[Considerations for Perioperative Management of Patients with Complicated Respiratory Dysfunction].

This article describes the perioperative complications, perioperative risk assessment, and perioperative management of patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease, especially idiopathic pulmonary fibrosis( IPF), which are the leading diseases in respiratory dysfunction. In COPD, testing for forced expiratory volume during the first second and pulmonary diffusing capacity is important and an algorithm for testing has been presented by the Japanese Association for Chest Surgery. Acute exacerbation of IPF is the leading cause of postoperative mortality in Japan, and risk factors are being analyzed. To reduce the occurrence of postoperative complications, it is important to carry out a risk assessment, select appropriate surgical strategy, and implement a well-planned perioperative management.

[Anaphylaxis Induced by Fibrin Glue During Surgery for Pneumothorax].

We report here our experience with a case of anaphylactic shock caused by fibrin glue. A 51-year-old male underwent a thoracoscopic surgery for refractory pneumothorax under local anesthesia. Bullae were revealed, and subsequently covered with fibrin glue and a polyglycolic acid sheet. Twenty-minutes after application of the fibrin glue, sudden drop of blood pressure less than 80 mmHg and a skin rash appeared. Since the patient was not administered any other drugs prior to the reduction in blood pressure, anaphylactic shock was considered to be caused by fibrin glue. The patient recovered after the treatment by dopamine and steroid.

[Structural Deterioration of a Bovine Pericardial Valve in a Tricuspid Position 14 Years Postoperatively;Report of a Case].

Although nonstructural dysfunction of a bioprosthesis caused by pannus formation or native valve attachment has been well described, structural valve deterioration( SVD) caused by calcification or tear of a bioprosthesis, especially a bovine pericardial valve, is very rare in the tricuspid position. We report a case of redo tricuspid valve surgery for SVD 14 years after tricuspid valve replacement( TVR) using a Carpentier-Edwards Perimount (CEP) pericardial valve. A 71-year-old woman was referred to our hospital because of exertional dyspnea and pre-syncope. She had undergone mitral valve replacement with a St. Jude Medical mechanical valve and TVR with a CEP pericardial valve 14 years previously. Transthoracic echocardiography revealed tricuspid valve stenosis with a mean trans-tricuspid valve pressure gradient (TVPG) of 7.3 mmHg. Redo TVR using a CEP Magna Mitral Ease valve was performed under cardiac arrest. Severe calcification was observed on the ventricular side of the leaflets of the explanted valve. The mean TVPG decreased to 3.2 mmHg after surgery, and the patient's postoperative course was uneventful.

[Salvage Surgery Following Chemoradiotherapy for Thymic Basaloid Cell Carcinoma].

We performed salvage surgery after chemoradiotherapy(CRT) in a patient with thymic basaloid cell carcinoma. A 46-year-old man with an abnormal chest shadow on X-ray findings was referred to our hospital. Computed tomography revealed a partially solid tumor along with a multilocular cyst in the anterior mediastinum with mediastinal lymph node swelling infiltrating to the superior vena cava(SVC). Positron emission tomography revealed FDG accumulation (SUVmax 7.94)in the tumor. Pathological findings of a tumor biopsy specimen obtained by thoracoscopy led to a diagnosis of thymic basaloid cell carcinoma. Following CRT (ADOC+RT:60 Gy), a complete resection (R0)with replacement of the SVC was performed. The postoperative course was uneventful, and the patient was alive at 20 months after surgery with metastasis to the cervical lymph nodes and bone.

[Docetaxel in combination with epirubicin as the first-line chemotherapy for advanced and recurrent breast cancer: a multicenter phase II study].

