A comparison of the Pentax Airway Scope™ with the Airtraq™ in an infant manikin.

We compared the Pentax Airway Scope(TM) with the Airtraq(TM) optical laryngoscope in an infant manikin. Twenty-three anaesthetists randomly performed tracheal intubation: at rest, (a) with the Airway Scope and (b) with the Airtraq; and during chest compressions, (c) with the Airway Scope and (d) with the Airtraq. The success rate, modified Cormack and Lehane classification for glottic view, time taken to view the glottis, and time to place the tracheal tube were recorded. There was no difference in intubation success rate or quality of glottic view between the two devices. The median (IQR [range]) time taken to obtain a view of the glottis was 4.5 (3.7-6.4 [1.8-14.0]) s using the Airway Scope compared with 7.1 (5.5-9.6 [3.3-12.0]) s using the Airtraq (p = 0.001), and to successful placement of the tracheal tube was 8.3 (6.8-9.4 [3.7-20.7]) s using the Airway Scope compared with 11.2 (10.4-13.8 [4.9-23.7]) s using the Airtraq (p = 0.001). During chest compressions, the median (IQR [range]) time taken to view the glottis was 5.1 (4.0-7.2 [2.0-12.4]) s using the Airway Scope compared with 7.5 (5.0-13.2 [4.2-26.4]) s using the Airtraq (p = 0.006), and to successful placement of the tracheal tube was 9.5 (6.6-13.7 [4.5-16.2]) s using the Airway Scope compared with 11.7 (9.1-18.1 [6.2-37.4]) s using the Airtraq (p = 0.022). We conclude that both devices provided good quality views of the glottis and successful tracheal intubation in an infant manikin both at rest and during external chest compressions. Use of the Airway Scope resulted in a shorter time to view the glottis and perform successful tracheal intubation compared with the Airtraq.

Effect of oxaliplatin-based chemotherapy on chemosensitivity in patients with peritoneal metastasis from colorectal cancer treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: proof-of-concept study.

BACKGROUND: Chemosensitivity testing, including collagen gel droplet-embedded culture drug sensitivity test, has proven to be a useful tool in therapeutic decision-making. This retrospective analysis investigated chemosensitivity testing of peritoneal metastases collected during cytoreductive surgery (CRS), and its impact on survival in patients with colorectal cancer. METHODS: All patients with peritoneal metastasis from colorectal cancer who underwent CRS with or without hyperthermic intraperitoneal chemotherapy (HIPEC) between November 2008 and October 2014 were included. The growth inhibition rate was expressed as the ratio between the image density after treatment (T) and that before treatment (control, C). Tumours with a reduction in T/C ratio of less than 20 per cent were defined as resistant and those with a reduction of 20 per cent or more as sensitive. Groups were compared for overall (OS) and disease-free (DFS) survival. RESULTS: Of 84 eligible patients, 81 received neoadjuvant chemotherapy (NACT), including 56 patients with an oxaliplatin-based regimen. Mean(s.d.) follow-up was 23·4(22·9) months. The median overall survival of all patients was 19·0 (i.q.r. 5·7-36·1) months, with a progression-free survival time of 10·1 (4·5-17·0) months. Patients who received oxaliplatin-based NACT had significantly altered chemosensitivity to oxaliplatin; only 20 of 51 such patients showed chemosensitivity to oxaliplatin compared with 16 of 24 who did not undergo oxaliplatin-based NACT (P = 0·046). However, patients who showed chemoresistance to oxaliplatin had similar OS to those with chemosensitivity (18·8 versus 18·1 months; P = 0·835). The choice of HIPEC agents in patients who received oxaliplatin-based NACT did not significantly influence survival (oxaliplatin versus mitomycin C: median OS 20·6 (10·9-24·8) versus 19·0 (10·5-34·6) months, P = 0·811; DFS 6·6 (2·8-25·7) versus 9·3 (4·1-13·9) months, P = 0·191). CONCLUSION: Patients who had oxaliplatin-based NACT showed a higher rate of chemoresistance to oxaliplatin at the time of CRS and HIPEC. The impact of chemosensitivity testing on OS remains unclear and needs further investigation.

Prognostic value of tumor cell proliferation and intratumor microvessel density in advanced gastric cancer treated with curative surgery.

