Difficult tracheal extubation

We describe a case of nasotracheal tube fixation with a screw. A second case is described in which a broken drill bit was found to impinge on the wall but not penetrate into the lumen of a nasotracheal tube. Possible sequelae of this complication include airway leak, aspiration, tube obstruction, and trauma from attempts at forceful extubation. We recommend the routine intraoperative testing for tracheal tube movement and routine fibreoptic bronchoscopy through the tube when blind surgical procedures occur in the vicinity of a tracheal tube.     

High glucose increases inducible NO production in cultured rat mesangial cells. Possible role in fibronectin production.

BACKGROUND/AIM: Increased nitric oxide (NO) generation and action have been suggested to be associated with glomerular hyperfiltration and increased vascular permeability early in diabetes. However, previous studies have primarily focused on the constitutive nitric oxide synthase (cNOS) pathway present in endothelial cells, and the role of the inducible NOS (iNOS) pathway in diabetic nephropathy has remained unclear. This study examined whether high glucose modulates NO synthesis by the iNOS pathway in rat mesangial cells. In addition, the effect of inhibition of the iNOS pathway on fibronectin production was determined to examine the role of the iNOS pathway in high glucose-induced extracellular expansion by mesangial cells. METHODS: NO synthesis by the iNOS pathway was evaluated by nitrite and iNOS mRNA and protein productions. The effects of protein kinase C (PKC) inhibitor and aldose reductase inhibitor on the iNOS mRNA expression and aminoguanidine, a relatively specific inhibitor of the iNOS on fibronectin protein production were examined. RESULTS: High 30 mM glucose concentration led to significant increases in nitrite production of rat mesangial cells upon stimulation with lipopolysaccharide (LPS) plus interferon-gamma (IFN-gamma) compared with control 5.6 mM glucose concentration. Mesangial iNOS mRNA expression and protein production also increased significantly in response to high glucose. The addition of calphostin C, a PKC inhibitor, and 6-bromo-1,3-dioxo-1H-benz[d,e]isoquinoline-2(3H)-acetic acid, an aldose reductase inhibitor, significantly suppressed the enhancement of iNOS mRNA expression in high glucose concentration. High glucose also significantly increased fibronectin protein production of mesangial cells upon stimulation with LPS plus IFN-gamma compared to control glucose. Aminoguanidine reversed this high glucose-induced fibronectin production at dose inhibiting iNOS mRNA expression. CONCLUSIONS: These results indicate that high glucose enhances cytokine-induced NO production by rat mesangial cells, and that the activation of PKC and aldose reductase pathway may play a role in this enhancement. In addition, high glucose-induced NO production by the iNOS pathway may promote extracellular matrix accumulation by mesangial cells under certain condition.     

Dispersion of organic contaminants from wastewater treatment outfall in Masan Bay, Korea

Masan Bay is a land locked shallow water system with poor water circulation. The bay is surrounded by thickly populated cities with considerable industrialization. A wastewater tratment plant (WWTP) manages both domestic and industrial sewage from Masan and Changwon cites and empties the treated water into the bay. Since persistent chemicals of toxic nature escape this process an experiment was designed to investigate in sediments the distribution and dissipation of 5 major groups of agro- and industrial chemicals (51 chemicals in total) from the point of discharge in all directions of the bay. Target chemicals showed patterns of distribution that agreed with expected spatial ditribution model and minor deviations due to diffuse sources of input (e.g. runoff from streams and creeks; ship building and port activities). Thus it is understood that WWTP plays an important role in distributing pollutants to Masan Bay.     

Removal of oral secretion prior to position change can reduce the incidence of ventilator‐associated pneumonia for adult ICU patients: a clinical controlled trial study

Aim. The purpose of this study was to explore the effect of oral secretion on aspiration and reducing ventilator‐associated pneumonia. Background. Ventilator‐associated pneumonia is a serious hospital‐acquired infection with reported incidence rate of 12·2% and mortality rate of 29·3%. Oral secretion is purported as a media which brings the oropharyngeal pathogens down to the respiratory track. Methods. Two‐group comparison study design was adopted. Subjects were recruited from an adult general intensive care unit of a medical centre in Taipei city. Patients in the study group received suction of oral secretion before each positional care, in contrast with patients in the control group who received routine care. Results. Ventilator‐associated pneumonia was found in 24 of 159 (15·1%) patients in the control group and in five of 102 (4·9%) patients in the study group with a reduction of risk ratio of 0·32 (95% CI 0·11–0·92). Eight of the 24 ventilator‐associated pneumonia patients died in the control group; however, none of those ventilator‐associated pneumonia patients died in the study group. The increased chance of survival was 1·50 (95% CI 1·13–1·99). The length of stay in ICU and duration of mechanical ventilation were reduced in the study group. In consideration of cost, the cost of tubes used to remove oral secretion is much less than the one used to do continuous subglottal suction. Conclusion. Removal of oral secretion is effective in reducing the incidence of ventilator‐associated pneumonia with minimum cost intervention. Relevance to Clinical Practice. This study provides evidence that removal of oral secretion prior to position change is cost effective to reduce the incidence of ventilator‐associated pneumonia. As such intervention is an easy task, routine removal of oral secretion is recommended as the standard of daily nursing care of patients on ventilator.     