This study examined the efficacy and tolerability of docetaxel(DOC)in combination with epirubicin(EPI)as the first-line treatment for patients with advanced and recurrent breast cancer. A total of 56 female patients with metastatic breast cancer not previously treated for metastatic disease received DOC(60mg/m²)and EPI(60mg/m2)on day 1 every 3 weeks. The patient characteristics included a median age of 53 years. Advanced disease was present in 86% of patients, and recurrent disease was found in 14%; 3 or more metastatic sites had been diagnosed in 38% of patients, and 59% patients were ER+. The median number of courses administered was 6. The median dose intensity was 18. 7mg/m²week for DOC and EPI, and the relative dose intensities were 93. 5%and 93. 3%, respectively. The clinical responses included a complete response in 5%, a partial response in 54%, and stable disease in 33% of patients, with a disease control rate of 92%. The progression-free survival was 78. 3%, and the overall survival was 91. 9% at 1 year. Grade 3/4 toxicities included neutropenia in 82%, leukopenia in 71%, febrile neutropenia in 16%, anorexia in 9%, and anemia in 7%of the patients. Neither congestive heart failure nor toxic death occurred. The D and E combination with doses of 60mg/m2 is an active and generally well-tolerated regimen that can be used as first-line chemotherapy for patients with metastatic breast cancer.

Expression of SATB2 in Neuroendocrine Carcinomas of the Lung: Frequent Immunopositivity of Large Cell Neuroendocrine Carcinoma with a Diagnostic Pitfall.

Small cell lung carcinoma (SCLC) and pulmonary large cell neuroendocrine carcinoma (LCNEC) are both classified as lung neuroendocrine carcinoma (NEC). It has recently been reported that the special AT-rich sequence-binding protein 2 (STAB2), known as a colorectal cancer marker, is also expressed in NECs occurring in various organs including the lung. However, few studies have examined any differences of SATB2 immunopositivity between SCLC and LCNEC. We investigated SATB2 expression in 45 SCLC and 14 LCNEC cases using immunohistochemistry as well as the expression of caudal-type homeobox 2 (CDX2) and keratin (KRT) 20. The LCNEC cases were more frequently positive for SATB2 (ten out of 14, 71%) than the SCLC ones (seventeen out of 45, 38%) with a statistically significance (P = 0.035). Furthermore, two LCNEC cases were positive for CDX2 while no positive findings were observed for any SCLC cases, the difference of which, however, was not statistically significant (P = 0.053). KRT20 was negative in all LCNEC and SCLC cases. These results require our attention when we use SATB2 and CDX2 as colorectal cancer markers because their expression in pulmonary NECs can lead to a misdiagnosis that the tumor is of metastatic colorectal adenocarcinoma, especially when the patient has a past history of colorectal cancer. Analyzing the relationship between the demographic/clinical variables and the SATB2 expression in the SCLC cases, just high Brinkman index (≥ 600) was significantly related to the positivity of SATB2 (P = 0.017), which is interesting considering the strong relationship between SCLC and smoking.

Effects of exogenous methyl jasmonate and light condition on grape berry coloration and endogenous abscisic acid content.

Suitable postharvest treatment methods were investigated to improve the color of grape berries. Culture solutions containing jasmonic acid (JA), methyl jasmonate (MeJA), and prohydrojasmon (PDJ) enhanced the skin coloration of grape berries ('Pione') harvested at the initial stage of coloration. MeJA vapor treatment under sealed conditions increased anthocyanin accumulation in grape berries ('AkiQueen' and 'Pione') harvested at the early stage of skin coloration. Furthermore, promoting skin coloration by MeJA vapor treatment was as effective in mature clusters as it was in detached berries. These effects were confirmed in light conditions but not in constant darkness. Our results showed that postharvest MeJA vapor treatment improved skin coloration in grapes. In addition, postharvest treatment with MeJA was found to have no effect on the endogenous abscisic acid content of grape berry skins. Therefore, we suggest that MeJA vapor treatment can be a useful and labor-saving method for the horticultural industry.

Analysis of porous carbon biocathodes via three-dimensional impedance spectroscopy using a double channel transmission line model.