To clarify the prognostic value of tumor cell proliferation [proliferating cell nuclear antigen (PCNA)-positive rate assessed by anti-PCNA immunostaining] and intratumor microvessel density (/0.74 mm2, assessed by anti-CD34 immunostaining) in gastric cancer, 192 advanced gastric cancer patients who underwent curative surgery were investigated. Multivariate analysis showed that the following variables were significantly related to prognosis: age (P=0.029), depth of invasion (P=0.005), lymph node metastasis (P=0.006), lymphatic invasion (P=0.038), venous invasion (P=0.0005), PCNA-positive rate (P=0.049) and intratumor microvessel density (P=0. 011). In conclusion, tumor cell proliferation and intratumor microvessel density were independent prognostic factors in patients with advanced gastric cancer undergoing curative surgery.

Readjustment of antihypertensive treatment in patients with unsatisfactory blood pressure control.

Blood pressure response in 75 patients with primary hypertension to a readjusted treatment regimen was studied. The patients were given 13 antihypertensive drugs in 18 combinations. Since they all suffered from severe hypertension, the first choice was a combination of beta-blocker and diuretic. A vasodilator (hydralazine or prazosin) was added when necessary to control blood pressure. During a three-year follow-up study the patients' systolic and diastolic blood pressures were significantly lowered, from 174 (SD, +/- 25)/113 (SD, +/- 12) to 154 (SD, +/- 19)/98 (SD, +/- 8) mmHg. There was a significant decrease in serum creatinine levels, but body weight, heart volume, and serum lipid levels remained unchanged. In 62 (83%) patients diastolic blood pressure was reduced below 100 mmHg, and in 13 (17%) it remained above 100 mmHg. During the three-year follow-up study no patients with a diastolic blood pressure below 100 mmHg had a stroke, while three patients with a diastolic blood pressure above 100 mmHg did. This study demonstrates that heterogeneous drug combinations might fail to adequately control blood pressure and reducing the number of combinations might improve control.

Surgical treatment for non-dilated biliary tract with pancreaticobiliary maljunction should include excision of the extrahepatic bile duct.

BACKGROUND/AIMS: The authors evaluated the surgical treatment for non-dilated biliary tract with pancreaticobiliary maljunction. METHODOLOGY: Sixty-nine patients with pancreaticobiliary maljunction were divided into 61 patients with the dilated biliary tract and 8 with the non-dilated biliary tract. The levels of amylase activity in the bile in the gallbladder and the bile duct, the incidence and severity of postoperative cholangitis, and cell proliferating activity of the biliary tract epithelium, examined the proliferating cell nuclear antigen labeling index (PCNALI), were examined. RESULTS: Of the 61 dilated type patients, 12 were of Ia, 1 was of Ib, 22 were of Ic, 25 were of IV-A, and 1 was of IV-B according to Todani's classification. Cancer was detected in 7 dilated type patients and in 3 non-dilated type patients. A high level of amylase activity was measured in the bile juice in both the gallbladder and bile duct in all of the patients with pancreaticobiliary maljunction. PCNALI of the biliary tract epithelium of the patients without cancer (dilated type: bile duct 11.4%, gallbladder 12.7%; non-dilated type: bile duct 5.9%, gallbladder 13.8%) was higher than that of the patients without pancreaticobiliary maljunction (bile duct 1.5%, gallbladder 1.4%). CONCLUSIONS: In a non-dilated type, as well as in a dilated type, a high level of amylase activity and increase of cell proliferative activity of the biliary tract epithelium were observed. Therefore, these results suggest that the extrahepatic bile duct should be prophylactically removed in patients with non-dilated type as well as in those with dilated type pancreaticobiliary maljunction.

Surgical treatment for congenital biliary dilatation, with or without intrahepatic bile duct dilatation.

