Risk factors contributing to the development of neutropenia in patients receiving oral trifluridine-tipiracil (TAS-102) chemotherapy for advanced/recurrent colorectal cancer.

Elucidating the factors influencing severe neutropenia could aid in earlier management of neutropenia during oral trifluridine-tipiracil (TAS-102) chemotherapy in advanced and recurrent colorectal cancer (CRC). This study was conducted to assess the risk of TAS-102-induced grade 3 or more neutropenia. Between August 2014 and July 2017, 60 patients underwent oral TAS-102 monotherapy at Ogaki Municipal Hospital, Japan. The patients were divided into two groups based on the development of grade 3 or more neutropenia (9 patients) or not (51 patients). Risk factors for grade 3 or more neutropenia were examined by univariate and multivariate analyses. Creatinine clearance rate (CrCl) before TAS-102 administration significantly correlated with the incidence of Grade 3 or more neutropenia after TAS-102 administration (odds ratio 6.5, 95% confidence interval 1.14-30.00; p = 0.02). Multivariate analysis revealed that a CrCl of lower than 57.1 mL/min before TAS-102 administration (odds ratio 54.06, 95% confidence interval 2.14-1364.2; p = 0.02) was an independent risk factor significantly contributing to the development of grade 3 or more neutropenia, induced by TAS-102. CrCl < 57.1 mL/min in patients with advanced and recurrent CRC who underwent TAS-102 chemotherapy was associated with grade 3 or more neutropenia.

Successful treatment of sternal osteomyelitis after pneumonectomy using a pedicled omental flap.

We report here the case of a 64-year-old man with sternal osteomyelitis after pneumonectomy through a median sternotomy who was successfully treated using a pedicled omental flap. This is the first report in the literature to describe sternal osteomyelitis and mediastinitis after pneumonectomy. In this case, the visceral pleura of the remnant right lung was located just under the infected sternum. Careful management is recommended because empyema pleurae can be a fatal complication.

Directed evolution of biphenyl dioxygenase: emergence of enhanced degradation capacity for benzene, toluene, and alkylbenzenes.

Biphenyl dioxygenase (Bph Dox) catalyzes the initial oxygenation of biphenyl and related compounds. Bph Dox is a multicomponent enzyme in which a large subunit (encoded by the bphA1 gene) is significantly responsible for substrate specificity. By using the process of DNA shuffling of bphA1 of Pseudomonas pseudoalcaligenes KF707 and Burkholderia cepacia LB400, a number of evolved Bph Dox enzymes were created. Among them, an Escherichia coli clone expressing chimeric Bph Dox exhibited extremely enhanced benzene-, toluene-, and alkylbenzene-degrading abilities. In this evolved BphA1, four amino acids (H255Q, V258I, G268A, and F277Y) were changed from the KF707 enzyme to those of the LB400 enzyme. Subsequent site-directed mutagenesis allowed us to determine the amino acids responsible for the degradation of monocyclic aromatic hydrocarbons.

Utility of measurements of oxygen cost of breathing in predicting success or failure in trials of reduced mechanical ventilatory support.