Porous carbon electrodes have considerably improved the performance of biofuel cells and biosensors in recent years. In this paper, we propose a novel in-situ analysis method for porous enzyme electrodes. By combining three-dimensional (3D) impedance measurement and a double-channel transmission line model, the stability of porous enzyme electrodes during operation can be evaluated. The proposed method can distinguish between the functional stability of the enzyme and mediator reaction and the general structural stability of the electrode. We demonstrated this method by evaluating bilirubin oxidase-modified carbon cloth (CC) electrodes with and without a magnesium oxide (MgO)-templated carbon coating. In case of the CC electrode, a remarkable increase in the charge transfer resistance within the first 500 s indicated the elution of the enzyme and mediator. When the CC was coated with MgO-templated carbon before enzyme modification, the charge transfer resistance remained constant, indicating an effective suppression of the elution of the enzyme and mediator. The electric double-layer capacitance values of both electrodes indicated that their general electrode structures were stable during the analysis. Thus, the proposed analytical method, based on 3D impedance, can be a powerful tool for simultaneously detecting possible changes in the general electrode structure of enzyme electrodes and in the amount of active enzymes and mediators on the electrode surface.

Spermidine levels are implicated in heavy metal tolerance in a spermidine synthase overexpressing transgenic European pear by exerting antioxidant activities.

To verify whether spermidine synthase (SPDS) can confer long-term multi-heavy metal tolerance, in vitro shoots of a transgenic European pear (Pyrus communis L. 'Ballad') line #32 overexpressing apple SPDS (MdSPDS1), as well as a wild type (WT) line, were subjected to stress using either CdCl(2), PbCl(2), ZnCl(2), or a combination thereof. Based on either shoot height increment or fresh weight and morphological changes upon heavy metal stress, the performance of the transgenic line #32 was better than that of WT. Although SPDS expression levels and spermidine (Spd) contents in line #32 were higher than those in WT, possibly due to transgene (MdSPDS1) expression, no obvious inductions of SPDS expression and increases in Spd-content were observed by long-term stress treatments in both lines. When the glutathione (GSH) content was compared with or without stress in each line, GSH was significantly depleted in line #32 with stress, but not as much as in WT. The activities of glutathione reductase and superoxide dismutase and the content of malondialdehyde, an indicator for lipid peroxidation, changed upon stress toward a more favorable status for survival in line #32 than in WT. These antioxidant parameters were positively related to Spd-content. The accumulation of heavy metals tended to be less in line #32 than in WT except for Zn stress, and the Ca content showed an opposite trend. These results suggest that Spd-levels are implicated in enhanced heavy metal tolerance, possibly by exerting an antioxidant activity as well as by the properties of Spd per se including metal chelator.

[A case of capecitabine-resistant recurrent breast cancer found to be responsive to S-1].

Thirteen months following surgery, local recurrence and multiple lung metastases occurred. Hormone therapy was continued following the recurrence but was found to be ineffective, so the patient was referred to our hospital 9 months after the recurrence. Capecitabine-based chemotherapy was administered but found to be ineffective; 3 months later, the anti-cancer drug was changed to S-1. After 3 months of S-1 administration, a CT scan showed a marked reduction in sites of recurrence and metastasis, making it possible to control progression of the disease over a longer period. No critical adverse reactions were observed, suggesting that S-1 can be useful and safe for the treatment of capecitabine-resistant recurrent breast cancer.

Pancreatogastrostomy with an elastic purse-string suture around the gastric orifice after pancreatoduodenectomy.

Postoperative pancreatic fistula (POPF) is a potentially fatal complication of pancreatoduodenectomy (PD). Fixation of the remnant pancreas to the gastric wall is considered essential to prevent anastomotic leakage in patients undergoing pancreatogastrostomy (PG) after PD. PG was performed with invagination of the pancreatic stump. To limit the number of sutures in the pancreas parenchyma to three or four, we placed an elastic purse string suture around the orifice of the posterior gastric wall in an attempt to fix the gastric wall to the remnant pancreas. We performed PG using this technique in 30 patients. According to the international POPF criteria, POPF developed in three (10%) patients; as grade A in one, and grade B in two. These results demonstrate the potential advantage of performing PG after PD, by using this invaginated technique with an elastic suture.

Impact of breast cancer diagnosis and treatment on women's sexuality: a survey of Japanese patients.

