prevention the hypertension after kidney transplantation.

Measuring the effect of femoral malrotation on knee joint biomechanics for total knee arthroplasty using computational simulation.

OBJECTIVES: Malrotation of the femoral component can result in post-operative complications in total knee arthroplasty (TKA), including patellar maltracking. Therefore, we used computational simulation to investigate the influence of femoral malrotation on contact stresses on the polyethylene (PE) insert and on the patellar button as well as on the forces on the collateral ligaments. MATERIALS AND METHODS: Validated finite element (FE) models, for internal and external malrotations from 0° to 10° with regard to the neutral position, were developed to evaluate the effect of malrotation on the femoral component in TKA. Femoral malrotation in TKA on the knee joint was simulated in walking stance-phase gait and squat loading conditions. RESULTS: Contact stress on the medial side of the PE insert increased with internal femoral malrotation and decreased with external femoral malrotation in both stance-phase gait and squat loading conditions. There was an opposite trend in the lateral side of the PE insert case. Contact stress on the patellar button increased with internal femoral malrotation and decreased with external femoral malrotation in both stance-phase gait and squat loading conditions. In particular, contact stress on the patellar button increased by 98% with internal malrotation of 10° in the squat loading condition. The force on the medial collateral ligament (MCL) and the lateral collateral ligament (LCL) increased with internal and external femoral malrotations, respectively. CONCLUSIONS: These findings provide support for orthopaedic surgeons to determine a more accurate femoral component alignment in order to reduce post-operative PE problems.Cite this article: K-T. Kang, Y-G. Koh, J. Son, O-R. Kwon, C. Baek, S. H. Jung, K. K. Park. Measuring the effect of femoral malrotation on knee joint biomechanics for total knee arthroplasty using computational simulation. Bone Joint Res 2016;5:552-559. DOI: 10.1302/2046-3758.511.BJR-2016-0107.R1.

Comparison of streamlined liner of the pharynx airway (SLIPA ™) and laryngeal mask airway: a systematic review and meta-analysis.

We performed a systematic review to compare the efficacy and safety of the streamlined liner of the pharynx airway and laryngeal mask airway used in adults during general anaesthesia. We included 14 studies with studies with 1273 patients in total. There was no evidence of a difference between the two devices in insertion success rate on the first attempt (13 studies, 1143 patients), insertion time (seven studies, 576 patients), ease of insertion (five studies, 466 patients), oropharyngeal leak pressure (eight studies, 771 patients) and the quality of the fibreoptic view of the larynx through the device (three studies, 281 patients). The relative risk (95% CI) of bloodstaining of the device (nine studies, 859 patients) was 2.09 (1.46-3.00) for the streamlined liner of the pharynx airway compared with the laryngeal mask airway. Other adverse events were comparable. Subgroup analysis suggested that the insertion by novice users might be faster and more successful with the streamlined liner of the pharynx airway than the laryngeal mask airway; however, this was from only two studies and 186 patients. The method of size selection of the streamlined liner of the pharynx airway device might also affect the speed of insertion: choosing according to the width of the patient's thyroid cartilage, rather than height, may produce better results.

Emergence agitation after orthognathic surgery: a randomised controlled comparison between sevoflurane and desflurane.

BACKGROUND: This study aimed to compare emergence agitation following sevoflurane and desflurane anaesthesia in adults undergoing orthognathic surgery. The hypothesis was that there might be a difference in the incidence of emergence agitation following sevoflurane and desflurane anaesthesia considering the difference in blood solubility and speed of recovery between the two. METHODS: In this prospective randomised double-blind study, 144 adults undergoing orthognathic surgery were randomly allocated to either sevoflurane or desflurane anaesthesia. The incidence of emergence agitation and possible causative factors were then compared between the groups. RESULTS: The incidence of emergence agitation was lower in the desflurane group than in the sevoflurane group (24% vs. 71%, P < 0.001). In addition, the time intervals between the discontinuation of anaesthetics and the first response, extubation, and discharge from post-anaesthesia care unit were significantly shorter in the desflurane group (P = 0.002, P < 0.001 and P = 0.003, respectively). The other variables were similar in the two groups. CONCLUSIONS: In adults undergoing orthognathic surgery, desflurane anaesthesia was associated with less emergence agitation than was sevoflurane anaesthesia.