OBJECTIVE: Test whether a change in oxygen consumption produced by a reduction in level of mechanical ventilatory support predicts failure to tolerate the reduction in level of support. DESIGN: Prospective study of the sensitivity and specificity of increased oxygen cost of breathing as a predictor of failure to tolerate a reduction in ventilatory support in patients undergoing weaning, using a protocol that incrementally reduces the level of mechanical ventilatory support. SETTING: University medical center. METHODS: We studied 228 trials in 30 patients who had required mechanical ventilatory support for at least 72 hours and who were being weaned using a standardized protocol that provided for three 30-minute trials of reduced mechanical ventilatory support per day, followed by ventilatory muscle rest. Using a metabolic monitor, we monitored oxygen consumption (V(O(2))) prior to and during 228 incremental reductions in level of mechanical ventilatory support conducted as part of a standardized weaning protocol. Oxygen cost of breathing was defined as the difference in V(O(2)) (Delta V(O(2))) during the trial of reduced mechanical ventilatory support, compared to a 30-minute resting period immediately before the trial. A successful trial was defined as one that could be continued for 30 minutes without development of clinical signs of ventilatory failure. Changes in V(O(2)) and the ratio of respiratory frequency to tidal volume (f/V(T)) during a weaning trial were evaluated as predictors for failure of a 30-minute trial of reduced ventilatory support. RESULTS: A 15% increase in oxygen cost of breathing predicted failure in the trial, with a sensitivity of 96.6%, specificity of 85.7%, positive predictive value of 98.5%, and negative predictive value of 72.0%. Neither change in V(O(2)) measured early in the trial nor f/V(T) proved to be as successful in predicting failure to tolerate an incremental reduction in ventilatory support. CONCLUSION: Change in V(O(2)) following an incremental reduction in level of mechanical ventilatory support may be a useful predictor for determining which patients will rapidly fail to tolerate that level of reduction.

Percutaneous ulnar artery approach for coronary angiography: a preliminary report in nine patients.

The radial artery approach is becoming more popular for diagnostic cardiac catheterization and interventional procedures because of its lower incidence of access site complications and decreased patient discomfort after the procedure. However, Allen's test reveals inadequate blood supply through the ulnar artery to the hand, and therefore the approach does not seem to be suitable in 10%-30% of patients. Here we demonstrated a new percutaneous ulnar artery approach for coronary angiography in nine patients. We succeeded in obtaining an entry site into the left ulnar artery in seven patients. The average time for cannulation and that for catheterization procedure were comparable with those of the radial approach previously reported from other laboratories. Complications such as bleeding, loss of an ulnar pulse, ulnar nerve injury, and the formation of an aneurysm or fistula were not observed in any patient. The ulnar approach may be another technique that decreases patient discomfort and risk, while preserving the radial artery as a potential coronary bypass graft for surgical myocardial revascularization. Cathet Cardiovasc Intervent 2001;53:410-414.

Bilateral pleural effusion following cervical abscess drainage: a case report.

Postoperative bilateral chylothorax after cervical surgery has been rarely reported, whereas unilateral chylothorax has been occasionally reported after thoracic surgery. Here, we report a rare case of bilateral pleural effusion that developed after cervical abscess drainage. On the second day after the drainage, the patient felt dyspnea, and bilateral pleural effusion was found on a chest X-ray. The effusion was thought to be chyle and was successfully treated with conservative management. Additionally here, we have suggested that non-traumatic chylothorax was caused by increasing intraluminal pressure occurring inside the thoracic duct after its ligation. Careful follow up of any respiratory symptoms and of chest X-rays is recommended after cervical intervention.

A preoperative alternating chemotherapy and radiotherapy program for patients with stage IIIA (N2) non-small cell lung cancer.

The objective of the present study was to evaluate the feasibility and toxicity of a preoperative alternating chemotherapy and radiotherapy program followed by surgery in stage IIIA non-small cell lung cancer (NSCLC). The tumor response, resection rate, tumor/lymph node downstaging, and survival were also evaluated. The positive predictive value (PPV) in the diagnosis of mediastinal lymph node metastasis was 81% using conventional magnetic resonance imaging (MRI) with short inversion-time inversion recovery (STIR) technique (STIR-MRI) on our criteria. Eligible patients had clinical N2 lesions (stage IIIA) and a World Health Organization (WHO) performance status of 0-2. The treatment program consisted of two courses of preoperative cisplatin, vindesine, and ifosfamide; alternating with radiotherapy, including two courses of 20 Gy radiation. Surgery was performed within 4 weeks after the treatment. Twenty-two patients with stage IIIA (N2) NSCLC (20 men and two women, age 35-71 years) were enrolled into the study. Hematologic and other toxicities were within an acceptable range. Surgery was not indicated for two patients because of distant metastasis; one patient with renal dysfunction and one with pancytopenia during this treatment underwent surgery subsequently. The clinical response rate was 50% (partial response in 11/22). Definitive surgery was indicated for 18 patients resulting in 17 patients with complete resection and one exploratory thoracotomy. A pathologic complete response of the primary tumor occurred in 41% of the patients (seven of 17; without residual tumor), whereas 58% (ten of 17) were pathologic N0. The median survival was 33 months with an actuarial 4-year survival rate of 33% in 17 patients with complete resection and 30 months with 28% 4-year survival rate in all entered patients. A randomized phase-III study using this approach for stage IIIA (clinical N-2 disease) is warranted.