OBJECTIVE: Research on the impact of breast cancer on Asian women's sexual lives is extremely scarce. This study investigated the sexual changes experienced by breast cancer patients in Japan following surgery, and their sexuality-related information needs. METHODS: An anonymous, cross-sectional survey of breast cancer out-patients was conducted in 2005. Data from 85 subjects, who were without recurrence and reported being sexually active pre-surgery, were analyzed. RESULTS: Subjects were mainly in their 40's and 50's, and the median time since surgery was 43 months. Seventy-three (85.9%) had resumed sex after surgery with the median time being 3.5 months after surgery. Among 73 who resumed sex, 43 reported that the frequency of sex decreased, and 72 reported at least one sexually related change. The multiple logistic regression analysis revealed that those who had perceived the sexual relationship with their partner important before surgery (OR, 6.705; 95%CI, 1.320-34.051; p = 0.022) were more likely to maintain the same frequency of sex as before surgery. Perceived changes in respondents' sexual relationship did not necessarily result in deterioration of the couple's overall relationship. Regarding sexuality-related information needs, respondents wished to have information on treatment-induced sexual changes as well as sexual and general inter-couple communication strategies. CONCLUSION: This research revealed that breast cancer patients in Japan experience various sexual problems following breast cancer treatment. Sexuality-related information should be provided to all patients, regardless of patients age or type of surgery, as a part of routine treatment information giving.

Enhancement of spermidine content and antioxidant capacity in transgenic pear shoots overexpressing apple spermidine synthase in response to salinity and hyperosmosis.

In our previous work, an apple spermidine synthase (SPDS)-overexpressing transgenic European pear (Pyrus communis L. 'Ballad'), line no. 32 (#32), demonstrated attenuated susceptibility to stress treatment. In the current paper, changes in enzymatic and non-enzymatic antioxidant capacity of the transgenic pear (line #32) were investigated in response to NaCl or mannitol stress. Under non-stressed conditions (before stress treatment), spermidine (Spd) contents and SPDS activity of line #32 were higher than those of the non-transformant (wild type). However, no significant differences were detected between line #32 and the wild type as regards contents of malondialdehyde (MDA) and H2O2, and activities of antioxidant enzymes like superoxide dismutase (SOD), ascorbate peroxidase (APX), monodehydroascorbate reductase (MDHAR) and glutathione reductase (GR). When exposed to NaCl or mannitol stress, both the wild type and line #32 exhibited accumulation of Spd with the latter accumulating more. The transgenic line contained higher antioxidant enzyme activities, less MDA and H2O2 than the wild, implying it suffered from less injury. These results suggested that increase of Spd content in the transgenic line could, at least in part, lead to enhancing enzymatic and non-enzymatic antioxidant capacity.

Molecular cloning and expression analysis of cDNAs encoding a putative Nrt2 nitrate transporter from peach.

Two cDNA clones encoding a putative high-affinity nitrate transporter (Nrt2) were isolated from a cDNA library of peach (Prunus persica (L.) Batsch) roots. The nucleotide sequences of the clones, named PpNrt2.1 and PpNrt2.2, showed 99% identity in their coding regions, but their 3'-untranslated sequences showed only 40% identity. The deduced amino acid sequences of the clones showed 44-90% homology to NRT2 proteins from other plants. Both clones contained open reading frames encoding polypeptides of 530 amino acid residues, each with a predicted molecular mass of about 57 kDa. Both polypeptides had 12 putative transmembrane domains and a long hydrophilic C-terminal domain like other members of this protein family. Analyses of the genomic structures and of Southern blots suggested that PpNrt2.1 and PpNrt2.2 originated from different loci in the peach genome. In Northern blots, transcripts of PpNrt2.1 and PpNrt2.2 were detected in roots but not shoots of seedlings after nitrate application. They were not detected in leaves, stems, flowers, fruits or seeds of mature trees in the field, indicating root-specific expression of PpNrt2.1 and PpNrt2.2. Application of nitrate to roots of nitrogen-deprived seedlings strongly induced expression of PpNrt2.1 within 0.5 h, and gradually induced expression of PpNrt2.2. Application of ammonium to roots of nitrogen-deprived seedlings repressed expression of PpNrt2.1 and PpNrt2.2. The relationship of PpNrt2.1 and PpNrt2.2 to the inducible high-affinity transport system (iHATS) involved in the uptake of nitrate in peach roots is discussed.