BACKGROUND/AIMS: The incidence of postoperative cholangitis differs between patients with and those without congenital intrahepatic bile duct dilatation. The aim of this study was to evaluate comparatively the treatment results in these two patients groups. METHODOLOGY: Forty-eight patients were classified into those with (dilated type) and those without (nondilated type) intrahepatic bile duct dilatation. The surgical procedure used, clinical manifestation, and cell kinetics (proliferating cell nuclear antigen labeling index, PCNALI) of bile duct epithelium were examined with respect to the incidence and course of postoperative cholangitis. RESULTS: Nineteen patients were classified as the dilated type, and the other 29 patients were the nondilated type. In the dilated-type group, hepaticoduodenostomy was performed on five patients, hepaticojejunostomy (Roux-en-Y method) on eight and jejunal interposition on six. Among the 29 nondilated-type patient, hepaticoduodenostomy was performed on 19 patients, hepaticojejunostomy (Roux-en-Y method) on seven, and jejunal interposition on three. Hepatectomy was performed in one dilated-type adult patient with marked cholangiectasia in the left hepatic lobe. The incidence of postoperative cholangitis was 26.3% (5/19) in the dilated-type group and 6.9% (2/29) in the nondilated-type group. The clinical manifestation was generally mild in the nondilated-type patients. However, among the adult dilated-type patients, on whom jejunal interposition had been performed, there were two patients who required additional surgery for the treatment of cholangitis that occurred postoperatively. The PCNALI in the bile duct epithelium was 13.9% for the dilated-type and 8.8% for the nondilated-type groups, respectively. CONCLUSIONS: Jejunal interposition for biliary reconstruction seems a contraindicated maneuver for adult dilated-type patients, because of the possible development of postoperative cholangitis. The cellular proliferating activity in the bile duct epithelium of the patients of both the dilated and nondilated type was significantly increased compared to that of a control group. Consequently, the extrahepatic bile duct might have to be removed in patients with pancreaticobiliary maljunction regardless of the presence or absence of biliary dilatation.

The relationship between levels of neutrophil-related factors and the degree of surgical stress.

To find a method for estimating the degree of surgical stress, 53 patients were divided into 3 groups according to operation time (group I, > or =5 h or more; group II, 1-4 h; and group III, <1 h) and measurement of neutrophil-related factors was performed. The postoperative levels of chemiluminescence (CL) generated by neutrophils (5.5 x 10(8)cpm) in group I was significantly higher than that in group II (2.1 x 10(8)cpm). The postoperative levels of CL in whole blood (5.7, 2.9, 1.0 x 10(6)cpm for groups I, II and III, respectively) and plasma lactoferrin levels (Lf) (653, 302, 143 ng/ml) were highest in group I and lowest in group III. The serum iron (Fe) level (24, 32, 58 microg/dl for groups I, II, III) was highest in group III and lowest in group I. In conclusion, whole blood CL, neutrophil CL, Lf and Fe levels after surgery can be useful indicators of the degree of surgical stress.

Liver drug metabolism and blood pressure response to a lipophilic and hydrophilic beta blocker.

The role of liver drug metabolism on blood pressure (BP) response to a lipophilic (propranolol) and hydrophilic (sotalol) beta blocker in thirty hypertensive patients was studied. Ten patient treated with diuretics were classified according to plasma antipyrine clearance rate as rapid and slow metabolizers. They were first treated for one month with propranolol and then for one month with sotalol at equivalent dosage. Four patients, classified as rapid drug metabolizers had a better response to sotalol, 139 (SD 13)/92 (SD 6) mmHg, than to propranolol, 164 (21)/104 (10) mmHg. For the other six patients, with slow drug metabolism, the response to propranolol, 142 (8)/95 (8) mmHg was equal to sotalol, 143 (19)/93 (8) mmHg. Twenty patients were randomly divided into two groups. The patients in these groups were similar as to sex, age, body mass index, BP and rate of drug metabolism. The subjects in the first group were treated with propranolol and diuretic and those in the second with sotalol and diuretic. The BP response was equal in both groups, propranolol 147 (14)/96 (7) mmHg and sotalol 143 (12)/95 (9) mmHg after two years' follow-up. The rate of drug metabolism must be considered when evaluating response to lipophilic but not to hydrophilic beta blocker.

[Heart failure due to rapid right ventricular volume overload in patients with pulmonary hypertension].

We have described three cases of pulmonary artery hypertension (PAH). Two of them developed severe systemic hypotension and cardiac arrest following cardiopulmonary bypass (CPB). Imminent pre-operative right ventricular (RV) failure and subsequent myocardial injury during CPB may have contributed to the insult following CPB. In these cases, RV failure is presumably due to rapid volume overloading, since left atrial pressure (LAP) was essentially unchanged while right atrial pressure (RAP) was markedly elevated during the period of severe hypotension. Furthermore, these events may be attributed to protamine, since the circulatory derangement coincides with its administration. Thus, in these patients with severe PAH, blood transfusion should be carefully titrated under the strict evaluation of both LAP and RAP. Additionally, protamine should be infused at a rate slow enough to avoid concomitant hemodynamic changes. We have also reported a case of over-systemic PAH who was successfully managed intraoperatively by careful monitoring and discreet administration of protamine.

