A "NIRS" death experience: a reduction in cortical oxygenation by time-resolved near-infrared spectroscopy preceding cardiac arrest.

Near-infrared spectroscopy (NIRS) has been used effectively post-cardiac-arrest to gauge adequacy of resuscitation and predict the likelihood of achieving a return of spontaneous circulation. However, preempting hemodynamic collapse is preferable to achieving ROSC through advanced cardiac life support. Minimizing "time down" without end-organ perfusion has always been a central pillar of ACLS. In many critically ill patients there is a prolonged phase of end-organ hypoperfusion preceding loss of palpable pulses and initiation of ACLS. Due to the relative infrequency of in-hospital cardiac arrest, NIRS has not previously evaluated the period immediately prior to hemodynamic collapse. Here we report a young man who suffered a pulseless electrical activity (PEA) arrest while cortical oxygenation was monitored using time-resolved near-infrared spectroscopy. The onset of cortical deoxygenation preceded the loss of palpable pulses by 15 min, suggesting that TRS-NIRS monitoring might provide a means of preempting PEA arrest. Our experience with this patient represents a promising new direction for continuous NIRS monitoring and has the potential to not only predict clinical outcomes, but affect them to the patient's benefit as well.

Gender differences in chewing discomfort in older South Koreans.

AIMS: The purpose of this study was to identify gender differences in chewing discomfort among elderly Koreans. METHODS: This study used data from 56 616 (weighted sample: 5 638 394) subjects aged over 65 years who participated in the 2011 Community Health Survey in Korea. Of them, 23 059 (weighted sample: 2 368 200, 42.0%) were men and 33 357 (weighted sample: 3 270 194, 58.0%) were women. Data were analysed using chi-square tests and hierarchical logistic regression analyses, with SPSS 20.0. Chewing discomfort was set as the dependent variable, and independent variables were divided into socio-economic factors (place of residence, age, education, monthly household income, basic living security stipend, private insurance, economic activity, living arrangements), general health factors (hypertension, diabetes) and oral health factors (tooth defects, denture use, subjective periodontal health status). RESULTS: A greater proportion of women (50.2%) than men (42.6%) exhibited chewing discomfort (P < 0.001). In men, place of residence, monthly household income, private health insurance, tooth defects and periodontal health were associated with chewing discomfort (P < 0.05). In women, age, education level, basic living security stipend and denture use were associated with chewing discomfort (P < 0.05). CONCLUSIONS: Elderly Korean women experience more severe chewing discomfort than their male counterparts. The factors associated with chewing also differ by gender.

Community periodontal treatment needs in South Korea.

OBJECTIVES: This study aimed to assess the relationship between socio-economic factors and community periodontal treatment needs in Korea. METHODS: Data were obtained from the year 2009 Korean National Health and Nutrition Examination Survey. Our analysis included 7510 survey participants over the age of 19 years. To assess the relationship between socio-economic factors and the need for periodontal scaling, we performed multivariate logistic regression analyses for data with a complex sampling structure. PASW statistics 19.0 (SPSS Inc., Chicago, IL, USA) was used to perform the statistical analyses, and the results were expressed as odds ratios (OR) with corresponding 95% confidence intervals (CIs). RESULTS: A very high percentage of Korean adults required periodontal scaling (71.5%). After adjusting for sex, age, and socio-economic factors, the need for periodontal scaling was associated with low levels of education (OR: 1.41, 95% CI: 1.03-1.93), low incomes (OR: 1.27, 95% CI: 1.01-1.60), employment as a service and sales worker (OR: 1.39, 95% CI: 1.10-1.77), and employment as a manual worker (OR: 1.31, 95% CI: 1.02-1.69). CONCLUSIONS: In South Korea, the need for periodontal scaling was associated with socio-economic factors, such as low levels of education, low incomes, employment as a service and sales worker and employment as a manual worker. Consequently, clinical and community dental hygienists should consider adults with these risk factors as belonging to high-priority subgroups to whom they should respond first.

Reduction in dental plaque in patients with mental disorders through the dental hygiene care programme.