An experimental study of atrial natriuretic peptide levels and the effect of inhaled nitric oxide after pneumonectomy.

The aim of this study was to investigate the changes in atrial natriuretic peptide (ANP) levels and lung cyclic guanosine 3',5'-monophosphate (cGMP) concentrations caused by pneumonectomy (Pn), and the effect of inhaled nitric oxide (NO) after Pn in a canine model. The mean pulmonary arterial pressure (PAP) and plasma ANP levels were measured over 180 min in two groups of dogs, one subjected to 60 min of 5 ppm NO inhalation (Pn + NO group, n = 5) and one subjected to 180 min without NO inhalation (Pn group, n = 5). The ANP and cGMP levels in the lung were also measured before and after Pn. Both the PAP and ANP levels increased significantly. Inhaled NO rapidly reduced the PAP and plasma ANP to levels similar to those before Pn. The lung ANP level was significantly increased after Pn, but inhaled NO reduced it to a level similar to that before Pn. The lung cGMP level, which was significantly decreased after Pn, was significantly increased by NO inhalation. These results indicate that NO administration may be effective for preventing post-Pn pulmonary hypertension, although an elevation in ANP does not reduce the PAP.

Response of the radial artery to three vasodilatory agents.

We examined the response of the radial artery to vasoactive agents (isosorbide dinitrate, ISDN, 1 mg, 3 mg, and 5 mg; verapamil, 1 mg, 3 mg, and 5 mg; and lidocaine, 10 mg, 30 mg, and 50 mg) in 100 consecutive patients admitted for elective coronary angiography. The drug solutions were directly injected into the radial artery from the puncture site. As a result, 5 mg of ISDN increased the diameter of the radial artery by 31% and 28.8% at the proximal and distal sites, respectively. Similarly, 5 mg of verapamil increased it by 9% and 10.8% at the proximal and distal site, respectively. But 10 mg of lidocaine decreased it by -15.6% and -12.1% at the proximal and distal site, respectively. At the doses utilized, ISDN was the most potent vasodilator for the radial artery and lidocaine caused paradoxical vasoconstriction.

Thoracoscopic lung biopsy for diffuse infiltrative lung disease.

Thoracoscopic lung biopsy is becoming the procedure of first choice for the diagnosis of many localized and diffuse lung diseases. We have performed thoracoscopic lung biopsy for 17 patients with diffuse infiltrative lung disease, in Kurume University Hospital. There were 13 females and 4 males with a mean age of 48 years (range: 19-71 years). Thoracoscopic surgical biopsy was performed in the right lung in 12 and in the left lung in 5. Adequate lung tissue from each case was obtained for pathological examination. The mean surgical biopsy time was 49 min (range: 25-72 min) and bleeding was negligible. The mean duration for chest tube drainage was 2.6 days. No postoperative complication such as prolonged air leakage occurred. A specific diagnosis from the biopsy was achieved in 13 (76.4%) of the 17 cases. In only 6 (35.2%) of the 17 cases, the pathological diagnosis was the same as that from the thoracoscopic biopsy. In these 6 cases, the same diagnosis was obtained only in those with idiopathic interstitial pneumonitis or diffuse panbronchitis. Thoracoscopic lung biopsy was safe and useful for diagnosis for diffuse infiltrative lung disease.

Improvement of dysgeusia after thymectomy with thymoma.