[Preoperative diagnosis and surgical treatment for lymph node metastasis in gastric cancer].

In order to clarify the preoperative diagnostic ability for lymph node metastasis, images from magnetic resonance imaging (MRI), computed axial tomography (CT) and ultrasonography (US) were evaluated in 200 gastric cancer patients. The long-term results of 2,000 gastric cancer patients who had undergone gastrectomy were also studied to evaluate the effectiveness of lymphadenectomy. 1) Preoperative diagnosis of lymph node metastasis: The detection rate of lymph nodes around the stomach was 34.1% in MRI, 18.7% in CT and 5.0% in US. The incidence of metastasis was over 80% when the size of lymph node imaged was 1.5 cm and over, against 25% for lymph nodes less than 1.0 cm in size. The detection rate of metastatic lymph node according to the mode of metastasis was 88% for macro-nodular type, 66% for micro-nodular type, 57% for diffuse type in MRI, 70, 41 and 15% in CT, and 38, 3, 0% in US, respectively. Therefore, MRI was most useful for detecting metastatic lymph node preoperatively. 2) Long-term results of gastric cancer with lymph node metastasis: The cumulative 5-year survival rate was 84.2% in n0, 56.1% in n1, 33.7% in n2, 16.5% in n3, and 5.1% in n4 patients. Satisfactory long-term results were obtained for n2 or less patients without serosal invasion. Moreover, by paraaortic lymph node dissection, the cumulative 5-year survival rate in n4 patients was 16.4% (27.8% for cases with radical resection). These results showed the effectiveness of lymph node dissection for gastric cancer.

[Quantitative analysis of myocardial fibrosis in myocardial biopsies--a comparison between computer analysis and point counting method].

To select an appropriate method to analyze quantitatively myocardial fibrosis in myocardial biopsies, two methods, the computer analysis and the point-counting method observed at magnifications of x200 and x400, were compared. Our targeted points of examination were the accuracy and reproducibility of these methods. Twenty patients (10 with dilated cardiomyopathy and 10 with hypertrophic cardiomyopathy) were randomly selected, and the percent area of myocardial fibrosis in myocardial biopsies obtained from the right ventricular septum was measured by both the computer analysis and the point-counting method. Two observers measured the same area twice on the different days, independently. In the area of analysis, the endocardium was excluded to avoid the observer's bias. By comparing the data obtained from two observers, it was shown that the point-counting method tended to give a larger mean value and standard deviation than the computer analysis method, but that the latter indicated better reproducibility than the former. Our result showed that the degree of myocardial fibrosis varied according to methods of analysis and observer's experiences. It is recommended that the comparison of myocardial fibrosis should be made only when the methods of analysis of fibrosis are identical.

Subaru telescope observations of Deep Impact.

The impact cratering process on a comet is controversial but holds the key for interpreting observations of the Deep Impact collision with comet 9P/Tempel 1. Mid-infrared data from the Cooled Mid-Infrared Camera and Spectrometer (COMICS) of the Subaru Telescope indicate that the large-scale dust plume ejected by the impact contained a large mass (approximately 10(6) kilograms) of dust and formed two wings approximately +/-45 degrees from the symmetric center, both consistent with gravity as the primary control on the impact and its immediate aftermath. The dust distribution in the inner part of the plume, however, is inconsistent with a pure gravity control and implies that evaporation and expansion of volatiles accelerated dust.

Secondary hypertension in a medical ward.

The prevalence of secondary hypertension was evaluated by investigating 400 consecutive patients with arterial hypertension in a medical ward. They were classified into four groups according to the case history. Group A: 104 subjects with therapy-resistant hypertension, group B: 247 patients who had another concomitant disease as the primary reason for admission, group C: 34 patients referred to the ward for basic investigation due to recently diagnosed hypertension, group D: 15 patients with unwanted hypertension was 15.5% in the entire series, and 14.4%, 18.6%, 2.9% and 0% in groups A - D, respectively. Ten patients (2.5%) were operated on, nine of them from group A and one from group B. The findings demonstrate the importance of a careful examination of patients with therapy-resistant hypertension, since they might include subjects whose hypertension can be treated by surgery.

Effect of high thoracic extradural anaesthesia on ventilatory response to hypercapnia in normal volunteers.