OBJECTIVE: To develop a dental hygiene care programme based on the specific needs of patients with mental disorders and to suggest practical guidelines to improve the oral health care of these patients. METHODS: A total of 73 patients with mental illness participated in the study. The patients were randomly classified into three groups and followed over 12 weeks at 4-week intervals. A newly designed dental hygiene care programme using flash-based video, brochures and a toothpick method was implemented by five dental hygienists. Plaque index, stimulated saliva, subjective oral dryness and dental caries activity were analysed as outcome variables. RESULTS: Results showed that the dental plaque index significantly decreased after each session (P < 0.0001) in all three groups, and significant differences were found between groups (P = 0.036). Patients' oral dryness decreased significantly, but stimulated saliva and dental caries activity did not improve. CONCLUSION: The results of this study suggest that the dental hygiene care programme, which made use of a short, 10-min flash-based video and brochures every 4 weeks, was effective in reducing the dental plaque index of patients with mental disorders.

Factors affecting unmet healthcare needs of older people in Korea.

BACKGROUND: Despite the fact that the National Health Insurance programmes have ensured universal coverage for Koreans, disparities in access to health care and unmet healthcare needs still exist in Korea. AIM: The purpose of this study was to analyse factors affecting unmet healthcare needs of older people in Korea. METHODS: This study had a cross-sectional, descriptive design using secondary data taken from the Korean National Health and Nutrition Survey conducted in 2007-2009. A complex sampling design was used, and the participants included a nationally representative sample of 3943 people older than 64 years. Socio-demographic variables, subjective health, existence of chronic diseases, quality of life and unmet healthcare needs were included in the study instruments. Logistic regression analyses were performed in order to examine the relationship between unmet healthcare needs and independent variables. RESULTS: According to the results, 29.4% of older women and 14.0% of older men had not visited clinics or hospitals when they needed to obtain healthcare services (unmet healthcare needs) during the past 12 months. Older women [odds ratio (OR) = 1.831, 95% confidence interval (CI) = 1.428-2.347] and those with poor subjective health (OR = 1.708, 95% CI = 1.371-2.126) and arthritis (OR = 1.278, 95% CI = 1.029-1.586) were more likely to have unmet healthcare needs than their counterparts. CONCLUSIONS: Efforts to decrease unmet healthcare needs, targeting high-risk groups (especially for older women), are needed in order to prevent disability, decrease mortality and promote the quality of life of older people.

K-ras activation generates an inflammatory response in lung tumors.

Activating mutations in K-ras are one of the most common genetic alterations in human lung cancer. To dissect the role of K-ras activation in bronchial epithelial cells during lung tumorigenesis, we created a model of lung adenocarcinoma by generating a conditional mutant mouse with both Clara cell secretory protein (CC10)-Cre recombinase and the Lox-Stop-Lox K-ras(G12D) alleles. The activation of K-ras mutant allele in CC10 positive cells resulted in a progressive phenotype characterized by cellular atypia, adenoma and ultimately adenocarcinoma. Surprisingly, K-ras activation in the bronchiolar epithelium is associated with a robust inflammatory response characterized by an abundant infiltration of alveolar macrophages and neutrophils. These mice displayed early mortality in the setting of this pulmonary inflammatory response with a median survival of 8 weeks. Bronchoalveolar lavage fluid from these mutant mice contained the MIP-2, KC, MCP-1 and LIX chemokines that increased significantly with age. Cell lines derived from these tumors directly produced MIP-2, LIX and KC. This model demonstrates that K-ras activation in the lung induces the elaboration of inflammatory chemokines and provides an excellent means to further study the complex interactions between inflammatory cells, chemokines and tumor progression.

Effect of H-7 and Lat-B on retinal physiology.

PURPOSE: To investigate the effects of H-7 and Latrunculin B (Lat-B) on retinal vascular permeability and electrophysiology at concentrations that increase outflow facility in monkeys. METHODS: One eye of 1 rhesus and 22 cynomolgus monkeys received an intravitreal bolus injection of H-7 or Lat-B; the opposite eye received vehicle. Multifocal electroretinograms (mfERGs), and photopic and scotopic full-field electroretinograms (ffERGs, sERGs) were recorded in subsets of monkeys at baseline and at multiple time-points post-H-7 or Lat-B. Vitreous fluorophotometry (VF) and fluorescein angiography (FA) were also performed. RESULTS: No differences between the H-7 or Lat-B treated and control eyes were found in ffERGs, mfERGs, sERGs, or in FAs in any monkey. No significant difference was found in vitreous fluorescein levels between H-7 treated or Lat-B treated vs. control eyes. CONCLUSIONS: No effect on retinal vascular permeability or retinal electrophysiology was apparent after intravitreal administration of H-7 or Lat-B at doses that increase outflow facility and lower IOP when given intracamerally.

