Robotic techniques improve quality of life in patients undergoing atrial septal defect repair

BACKGROUND: Minimally invasive cardiac surgery has emerged as an alternative to conventional, open surgery. Although most studies of robotically assisted cardiac surgery have reported morbidity and mortality, few have addressed outcome measures, such as pain and quality of life, which was the aim of this study. METHODS: Eleven patients with atrial septal defects (ASD), and five patients with patent foramen ovale, underwent repair using the Da Vinci system (Intuitive Surgical, Mountain View, CA). The Medical Outcomes Study Short Form Survey (SF-36), along with two additional questions, were administered to these patients on postoperative day 30, along with a similar number of patients who underwent ASD repair by mini-thoracotomy or sternotomy. Quality of life endpoints included bodily pain, vitality, mental health, general health, physical function, and social function. RESULTS: Robotic patients demonstrated significantly higher scores in 6 of the eight variables (p < 0.05). There was no significant difference in intensive care unit or overall hospital stay among the groups (p = NS). Robotic patients returned to work after 40.2 +/- 30.2 days, mini-thoracotomy patients after 45.6 +/- 27.9 days, and sternotomy patients after 51.7 +/- 40.2 days (p = 0.767). There were no significant differences in SF-36 scores between patients who underwent mini-thoracotomy and sternotomy approaches. CONCLUSIONS: Closure of an ASD can be performed safely and effectively via an endoscopic approach. Robotic technology minimized the degree of invasiveness, hastened postoperative recovery, and improved quality of life, although length of hospital stay was unchanged.     

Late bleeding from right internal mammary artery after HeartMate left ventricular assist device implantation

Postoperative bleeding is one of the major complications after implantation of left ventricular assist devices. We experienced 5 unusual cases, which had bleeding from the right internal mammary artery between 5 and 69 days after implantation of a Heartmate (Thoratec Corporation, Pleasanton, CA) device. It was evident that the outflow graft had eroded through the vessel. Sudden decreases in device flow, hypotension, bleeding from the driveline or chest tube sites, and a drop in hematocrit were the initial manifestations. Chest roentgenogram and transthoracic echocardiography were effective in identifying hemothorax and cardiac tamponade. Four out of 5 patients survived to heart transplantation and were discharged from the hospital. When identified and treated appropriately, this complication does not impair patient outcome.     

Hand-assisted laparoscopic splenectomy for solitary splenic metastasis from uterine corpus carcinoma

Solitary splenic metastasis is a rare condition. We performed hand-assisted laparoscopic splenectomy (HALS) for a solitary splenic metastasis from a uterine corpus carcinoma that had directly invaded the wall of the stomach. HALS is a superior technique that offers the advantages of both open and laparoscopic splenectomy, and it may become one of the options for the management of primary and secondary cancer of the spleen. Presented at the Eighth World Congress of Endoscopic Surgery, New York City, New York, USA, 13–16 March 2002     

Socioeconomic health inequalities in Latvia: a cross-sectional study

AIMS: Socioeconomic health differences have been studied elaborately for many Western societies. Relatively little is know about the social variations in health in the former communist states of Eastern Europe. This study investigated socioeconomic health inequalities in Latvia. METHODS: Cross-sectional analysis was undertaken of the 1999 Norbalt-II Living Conditions Survey, a random population-based sample in Latvia, and included males and females aged 25 to 70. RESULTS: Lower educated subjects had higher rates of self-assessed poor health than those with tertiary education (men OR 2.21; 1.31-3.71 95% CI, and women OR 2.48; 1.74-3.54 95% CI). After adjusting for income, educational differences were significant only for women. Income differences were larger than educational differences in self-assessed poor health for both genders (OR of highest vs. lowest quintile for men: 5.10; 2.26-11.5 95% CI, women: OR 3.26; 1.92-5.51 95% CI). For long-standing health problems socioeconomic differences were smaller. After adjusting for income no educational differences were found, but income differences were significant (men: OR 2.06; 1.15-3.69 95% CI, women: OR 1.42; 1.12-2.63 95% CI). The economically non-active were in worse health than the (self-)employed subjects (men: OR 6.12; 3.65-10.3 95% CI, women: OR 2.79; 1.66-3.39 95% CI). CONCLUSIONS: Substantial social inequalities in self-assessed poor health and longstanding health problems exist in Latvia for both sexes. Inequalities by material circumstances, as measured by income, appear to be larger than educational differences. Economic activity was also strongly associated with health. There were no inequalities with regard to urbanization and ethnic differences were found only for long-standing health problems among women.     