Team approach to providing the multidisciplinary medical treatment derived by the patients and their family.

To date, the biological approach to breast cancer, such as pathologic subtype genetic analysis has been well investigated, and is considered to be the most important approach to under breast cancer treatment. Recently, the importance of a team approach to multidisciplinary medical treatment and holistic medical treatment has been recognized. The five following points are important: 1) recognition of patients' needs, 2) clarifying responsibility, 3) respect for each other, 4) maintaining good communication, 5) updating the system. Our original 'team approach path' is useful as a communication tool between a patient and the staff. Patient satisfaction is the purpose and a team approach is one method of carrying out medical treatment led by a patient as well as the medical treatment and informed decision based on narrative.

Visual assessment of Ki67 at a glance is an easy method to exclude many luminal-type breast cancers from counting 1000 cells.

BACKGROUND: The Ki67 labeling index (LI) reflects the proliferative activity of breast cancers and defines luminal A and B tumors; however, no detailed method to measure Ki67 has been standardized. Here, we propose a fast and easy way to evaluate Ki67. METHODS: Immunohistochemical staining of estrogen receptor (ER), progesterone receptor (PgR), HER2 and Ki67 (MIB-1) was performed on 235 primary invasive ductal carcinomas. For each sample, a hot spot with many Ki67+ cells was identified using a low-power field (40×, 4× objective). Three independent areas in high-power field (400×) were selected at the hot spot, and all cancer cells in the 3 areas were manually counted to calculate LI (% Ki67+ cells). Alternatively, micrographs taken at 100× and 200× fields including the hot spot were shown to 2 pathologists, who visually assessed percentages of Ki67+ cells in 10 % intervals at a glance (Eye-10). RESULTS: Eye-10 and LI were strongly correlated (r = 0.9412, P < 0.0001). All cases of Eye-10 ≥ 30 % had LI > 14 %; most of those <10 % had LI < 14 %. Of 170 ER+/HER2- tumors, Eye-10-based subtypes matched 87 % of LI-driven subtypes, and interobserver agreement was good (κ = 0.705). CONCLUSION: Eye-10 is far easier than counting many cancer cells and useful for classifying breast cancers. Eye-10 can exclude obviously high and low Ki67 cases, leaving a "gray zone" around a cutoff point. Combining Eye-10 and manual counting is a good candidate for a standard method to evaluate Ki67.

Visual assessment of Ki67 using a 5-grade scale (Eye-5) is easy and practical to classify breast cancer subtypes with high reproducibility.

AIMS: Personalised breast cancer therapy requires pathological characterisation of tumours. The proliferative index, based on Ki67, is pivotal, but a standard method has not been established. Here we look for an easy and practical way to evaluate Ki67. METHODS: Immunohistochemical staining of estrogen receptors, progesterone receptors, HER2 and Ki67 (MIB-1) was performed on resected specimens from 406 primary invasive ductal carcinomas. Ki67 labelling index (LI) from manual counting was compared with visual assessment using a 5-grade scale (Eye-5). Next, 10 pathologists evaluated 100 samples with marked hot spots by using Eye-5. Another 100 samples without marking were also assessed by eight pathologists. One year later, two pathologists reviewed 222 cases with Eye-5. Prognosis was analysed among estrogen receptor-positive cases with postoperative endocrine therapy. RESULTS: Eye-5 showed good correlation to LI. All 136 cases of score 4-5 had LI >20% and all 56 cases of score 1 had LI<20%, which means that manual counting was not necessary for about half of the cases. Interobserver and intraobserver variability was low even when a hot spot was not fixed. Eye-5 also correlated with histological grade and lymph node metastasis. Combining Eye-5 and histological grade created a new algorism to predict LI, which allows 80% of all cases (74% of luminal cases) without manual counting. Cases of Eye-5 score 1-2 had significantly better survival than score 3-5. CONCLUSIONS: Visual assessment of Ki67 by a 5-grade scale (Eye-5) is fast, easy, and reliable with acceptably low interobserver and intraobserver variability. Eye-5 can replace LI in many luminal tumours, and is a strong candidate as a standard method of evaluating Ki67.