A systematic review and meta-analysis of the i-gel® vs laryngeal mask airway in children.

We systematically reviewed randomised controlled trials of the i-gel® vs different types of laryngeal mask airway in children. We included nine studies. There was no evidence for differences in: rate of insertion at first attempt; insertion time; ease of insertion; or gastric tube insertion. The mean (95% CI) oropharyngeal leak pressure was 3.29 (2.25-4.34) cmH2 O higher with the i-gel, p < 0.00001. The relative rate (95% CI) of a good fibreoptic view through the i-gel was 1.10 (1.01-1.19), p = 0.02. There were no significant differences in the rates of complications, except for blood on the airway, relative rate with the i-gel 0.46 (0.23-0.91), p = 0.02. We concluded that the clinical performance of the i-gel and LMA was similar, except for three outcomes that favoured the i-gel.

Role of glycogen synthase kinase-3ß in ketamine-induced developmental neuroapoptosis in rats.

BACKGROUND: Ketamine-induced neuroapoptosis has been attributed to diverse stress-related mechanisms. Glycogen synthase kinase-3ß (GSK-3ß) is a multifunctional kinase that is active in neuronal development and linked to neurodegenerative disorders. We hypothesized that ketamine would enhance GSK-3ß-induced neuroapopotosis, and that lithium, an inhibitor of GSK-3ß, would attenuate this response in vivo. METHODS: Protein levels of cleaved caspase-3, protein kinase B (AKT), GSK-3ß, and cyclin D1 were measured in post-natal day 7 rat pups after 1.5, 3, 4.5, and 6 h exposure to ketamine. A cohort of rat pups was randomized to a 6 h exposure to ketamine with and without lithium. Neuroapoptosis was measured by cleaved caspase-3 and terminal deoxynucleotidyl transferase-mediated dUTP nick end-labelling staining by immunohistochemistry. Protein levels of cleaved caspase-3 and -9 and the total and phosphorylated forms of AKT, GSK-3ß, and cyclin D1 (cell cycle protein) were also measured. RESULTS: Ketamine produced a duration-dependent increase in cleaved caspase-3 and cyclin D1, which corresponded to decreases in phosphorylated AKT and GSK-3ß. Co-administration of lithium with ketamine attenuated this response. CONCLUSIONS: Ketamine-induced neuroapoptosis is associated with a temporal decrease in GSK-3ß phosphorylation, and simultaneous administration of lithium mitigated this response. These findings suggest that GSK-3ß is activated during this ketamine-induced neuroapoptosis.

Hepatocellular carcinoma in patients with chronic liver disease: a comparison of gadoxetic acid-enhanced MRI and multiphasic MDCT.

AIM: To compare the diagnostic performances of gadoxetic acid-enhanced magnetic resonance imaging (MRI) and multiphasic multidetector computed tomography (MDCT) in the detection of hepatocellular carcinoma (HCC) in patients with chronic liver disease. MATERIALS AND METHODS: Institutional review board approval was obtained for this study and informed consent was obtained from all patients. Fifty-one patients (43 men, eight women; age range 32-80 years) with 73 HCCs underwent gadoxetic acid-enhanced MRI and multiphasic MDCT. Two readers independently analysed each image in three separate reading sessions. The alternative free-response receiver operating characteristic (AFROC) method was used to analyse the diagnostic accuracy. Positive and negative predictive values and sensitivity were evaluated. RESULTS: A total of 73 HCCs were detected in 51 patients. Although not significant (p>0.05), the areas under the receiver operating characteristic curves were 0.877 and 0.850 for MDCT, 0.918 and 0.911 for dynamic MRI, and 0.905 and 0.918 for combined interpretation of dynamic and hepatobiliary phase MR images. Differences in sensitivity, specificity, and positive and negative predictive values between the readers were not statistically significant (p>0.05). Combined interpretation of dynamic and hepatobiliary phase MRI images was more useful than MDCT in the detection of HCC lesions ≤1cm in diameter for one reader (p=0.043). CONCLUSION: Gadoxetic acid-enhanced MRI and MDCT show similar diagnostic performances for the detection of HCC in patients with chronic liver disease. However, the combined interpretation of dynamic and hepatobiliary phase MRI images may improve diagnostic accuracy in the detection of HCC lesions ≤1cm in diameter.