Accuracy of biplane and multiplane transesophageal echocardiography in diagnosis of typical acute aortic dissection and intramural hematoma.

OBJECTIVES: The purpose of this study was to evaluate the diagnostic accuracy of biplane and multiplane transesophageal echocardiography in patients with suspected aortic dissection, including intramural hematoma. BACKGROUND: Transesophageal echocardiography is a useful technique for rapid bedside evaluation of patients with suspected acute aortic dissection. The sensitivity of transesophageal echocardiography is high, but the diagnostic accuracy of biplane and multiplane transesophageal echocardiography for dissection and intramural hematoma is less well defined. METHODS: We studied 112 consecutive patients at a major referral center who had undergone biplane or multiplane transesophageal echocardiography to identify aortic dissection. The presence, absence and type of aortic dissection (type A or B, typical dissection or intramural hematoma) were confirmed by operation or autopsy in 60 patients and by other imaging techniques in all. The accuracy of transesophageal echocardiography for ancillary findings of aortic dissection (intimal flap, fenestration and thrombosis) was assessed in the 60 patients with available surgical data. RESULTS: Of the 112 patients, aortic dissection was present in 49 (44%); 10 of these had intramural hematoma (5 with and 5 without involvement of the ascending aorta). Of the remaining 63 patients without dissection, 33 (29%) had aortic aneurysm and 30 (27%) had neither dissection nor aneurysm. The overall sensitivity and specificity of transesophageal echocardiography for the presence of dissection were 98% and 95%, respectively. The specificity for type A and type B dissection was 97% and 99%, respectively. The sensitivity and specificity for intramural hematoma was 90% and 99%, respectively. The accuracy of transesophageal echocardiography for diagnosis of acute significant aortic regurgitation and pericardial tamponade was 100%. CONCLUSIONS: Biplane and multiplane transesophageal echocardiography are highly accurate for prospective identification of the presence and site of aortic dissection, its ancillary findings and major complications in a large series of patients with varied aortic pathology. Intramural hematoma carries a high complication rate and should be treated identically with aortic dissection.

Effects of aging on the densities, numbers, and sizes of retinal ganglion cells in rhesus monkey.

We used sterological procedures that yield unbiased estimates to quantify the densities, numbers, and soma sizes of retinal ganglion cells in seven young adult and six old rhesus monkeys. The retinae were flat mounted so that we could determine whether there are different aging-related losses in different retinal regions. The mean (+/-standard deviation) total number of ganglion cells was 1,529,039 +/- 115,260 in young-adult retinae and 1,556,698 +/- 165,056 in old retinae, a difference that was not statistically significant. There also were no significant differences between young and old retinae in the densities or total numbers of ganglion cells in the four retinal quadrants, in four concentric retinal zones from fovea to peripheral retina, or in smaller hemiretinal regions of the concentric zones. Ganglion-cell soma sizes also did not differ significantly between young and old animals. Moreover, counts of the largest ganglion cells, which probably correspond to P alpha ganglion cells, revealed no selective loss of these cells with aging. These results are consistent with our previous anatomical and physiological studies of the LGN. Together they suggest that the retino-geniculate pathways are relatively unaffected by aging in the rhesus monkey.

Mid-frequency loss of foveal flicker sensitivity in early stages of age-related maculopathy.

Temporal contrast sensitivity in eyes at risk for exudative age-related maculopathy (ARM) was compared to that in age-matched healthy older eyes. The test stimulus was a foveally viewed, flickering, long-wavelength 2.8 degrees diameter circle in an equiluminant (photopic) surround. Retinal illuminance and decision criterion differences were experimentally controlled. Eyes in the healthy and ARM-risk groups had 20/30 or better Snellen acuity and intraocular pressure of less than 22 mmHg. Nevertheless, the ARM-risk patients were less sensitive to flicker contrast, especially for mid-temporal frequencies. This suggests that flicker sensitivity may be useful in identifying patients at risk for exudative ARM. In addition, comparison with other research reveals a paradox: Mid-temporal frequency sensitivity losses may be attributable primarily to a "high temporal frequency" mechanism.

Foveal flicker sensitivity discriminates ARM-risk from healthy eyes.

The "good" eyes of 13 patients with monocular exudative ARM were compared with age-matched healthy eyes of 19 subjects. Membership in the two study groups was based upon careful clinical evaluation of the tested eye as well as upon status of the fellow eye. We asked whether temporal contrast sensitivity for a long-wavelength, low spatial frequency stimulus can be used to identify the group in which a given eye belongs. Using step-wise discriminant analysis, we found that the ARM-risk and healthy eyes could be classified with 78% accuracy on the basis of foveal flicker sensitivity at two temporal frequencies--14 and 10 Hz (in order of estimated weight.)