We present a case of 39-year-old woman with thymoma complaining of dysgeusia. This patient had suffered from dysgeusia for the previous 6 months. Thymectomy with the thymoma was performed, and her dysgeusia was improved within 6 months after the operation. The anti-acetylcholine-receptor antibody was reduced from 0.9 nmol/l to 0.4 nmol/l (normal: below 0.6 nmol/l) by the surgical intervention. This case suggested that symptoms of dysgeusia can be associated with myasthenic status.

Experimental and clinical evaluation of the harmonic scalpel in thoracic surgery.

The Harmonic Scalpel is an ultrasonic instrument for cutting and coagulating tissue. We are reporting our evaluation of the Harmonic Scalpel safety and efficacy in both experimental and clinical thoracic surgery. First, we confirmed the safety in thoracic surgery by following two preliminary studies using the Harmonic Scalpel. 1: Pulmonary parenchyma was incised using "Coagulating Shears" to evaluate hemostasis and air leakage. 2: Pulmonary hilar vessels were contacted directly with "Dissecting Hook" blade at optimum cutting power mode to evaluate potential vascular wall injury by the Harmonic Scalpel. Subsequently, the Harmonic Scalpel was used for a partial lung resection due to metastatic lung cancer. Particular application was for a chest wall incision, interlobar separation of the lung, and dissection of a pulmonary artery, in lung cancer operations. We concluded that cutting and hemostasis of pulmonary parenchyma could be achieved with minimal tissue damage using the Harmonic Scalpel. Compared to electric coagulation, the Harmonic Scalpel minimizes tissue charring and dissection, and eliminates thermal injury in thoracic surgery.

Primary hemangiopericytoma of the superior mediastinum: a case report.

We present a case of hemangiopericytoma arising in the superior mediastinum. A 48-year-old man demonstrated a superior mediastinal mass lesion on chest x-ray and was admitted to our hospital. A CT scan of the chest showed a well-circumscribed, heterogenously-enhanced mass, 7.0 x 6.5 x 6.5 cm in size, located in the right superior posterior mediastinum, compressing the trachea. The tumor was extirpated by surgical resection. Based on the histological findings, electron microscopic findings, and immunohistochemical studies, the tumor was diagnosed as hemangiopericytoma.

Resection of malignant fibrous histiocytoma invading the thoracic aorta.

We report a case of surgically resected malignant fibrous histiocytoma which arose in the posterior mediastinum. Tumor removal with the required sufficient-margin and the resection of the affected thoracic aorta, led to flaccid paraplegia below the tenth thoracic level. This patient is now surviving with no evidence of recurrence at 42 months after the operation. Although malignant fibrous histiocytoma in the thorax generally shows a poor prognosis, this patient with complete resection could have a relatively long survival.

Experimental study of the histocompatibility of covered expandable metallic stents in the trachea.

STUDY OBJECTIVES: To evaluate the histocompatibility of four different materials used to cover expandable metallic stents. DESIGN: Prospective, randomized, unblinded study. SETTING: Animal research laboratory of Kurume University. PATIENTS OR PARTICIPANTS: Twenty 12- to 18-kg mongrel dogs. INTERVENTIONS: Handmade Gianturco-type stents with six bends, 20 mm in length, and 15 to 20 mm in diameter were covered using four different materials: polypropylene mesh, silicone-coated mesh, polyester mesh, and ePTFE. Covered stents were inserted into the trachea after i.v. anesthesia. Five animals were used in each group. MEASUREMENTS AND RESULTS: Postinsertion status was observed using clinical and bronchoscopy measures 7, 14, 28, and 56 days after intervention. Eight weeks after stent insertion, the tracheal specimens were studied pathologically. A scoring system was used to evaluate the histocompatibility of covered stents in each study group. The mean of clinical scores in the polypropylene group was 1.84+/-0.36, which was significantly higher than those in the groups of silicone, polyester, and ePTFE. The means of histopathologic scores in the polypropylene group and the silicone group were 1.60+/-0.55, which were significantly higher than those in groups of polyester and ePTFE. CONCLUSIONS: Polypropylene mesh cover was more suitable than silicone-coated mesh, polyester mesh, and ePTFE because of its excellent histocompatibility.