Neuregulin-1 protects against neurotoxicities induced by Swedish amyloid precursor protein via the ErbB4 receptor.

Neuregulin-1 (NRG1) plays an important role in the development and plasticity of the brain and exhibits potent neuroprotective properties. However, little information on its role in Alzheimer's disease (AD) is known. The neuroprotective effect and mechanisms of NRG1 in SH-SY5Y cells overexpressing the Swedish mutant form of amyloid precursor protein (Swe-APP) and primary cortical neuronal cells treated with amyloid beta peptide(1-42) (Aß(1-42)) were investigated in this study. NRG1 attenuated Swe-APP- or Aß(1-42)-induced lactate dehydrogenase (LDH) release in a concentration-dependent manner. The mitigating effects of NRG1 on neuronal cell death were blocked by ErbB4 inhibition, a key NRG1 receptor, which suggests a role of ErbB4 in the neuroprotective function of NRG1. Moreover, NRG1 reduced the number of Swe-APP- and Aß(1-42)-induced TUNEL-positive SH-SY5Y cells and primary cortical neurons, respectively. NRG1 reduced the accumulation of reactive oxygen species and attenuated Swe-APP-induced mitochondrial membrane potential loss. NRG1 also induced the upregulation of the expression of the anti-apoptotic protein, Bcl-2, and decreased caspase-3 activation. Collectively, our results demonstrate that NRG1 exerts neuroprotective effects via the ErbB4 receptor, which suggests the neuroprotective potential of NRG1 in AD.

Cloning of a Family 11 Xylanase Gene from Bacillus amyloliquefaciens CH51 Isolated from Cheonggukjang.

Bacillus amyloliquefaciens CH51, an isolate from cheonggukjang, Korean fermented soyfood, secretes several enzymes into culture medium. A gene encoding 19 kDa xylanase was cloned by PCR. Sequencing showed that the gene encoded a glycohydrolase family 11 xylanase and named xynA. xynAHis, xynA with additional codons for his-tag, was overexpressed in Escherichia coli BL21(DE3) using pET-26b(+). XynAHis was purified using HisTrap affinity column. Km and Vmax of XynAHis were 0.363 mg/ml and 701.1 µmol/min/mg, respectively with birchwood xylan as a substrate. The optimum pH and temperature were pH 4 and 25 °C, respectively. When xynA was introduced into Bacillus subtilis WB600, active XynA was secreted into culture medium.

The effect on the recovery profile of a change from enflurane to desflurane during the latter part of anaesthesia.

This study compared emergence and recovery characteristics after either enflurane anaesthesia or crossover from enflurane to desflurane anaesthesia. At an estimated 1 h prior to the end of operation, enflurane was either reduced (group E, n = 23) or replaced with desflurane (group X, n = 23). At the end of the operation, emergence and recovery characteristics of the two groups were compared. The crossover technique accelerated recovery compared with enflurane anaesthesia. The time taken for the eyes to open in response to painful pinching or a verbal command, and to regain awareness of age and name, were significantly shorter after crossover anaesthesia than after enflurane anaesthesia. The digit symbol substitution test and serial seven test scores were significantly better in patients subjected to crossover anaesthesia than in those subjected to enflurane anaesthesia. We conclude that, during surgery, the substitution of enflurane with desflurane in the latter part of anaesthesia can improve recovery.