A new antifungal metabolite from Penicillium expansum

A new antifungal compound, (3S)-4,6-dihydro-8-methoxy-3,5-dimethyl-6-oxo-3H-2-benzopyran (4), was isolated from Penicillium expansum. During the isolation procedure 4 was determined to be unstable and readily reacted with methanol, ethanol, and water, forming three new isochromans, (1S,3S)-6-hydroxy-1,8-dimethoxy-3,5-dimethylisochroman (1), 1-ethoxy-6-hydroxy-8-methoxy-3,5-dimethylisochroman (2), and 1,6-dihydroxy-8-methoxy-3,5-dimethylisochroman (3), respectively. (3S)-6-Hydroxy-8-methoxy-3,5-dimethylisochroman (5) was reisolated from P. expansum. In fungicide disk assays, compounds 1, 2, and 4 inhibited the mycelial growth of Lasiodiplodia theobromae at 100 microg/mL by 76%, 74%, and 69%, respectively.     

Preoperative intraperitoneal chemotherapy for patients with serosa-infiltrating gastric cancer

BACKGROUND AND OBJECTIVES: Serosa-infiltrating gastric cancer poses a high risk for peritoneal recurrence. This study examined the feasibility and efficacy of preoperative intraperitoneal (i.p.) chemotherapy for such cancer. METHODS: Patients with serosa-infiltrating tumors, diagnosed by conventional examinations as well as by staging laparoscopy, were enrolled in this study. Those with unresectable T4 tumors, visible peritoneal metastasis or distant organ metastasis were excluded. Twenty-five eligible patients received preoperative i.p. chemotherapy, which consisted of i.p. injection of 20 mg of mitomycin C on day 1 and 10 mg of cisplatin for 5 days, followed by surgery. RESULTS: Of the 25 patients, 24 underwent gastrectomy with lymph node dissection and 1 underwent palliative gastrojejunostomy. The curability of the surgery was curability A in 6, B in 16, and C in 3. Preoperative T stages (T3 in 21 and T4 in 4) were downstaged postoperatively (T1 in 1, T2 in 10, T3 in 11, and T4 in 3). The 1- and 2-year overall survival was 83.3 and 51.3%, respectively. The median survival time was 24.4 months. The toxicity of the preoperative treatment was tolerable and no serious postoperative complication was seen. CONCLUSIONS: Preoperative i.p. chemotherapy seems to be a safe and effective therapy for serosa-infiltrating gastric cancer. Randomized clinical trials comparing preoperative i.p. chemotherapy followed by surgery and surgery alone are needed.     

Application of metallic stents for both inferior vena cava and biliary obstruction by lymph node involvement in a patient with recurrent hepatocellular carcinoma

The authors experienced a case with obstruction of the inferior vena cava (IVC) and the common bile duct due to a recurrent hepatocellular carcinoma. In order to improve severe edema of the lower extremities and obstructive jaundice, IVC metallic stent as well as biliary stent were applied. A Luminexx stent of 8 cm in length was placed in the bile duct via subcutaneous route after biliary drainage. A spiral zigzag stent of 8 cm in length was also inserted into the IVC through the femoral vein following balloon dilatation of the obstructed portion. Subsequently, jaundice and edema were dramatically improved in a short period of time, which resulted in patient discharge from the hospital. Although the patient died of the cancer in 2 months, the quality of life was well maintained until death.     

mRNA expression level of estrogen-inducible gene, alpha 1-antichymotrypsin, is a predictor of early tumor recurrence in patients with invasive breast cancers

We previously identified 18 genes that correlated with ER positivity by adapter-tagged competitive-PCR analysis of 2412 genes in human breast cancer tissues. The aim of the present study was to determine the prognostic significance of these genes. mRNA expression levels of 12 of the above 18 genes were quantified in breast cancer tissues by real-time PCR assay, and their association with patients' prognosis (n = 110) was studied according to hormone receptor (HR) status. In addition, the genes found to influence prognosis were further investigated to examine whether their mRNA expression could be induced by estrogen in MCF-7 cells in vitro. Of the 12 genes, mRNA expression levels of two [alpha 1-antichymotrypsin (ACT) and stanniocalcin 2 (STC2)] were significantly (P = 0.002 and P = 0.007, respectively) associated with good prognosis in HR-positive (ER and/or PR positive) breast cancer patients treated with adjuvant hormone therapy. Multivariate analysis showed that ACT mRNA level, but not STC2 mRNA level, in HR-positive patients, was a significant prognostic factor (P = 0.042), which was independent of tumor size and lymph node metastases. On the other hand, mRNA expressions of ACT and STC2 were not significantly associated with prognosis in HR-negative patients. Estradiol treatment resulted in a significant increase in the mRNA levels of both ACT and STC2 in MCF-7 cells. The mRNA level of ACT, which is an estrogen-inducible gene, is a significant predictor of good prognosis in HR-positive, but not HR-negative, patients with breast cancers. Since HR-positive patients were treated with adjuvant hormone therapy, we suggest that ACT mRNA level could potentially be used as a predictor of response to hormone therapy, rather than a prognostic factor (predictor of metastatic potential).     