Preliminary evaluation of flicker sensitivity as a predictive test for exudative age-related maculopathy.

Flicker contrast sensitivity was tested in the "good" eyes of 13 patients with monocular exudative age-related maculopathy (ARM). The stimulus was a foveal, long-wavelength, low spatial frequency 2.8 degrees circle in an equiluminant (photopic) surround. Two of these ARM-risk eyes have since developed exudative ARM. Compared to healthy age-matched eyes, the two eyes that developed exudative ARM had significantly lower sensitivity at 10-40 Hz up to 9 mo before exudative symptoms appeared. The implications of these results regarding the time-course of ARM and the predictive value of foveal contrast sensitivity testing are considered. Based upon data and theoretical considerations, the authors speculate that sensitivity loss between 10 and 40 Hz is a good predictor of which eyes will develop exudative ARM. This proposal will be tested by new data from current as well as new ARM-risk subjects.

Evolution of chordate hox gene clusters.

In this article, we consider the role of the Hox genes in chordate and vertebrate evolution from the viewpoints of molecular and developmental evolution. Models of Hox cluster duplication are considered with emphasis on a threefold duplication model. We also show that cluster duplication is consistent with a semiconservative model of duplication, where following duplication, one daughter cluster remains unmodified, while the other diverges and assumes a new architecture and presumably new functions. Evidence is reviewed, suggesting that Hox gene enhancers have played an important role in body plan evolution. Finally, we contrast the invertebrates and vertebrates in terms of genome and Hox cluster duplication which are present in the latter, but not the former. We question whether gene duplication has been important in vertebrates for the introduction of novel features such as limbs, a urogenital system, and specialized neuromuscular interactions.

Functional plasticity in extrastriate visual cortex following neonatal visual cortex damage and monocular enucleation.

Neonatal lesions of primary visual cortex (areas 17, 18 and 19; VC) in cats lead to significant changes in the organization of visual pathways, including severe retrograde degeneration of retinal ganglion cells of the X/beta class. Cells in posteromedial lateral suprasylvian (PMLS) cortex display plasticity in that they develop normal receptive-field properties despite these changes, but they do not acquire the response properties of striate neurons that were damaged (e.g., high spatial-frequency tuning, low contrast threshold). One possibility is that the loss of X-pathway information, which is thought to underlie striate cortical properties in normal animals, precludes the acquisition of these responses by cells in remaining brain areas following neonatal VC damage. Previously, we have shown that monocular enucleation at the time of VC lesion prevents the X-/beta-cell loss in the remaining eye. The purpose of the present study was to determine whether this sparing of retinal X-cells leads to the development of striate-like response properties in PMLS cortex. We recorded the responses of PMLS neurons to visual stimuli to assess spatial-frequency tuning, spatial resolution, and contrast threshold. Results indicated that some PMLS cells in animals with a neonatal VC lesion and monocular enucleation displayed a preference for higher spatial frequencies, had higher spatial resolution, and had lower contrast thresholds than PMLS cells in cats with VC lesion alone. Taken together, these results suggest that preserving X-pathway input during this critical period leads to the addition of some X-like properties to PMLS visual responses.

Effect of duodenal switch procedure on gastric acid production, intragastric pH, gastric emptying, and gastrointestinal hormones.

The duodenal switch operation preserves the pylorus and the proximal 3 to 7 cm of duodenum in continuity with the stomach while diverting pancreaticobiliary secretions. We compared it with the Roux-en-Y without vagotomy or antrectomy in 12 dogs with innervated gastric pouches. Acid secretion was inhibited between tests using ranitidine in the Roux-en-Y group only, but two of the six dogs still developed stomal ulcers and the remainder showed stomal hyperemia. This may be due to a significant increase in gastric acid output after Roux-en-Y, but gastric emptying and plasma gastrin, cholecystokinin, secretin, gastric inhibitory polypeptide, peptide YY, and neurotensin were similar after both procedures. In 12 patients and a further 6 dogs, the duodenal switch caused no significant change in the intragastric pH environment as assessed by intragastric pH monitoring. The duodenal switch is a suitable procedure for pancreaticobiliary diversion.