Enhanced degradation of polychlorinated biphenyls by directed evolution of biphenyl dioxygenase.

Biphenyl dioxygenases (BP Dox) from different organisms, which are involved in the initial oxygenation and subsequent degradation of polychlorinated biphenyls (PCB), are similar in structure but have different functions. The large subunit of BP Dox, encoded by the bphA1 gene, is crucial for substrate selectivity. Using the process of DNA shuffling, we randomly recombined the bphA1 genes of Pseudomonas pseudoalcaligenes KF707 and Burkholderia cepacia LB400 and selected for genes that expressed proteins with altered function. Upon expression in Escherichia coli, some of these evolved genes exhibited enhanced degradation capacity, not only for PCB and related biphenyl compounds, but for single aromatic hydrocarbons such as benzene and toluene, which are poor substrates for the original BP Dox.

Thoracoscopic resection of a giant leiomyoma of the esophagus with a mediastinal outgrowth.

We reported a case of a 20-year-old man with a giant leiomyoma of the esophagus resected under video-assisted thoracic surgery (VATS). The patient demonstrated an abnormal shadow on a chest x-ray and a posterior mediastinal tumor 11 cm in diameter on a computed tomogram (CT) and on magnetic resonance imaging (MRI). A leiomyoma or a neurogenic tumor of the esophagus was suspected, and VATS was performed. The resected tumor was pathologically confirmed to be a leiomyoma of the esophagus. A giant esophageal leiomyoma showing extraluminal outgrowth should be treated by VATS.

Thymolipoma: clinical and pathological features--report of three cases and review of literature.

We report three recently resected cases of thymolipoma. Two cases (case 2 and 3) were female and the other (case 1) was male. The age of these three were 41 years, 63 years, and 29 years, respectively. While two cases (case 1 and 2) were asymptomatic, the other (case 3) had associated myasthenia gravis. Preoperative examination in each case was performed using chest CT scan or chest MRI, or both. Only one case (case 1) was diagnosed as thymolipoma preoperatively, and this was by a chest MRI showing the mass in continuity with the thymus. The diagnosis of each lesion was confirmed histologically by their composition of lobules of mature adipose tissue with minute islands of thymic tissue consisting of epithelial cells, lymphocytes, and Hassall's bodies.

Experience of expandable metallic stents for central airway obstruction.

The aim of this study was to investigate retrospectively the efficacy of expandable metallic stents (EMSs) for severe respiratory distress in patients with central airway obstruction. Twenty patients with central airway obstructions were treated with an EMS. An intraluminal stricture was present in 15 and an extraluminal stricture in 5 patients. Of the 15 patients with intraluminal stenosis, 11 exhibited symptomatic improvement. All 11 patients had tumor infiltration occupying less than 50% of the endoluminal diameter. The other four patients with intraluminal stenosis had tumor infiltration occupying > 50% of the endoluminal diameter and demonstrated no improvement. All five patients with extraluminal stenosis were improved. EMS is useful for an extraluminal stricture in the central airway and the effect of EMS for intraluminal stenosis is related to the degree of infiltration and of tumor progression itself.

Two survival cases of alcoholic lactic acidosis complicated with diabetes mellitus and alcoholic liver disease.

We have experienced two patients with alcoholic lactic acidosis complicated with liver disease and diabetes mellitus who were successfully treated. They developed hypoglycemia, dehydration, lactic acidosis, and renal failure after drinking a large volume of alcohol without eating for 1 week before onset. Acidosis was thought to be directly related to excessive alcoholic intake, because it was no associated with severe liver failure and rhabdomyolysis. During monitoring of respiratory and circulatory functions, a rapid infusion of fluids adjusting to water and electrolyte imbalance was performed. A mixture of physiological saline and 5% glucose solution was thought to be effective in these cases. Patients recovered from renal failure and lactic acidosis without hemodialysis. Our experience will hopefully provide a key to successful treatment of fatal alcoholic lactic acidosis.