Continuous monitoring of gastric intraluminal carbon dioxide pressure, cardiac output, and end-tidal carbon dioxide pressure in the perioperative period in patients receiving cardiovascular surgery using cardiopulmonary bypass

OBJECTIVE: To verify the hypothesis that the gastric intraluminal PCO2 (PgCO2) changes independently of the change in cardiac output (CO) during and after cardiovascular surgery using cardiopulmonary bypass (CPB), and that the elevation of PgCO2 affects the patients' morbidity. DESIGN: Prospective, noninterventional study. SETTING: Medical/surgical intensive care unit and operating theater of a university hospital. PATIENTS: Sixteen adults patients receiving elective cardiovascular surgery using CPB. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After induction of anesthesia, the patients were fitted with a gastric tube equipped at the tip with a CO2 sensor (ion-selective field effect transistor) that can continuously measure real-time PgCO2, and a pulmonary artery catheter capable of monitoring continuous CO (CCO) and end-tidal CO2. Data from the devices was uploaded to a personal computer every 2 mins until the catheter was pulled off based on clinical judgment (PgCO2 values were blinded to everyone except the investigator). One patient expired as a result of multiple organ failure subsequent to sepsis, and postoperative morbidity assessed by the peak SOFA (sequential organ failure assessment) score (mean +/- SD 6.9 +/- 3.5; range, 2-13) was correlated with the peak PgCO2 during intensive care unit stay (mean +/- SD 74.1 +/- 30.7 mm Hg; range, 45-169 mm Hg) (p < .01, by regression analysis). The peak PgCO2 during surgery (mean +/- SD 71.1 +/- 18.1 mm Hg; range, 44-115 mm Hg) had no correlation with the postoperative morbidity. From analysis of CCO before, during, and after returning from the above 60 mm Hg of PgCO2, PgCO2 changed independently of CCO. CONCLUSIONS: PgCO2 changed independently of CCO, and its postoperative elevation was related to morbidity, even in the group of patients with a good outcome. Continuous monitoring of PgCO2 is useful for the detection of morbidity and can be expected to help elucidate the pathophysiology of change of PgCO2.     

A novel TRH-PFTAIRE protein kinase 1 pathway in the cerebellum: subtractive hybridization analysis of TRH-deficient mice

TRH has been reported to possess several neurophysiological actions in the brain. To gain insights into the molecular mechanisms underlying these effects, particularly in the cerebellum, we attempted to clone a cDNA that was regulated by TRH using TRH knockout mice and subtractive cDNA analysis. Over 100 clones obtained by subtractive hybridization analysis between the wild-type and TRH-1-cerebellum were analyzed. Four clones among them were identical and cdc2-related kinase (PFTAIRE protein kinase 1 (PFTK1)) cDNA, which was previously reported to be expressed only in the brain and testis. PFTK1 mRNA levels in the euthyroid TRH-1- cerebellum supplemented with thyroid hormone were significantly decreased compared with those in the wild-type. Induction of PFTK1 mRNA by TRH was also observed in a time- and dose-dependent manner in human medulloblastoma-derived HTB-185 cells that expressed TRH receptor subtype I mRNA. In addition, treatment of 8-Br-cGMP significantly increased PFTK1 mRNA levels, and a specific inhibitor of cGMP production, ODQ, completely blocked TRH-induced expression of PFTK1 mRNA. Furthermore, induction of PFrK1 mRNA by TRH was significantly inhibited by a NOS specific inhibitor, L-NAME, but not by a MEK inhibitor, PD98059 or a calcium channel inhibitor, nimodipine. These findings demonstrated, for the first time, a novel pathway between a neuropeptide and a cell cycle related peptide in the brain, and PFTK1 may be a key regulator for TRH action in t he cerebellum through t he NO-cGMP pathway.