Predictors of Remission and Relapse of Diabetes after Conventional Gastrectomy for Gastric Cancer: Nationwide Population-Based Cohort Study

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Clinical presentation of carcinoma of unknown primary: 14 years of experience

A carcinoma of unknown primary (CUP) is a histologically confirmed metastatic cancer without a definitive primary site after performing a detailed medical examination. The purpose of the study was to classify unfavorable CUPs into more reliable disease entities, which reflect the clinical course. We reviewed the medical records of patients diagnosed with a CUP between January 1995 and March 2008. Patients were classified into a conventional favorable-risk group and a newly proposed unfavorable-risk group according to the clinicopathologic features. Five hundred eighty-six patients were diagnosed with CUPs. Fifty-six (9.6%) patients were classified in the conventional favorable-risk group, and 486 (82.9%) patients were classified in the unfavorable-risk group. We further classified the 486 patients into six subgroups with an unfavorable risk, while excluding 29 patients (5.0%) who were not classifiable. The overall survival of the conventional favorable-risk group was 47.0 months (95% CI, 11.1~82.9 months), which was significantly longer than that of any subgroup of the newly proposed unfavorable-risk group (P?<?0.001). Patients with squamous cell carcinoma in the abdominopelvic cavity showed similar overall survival with unfavorable-risk group (P?=?0.484). Women with non-papillary malignant ascites had a survival in between the favorable and unfavorable groups (P?<?0.001). The newly proposed unfavorable-risk group may assist in classifying CUP patients with an unfavorable risk in a clinically more meaningful way. Squamous cell carcinoma in the abdominopelvic cavity should be considered in the unfavorable-risk group and women with non-papillary malignant ascites in an intermediate-risk group. Further studies with molecular profiling would help in classifying and treating patients with CUPs and an unfavorable risk.     

希罗达作为二线药物治疗晚期乳腺癌10例报告

目的 观察希罗达作为二线药物治疗晚期乳腺癌的疗效及安全性。方法 对10例具有可测量病灶的晚期乳腺癌患者采用希罗达（2510mg/m^2，每天1次，连服14天，21天为1个周期）单药治疗2－4个周期。所有患者既往均接受过1种以上化疗方案的化疗，其中7例患者接受过阿霉素和（或）紫杉醇治疗。结果 10例患者中3例接受了希罗达2个周期化疗，7例完成4个周期化疗。PR3例，MR1例，SD1例，PD5例。最常见的不良反应为恶心、皮肤色素沉着、厌食、疲劳和腹泻。Ⅲ度不良反应仅见于少数患者，其中腹泻1例、中性粒细胞减少1例、总胆红素升高4例。结论 希罗达作为二线药物治疗晚期乳腺癌的疗效较好且不良反应较轻，有望成为紫杉类或蒽环类药物治疗失败的乳腺癌患者的理想治疗药物。     

肝细胞生长因子基因转染脂肪细胞对移植组织工程脂肪存活的影响**★

背景：在脂肪组织工程的研究中，若将种子细胞与支架材料复合后移植，则此组织工程脂肪将可替代颗粒脂肪。肝细胞生长因子可以促进血管生成、减少纤维组织增生。 目的：观察肝细胞生长因子基因修饰骨髓间充质干细胞来源的脂肪细胞对大鼠组织工程脂肪移植存活的影响。 设计、时间及地点：随机区组设计的动物实验，于2006-08/2007-07在解放军兰州军区兰州总医院医学科学实验中心完成。 材料：纳入Wistar大鼠用于分离、培养骨髓间充质干细胞及植入细胞-支架复合物。 方法：①分离培养雄性大鼠骨髓间充质干细胞，诱导成脂，携带绿色荧光蛋白基因及肝细胞生长因子基因的重组腺病毒毒株分别转染脂肪细胞，流式细胞仪测定转染效率，应用酶联免疫吸附试验法测定培养上清中肝细胞生长因子的表达，将脂肪细胞接种于聚乳酸聚乙醇酸共聚物支架。②将75只Wistar雌性大鼠按随机数字表法分为3组：脂肪细胞组、Ad-肝细胞生长因子转染组及Ad-绿色荧光蛋白转染组分别将脂肪细胞-聚乳酸聚乙醇酸共聚物、转染肝细胞生长因子基因脂肪细胞-聚乳酸聚乙醇酸共聚物、转染绿色荧光蛋白基因脂肪细胞-聚乳酸聚乙醇酸共聚物移植于大鼠腿部肌肉之间。 主要观察指标：移植后3，7，14，28，60 d，每组各取5只大鼠麻醉后处死，取出移植物。电镜观察；并行苏木精-伊红、油红O、Masson’s染色，观察病理改变；同时用免疫组织化学法检测组织中肝细胞生长因子表达，观察并计数血管生成。 结果：①骨髓间充质干细胞来源的脂肪细胞胞浆内富含丰富的脂滴，重组腺病毒感染复数=100时，携带绿色荧光蛋白基因的重组腺病毒株转染脂肪细胞效率可达64.39%。②移植3，7，14 d时，Ad-肝细胞生长因子转染组移植物中肝细胞生长因子的表达高于其他组（P < 0.05），且3 d达到高峰。③移植3，7，14，28，60 d时，Ad-肝细胞生长因子转染组移植物中血管生成高于其他组（P < 0.05），且7 d时血管增加的幅度最大。④移植28，60 d时，Ad-肝细胞生长因子转染组坏死程度均小于其他组，电镜下脂肪细胞也多于其他组。 结论：携带肝细胞生长因子基因的脂肪细胞在移植物中能够表达肝细胞生长因子，促进移植组织工程脂肪血管生成，进而促进移植组织的成活。