We have investigated, in six healthy male volunteers, the effect of high thoracic extradural anaesthesia on the ventilatory pattern and hypercapnic ventilatory response. Ventilatory variables were determined using a respiratory inductive plethysmograph. Duration of inspiration, rib cage excursion and its contribution to tidal volume decreased significantly following extradural anaesthesia, while mean inspiratory flow rate and minute ventilation increased. End-tidal PCO2 and the tidal excursion of the abdomen were unchanged. Hypercapnic ventilatory response decreased significantly following extradural anaesthesia, principally because of the rib cage component. The slope of the abdominal component did not change significantly. The results indicate that mechanical impairment of rib cage movement can produce decreased ventilatory response to carbon dioxide. The ventilatory impairment and the changes in breathing pattern induced by the high thoracic extradural anaesthesia probably reflect blockade of the efferent or afferent pathway (or both) of the intercostal nerve roots.

Hepatobiliary cystadenoma combined with multiple liver cysts: report of a case.

Hepatobiliary cystadenomas are rare benign tumors with malignant potential. They are almost always solitary lesions accompanied by multilocular cysts in the liver, and are difficult to differentiate from cystadenocarcinoma, despite the diagnostic modalities available. This report describes a case of hepatobiliary cystadenoma with multiple cysts in the left hepatic lobe, diagnosed by magnetic resonance imaging in a 48-year-old woman. Abdominal computed tomography revealed only multiple cystic lesions in the left lobe, but cholangiography via a nasogastric biliary drainage tube combined with percutaneous transhepatic cholangiography showed a stenotic region with fine irregularity in the left lateral posterior segmental bile duct and left lateral anterior segmental bile duct. Hepatobiliary cystadenocarcinoma with multiple liver cysts was suspected. We performed left hepatectomy, and microscopic examination confirmed a diagnosis of hepatic cystadenoma with multiple liver cysts. There was no nuclear atypia or mitosis in the epithelium of the locus, which was constructed of simple columnar-to-cuboidal epithelium with basal nuclei. The patient is well without recurrence more than 4 years after surgery.

Multiple early gastric carcinomas. Clinicopathologic features and histogenesis.

BACKGROUND: Multiple early gastric carcinomas were found in 5-15% of patients with early gastric carcinoma. The goals of this study were to clarify the clinicopathologic features of multiple early gastric carcinomas and to investigate their histogenesis. METHODS: Of 724 patients with early gastric carcinoma, there were 65 with multiple (159) gastric carcinomas. Investigation of the histogenesis of multiple gastric carcinomas was conducted using serial sections of the stomach of 33 patients with multiple early gastric carcinomas (MEGC) and 33 patients with solitary early gastric carcinoma (SEGC). The cancerous and epithelial dysplastic lesions were examined by hematoxylin and eosin staining and immunohistochemical staining of p53 protein with anti-p53 monoclonal antibody (BP53-12). RESULTS: The macroscopically depressed type was common. The flat type was observed only in accessory lesions, most of which were diagnosed postoperatively. There were 126 differentiated type lesions, and 33 poorly differentiated type lesions. In most cases both the main and accessory lesions were differentiated. The average number of epithelial dysplastic lesions (18.3) in the stomach of patients with differentiated MEGC was significantly higher than that in the stomach of patients with differentiated SEGC (7), poorly differentiated MEGC (2.1), and SEGC (2). Moreover, severe dysplastic lesions were frequently observed in the stomach of patients with differentiated MEGC. p53 protein expression was detected in 0.9% of mildly atypical epithelial dysplastic lesions, 3.7% of moderately atypical dysplastic lesions, and 18.2% of severely dysplastic lesions. CONCLUSIONS: In cases of early gastric carcinoma, small depressed type and flat type accessory lesions of multiple gastric carcinomas should be detected preoperatively. Epithelial dysplastic lesions probably are significant in the histogenesis of differentiated multiple gastric carcinomas.

Vitamin E deficiency has a pathological role in myocytolysis in cardiomyopathic Syrian hamster (BIO14.6).

This study revealed the occurrence of vitamin E deficiency in the myocardium of 60-day-old Syrian cardiomyopathic hamsters (BIO14.6), and that this deficiency might be related to the increase in lipid peroxide. Vitamin E administration for ten days effectively restored creatininekinase activity and decreased the lipid peroxide content in the myocardium, returning these to normal control levels (F1b). These results indicate that vitamin E deficiency, possibly combined with oxidative stress in the early cardiomyopathic stage plays an important role in initiating the pathogenesis of myocardial lesions.