Retrospective comparison of infusional 5-fluorouracil, doxorubicin, and mitomycin-C (modified FAM) combination chemotherapy versus palliative therapy in treatment of advanced gastric cancer.

About one-third of patients with gastric cancer are unresectable at the time of diagnosis. Their median survival is < 6 months, with a grave prognosis. The purpose of this study was to assess the efficacy of a modified FAM (mFAM) regimen in advanced gastric cancer. We retrospectively reviewed the clinical records of 409 advanced gastric cancer patients who had not received curative surgery. Among 409 patients, 202 patients were treated with an mFAM regimen (infusional 5-FU + doxorubocin + mitomycin-C), and 207 patients received no chemotherapy (control group). No differences were found in clinical parameters between the two groups. The 1-year survival rates were 34.1% for the mFAM-treated group and 22.5% for the control group (p = 0.0135). In subset analysis, a higher 1-year survival rate was demonstrated in patients with mFAM and palliative surgery. Of the 154 evaluable patients in the mFAM-treated group, the response rate was 17.5%. In these patients, median response duration was 30 weeks, and progression-free survival was 23 weeks. Overall toxicity of mFAM regimen was relatively tolerable and reversible. In conclusion, FAM combination chemotherapy, which has been used as a standard therapy, prolonged survival after modification of the administration schedule and combination with palliative surgery. A prospective randomized study is warranted to confirm this conclusion from our retrospective study.

Roux-en-Y end-to-side esophagojejunostomy with stapler after total gastrectomy.

One hundred gastric cancer patients who underwent total gastrectomy and Roux-en-Y, end-to-side esophagojejunostomy by using stapling devices were analyzed with regard to their operative results. The median time required for the anastomosis was 18 minutes (range of 15 to 45 minutes). A cartridge of 25 mm in diameter was preferred (85% of 25 mm vs. 15% of 28 mm). In 92 patients, procedures were uneventful. Intraoperative problems happened in 8 patients: Two misfirings of stapler due to mechanical problems, in 6 patients, doughnut tissues were incomplete. Mechanical problems were solved by a change of the stapler and for incomplete doughnut tissues, anastomosis was simply reinforced (2 cases) or reanastomosed with restaplings (4 cases). Anastomotic leakage occurred in 2 patients but it was seen only in radiological studies. During the follow up period, two cases of anastomotic stricture were found and they were treated with endoscopic dilatations. There was no operative mortality nor other complication. In addition, routine use of the Levin tube after total gastrectomy was appraised by comparing postoperative courses. Twenty patients were randomly divided into two groups; for 10 patients the Levin tube was removed at the recovery room and for another 10 patients the Levin tube was indwelled until peristalsis returned. Timing of the tube removal did not affect the duration of the hospital stay and starting day of oral intake. We think that the stapler, when properly used, can facilitate the esophagojejunostomy safely and routine use of the Levin tube after total gastrectomy may be unnecessary.

Long-term follow-up of gracilis muscle transposition in children.

Sixteen children of uncontrollable fecal incontinence have been treated with Pickrell's gracilis muscle transposition since 1983: 12 had an imperforate anuses with multiple corrective operative procedures and 4 had traumatic destructions of anal sphincters. We report a series of 11 cases whom we followed-up over a period of 0.8 to 10.5 years (mean; 5.6 years). Seven patients were evaluated by anorectal manometry. All patients except one who had left hemipelvectomy and permanent colostomy showed nearly normal continence during the follow-up period. There was no evidence of fibrosis in the transposed muscles and the tensions of the transposed muscles were well maintained. The voluntary contractions of the transposed muscles were well maintained and efficient in all cases. The general manometric parameters did not correlate well with the functional results; however, there was a strong correlation in the S/R ratio (maximum squeeze pressure/resting pressure) with the functional results. We believe that the good functional outcome of this procedure need not only the meticulous surgical technique but also the personal motivation and the compliance with physiotherapy. In conclusion, although the gracilis muscle transposition never results in normal continence, acceptable continence can be achieved in the selected patients.

Primary malignant melanoma of the esophagus.

Primary malignant melanoma of the esophagus is exceedingly rare. The existence of primary malignant melanoma in the esophagus had been in doubt until the presence of benign melanocytes was demonstrated within the esophagus. Hematogenous and lymphatic metastases are common. The prognosis is poor even after a radical procedure due to early metastasis. We report here two cases of primary malignant melanoma of the esophagus. One is a melanotic melanoma and the other is an amelanotic melanoma.