Early results of an endoscope-assisted subcutaneous mastectomy and reconstruction for breast cancer.

BACKGROUND: Subcutaneous mastectomy and reconstruction (SMR) is well established; however, most incisions are made directly on the breast, and the majority of patients care about visible scars even if they are satisfied with the reconstructed breast. METHODS: From August 1998 to March 2001, a total of 46 patients (including 2 bilateral cases) with breast cancer underwent SMR using a saline-filled prosthesis by lateral axillary incision. There were 25 patients who received previous SMR without endoscopic assistance (group A) and 21 patients who underwent an endoscope-assisted SMR (E-SMR) (group B). These 2 groups were compared for curability, morbidity, and cosmesis. RESULTS: The median follow-up period was 19.2 + 9.8 months (range, 5.8 - 35.2 months). No significant difference was found in clinicopathologic data between the 2 groups. The operation time was 176 minutes in group A and 237 minutes in group B, and the estimated blood loss was 189 mL vs 356 mL, respectively. No critical complications were seen in either group. The average length of incision was 10 cm in group A and 5.7 cm in group B. As for the patients' satisfaction, the incidence of "excellent" plus "good" ratings was 76% in group A and 90.4% in group B. CONCLUSIONS: E-SMR is a new option that can provide an improved operative view and better cosmetic results for the treatment of breast cancer than with SMR. The operation time is longer than for SMR, but the incision is drastically shorter, resulting in better cosmesis and increased patient satisfaction.

[Gastrointestinal stromal tumor of the omentum: report of a case].

A 69-year old man was found a mass becoming larger in abdominal computed tomography. The mass consisted of intermingling solid and cystic component was located below the liver. Abdominal angiography showed tumor staining supplied from right gastroepiploic artery. We considered the mass cystadenoma, lymphangioma, cystic mesothelioma, or gastrointestinal stromal tumor (GIST) preoperatively, and then surgical resection was performed. The tumor was found localized in the greater omentum. Pathological examination showed the tumor composed of proliferation of atypical sort spindle cells and tumor cells were immunohistochemically positive for C-KIT and CD34, identifying the tumor as a primary GIST of the greater omentum.

Over-expression of the apple spermidine synthase gene in pear confers multiple abiotic stress tolerance by altering polyamine titers.

An apple spermidine synthase (SPDS) gene (MdSPDS1) was verified to encode a functional protein by the complementation of the spe3 yeast mutant, which lacks the SPDS gene. To justify our hypothesis that apple SPDS is involved in abiotic stress responses and to obtain transgenic fruit trees tolerant to abiotic stresses as well, MdSPDS1-over-expressing transgenic European pear (Pyrus communis L. 'Ballad') plants were created by Agrobacterium-mediated transformation. A total of 21 transgenic lines showing various spermidine (Spd) titers and MdSPDS1 expression levels were obtained. Selected lines were exposed to salt (150 mM NaCl), osmosis (300 mM mannitol), and heavy metal (500 microM CuSO4) stresses for evaluating their stress tolerances. Transgenic line no. 32, which was revealed to have the highest Spd accumulation and expression level of MdSPDS1, showed the strongest tolerance to these stresses. When growth increments, electrolyte leakage (EL), and values of thiobarbituric acid reactive substances (TBARS) were monitored, line no. 32 showed the lowest growth inhibition and the least increase in EL or TBARS under stress conditions. Spd titers in wild-type and transgenic lines showed diverse changes upon stresses, and these changes were not consistent with the changes in MdSPDS1 expressions. Moreover, there were no differences in the sodium concentration in the shoots between the wild type and line no. 32, whereas the copper concentration was higher in the wild type than in line no. 32. Although the mechanism(s) underlying the involvement of polyamines in stress responses is not known, these results suggest that the over-expression of the SPDS gene substantially increased the tolerance to multiple stresses by altering the polyamine titers in pear. Thus, MdSPDS1-over-expressing transgenic pear plants could be used to improve desert land and/or to repair polluted environments.