Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy

The use of an ilioinguinal-hypogastric nerve block (IHNB) as part of a monitored anesthesia care (MAC) technique has been associated with a rapid recovery profile for outpatients undergoing inguinal herniorrhaphy procedures. This study was designed to compare the cost-effectiveness of an IHNB-MAC technique with standardized general and spinal anesthetics techniques for inguinal herniorrhaphy in the ambulatory setting. We randomly assigned 81 consenting outpatients to receive IHNB-MAC, general anesthesia, or spinal anesthesia. We evaluated recovery times, 24-h postoperative side effects and associated incremental costs. Compared with general and spinal anesthesia, patients receiving IHNB-MAC had the shortest time-to-home readiness (133+/-68 min vs. 171+/-40 and 280+/-83 min), lowest pain score at discharge (15+/-14 mm vs. 39+/-28 and 34+/-32 mm), and highest satisfaction at 24-h follow-up (75% vs. 36% and 64%). The total anesthetic costs were also the least in the IHNB-MAC group ($132.73+/-33.80 vs. $172.67+/-29.82 and $164.97+/-31.03). We concluded that IHNB-MAC is the most cost-effective anesthetic technique for outpatients undergoing unilateral inguinal herniorrhaphy with respect to speed of recovery, patient comfort, and associated incremental costs.     

Effects of a robot-assisted training of grasp and pronation/supination in chronic stroke: a pilot study

Background

Current guidelines for rehabilitation of arm and hand function after stroke recommend that motor training focus on realistic tasks that require reaching and manipulation and engage the patient intensively, actively, and adaptively. Here, we investigated the feasibility of a novel robotic task-practice system, ADAPT, designed in accordance with such guidelines. At each trial, ADAPT selects a functional task according to a training schedule and with difficulty based on previous performance. Once the task is selected, the robot picks up and presents the corresponding tool, simulates the dynamics of the tasks, and the patient interacts with the tool to perform the task.

Methods

Five participants with chronic stroke with mild to moderate impairments (> 9 months post-stroke; Fugl-Meyer arm score 49.2 ± 5.6) practiced four functional tasks (selected out of six in a pre-test) with ADAPT for about one and half hour and 144 trials in a pseudo-random schedule of 3-trial blocks per task.

Results

No adverse events occurred and ADAPT successfully presented the six functional tasks without human intervention for a total of 900 trials. Qualitative analysis of trajectories showed that ADAPT simulated the desired task dynamics adequately, and participants reported good, although not excellent, task fidelity. During training, the adaptive difficulty algorithm progressively increased task difficulty leading towards an optimal challenge point based on performance; difficulty was then continuously adjusted to keep performance around the challenge point. Furthermore, the time to complete all trained tasks decreased significantly from pretest to one-hour post-test. Finally, post-training questionnaires demonstrated positive patient acceptance of ADAPT.

Conclusions

ADAPT successfully provided adaptive progressive training for multiple functional tasks based on participant's performance. Our encouraging results establish the feasibility of ADAPT; its efficacy will next be tested in a clinical trial.     

The Timing of Calcium Measurements in Helping to Predict Temporary and Permanent Hypocalcaemia in Patients Having Completion and Total Thyroidectomies

INTRODUCTION

Postoperative hypocalaemia commonly occurs after extensive thyroid surgery and may require calcium and/or vitamin D supplements to alleviate or prevent the symptoms. In this study, we determined the risk factors for developing hypocalcaemia and whether early serum calcium levels can predict the development of or differentiate between temporary or permanent hypocalcaemia.

PATIENTS AND METHODS

A total of 162 patients who either had a completion or total thyroidectomy formed the basis of this prospective study. Serial serum calcium measurements were recorded as well as details of the operation, pathology, indications for surgery, number of parathyroids identified at operation and any complications.

RESULTS

Eighty-four (52%) patients did not develop hypocalcaemia but 69 (43%) were found to have temporary hypocalcaemia and 9 (5%) had permanent hypocalcaemia. Hypocalcaemia was more common after total than completion thyroidectomies and the identification of parathyroids at operation appears to have a significant adverse effect on outcome. The calcium levels measured on day 1 postoperatively and the slope (serum calcium levels of day 1 postoperative minus day of operation) were statistically significant in predicting the development of hypocalcaemia and possibly to differentiate between temporary or permanent hypocalcaemia.

DISCUSSION

Although almost half the patients having extensive thyroid surgery developed hypocalcaemia (as defined by any postoperative corrected serum calcium level of < 2.12 mmol/l) only 24% had a serum calcium of < 2.12 mmol/l associated with clinical symptoms of hypocalcaemia or a calcium level of < 2.0 mmol/l. Only 5% had persistent hypocalcaemia defined as requiring exogenous supplements at 6 months'' postoperatively. Patients having a completion thyroidectomy appear to be less likely to develop hypocalcaemia perhaps as a result of any iatrogenic effects on the parathyroids at the first operation being reversed before the second operation. Identification and, therefore, exposure of parathyroids at operation may have an adverse effect on the blood supply to the glands affecting their function.

CONCLUSIONS

Serum calcium levels measured 6 hours'' post-surgery and on day 1 postoperatively can be useful in predicting if the patient will develop hypocalcaemia and the slope may indicate whether the hypocalcaemia will be temporary or permanent. Patients with toxic goitres and those having a one-stage total thyroidectomy are most at risk of developing hypocalcaemia.     

“Receptivity”: An Important Factor Affecting Supportive Care Provision

The research on psychosocial need provides the foundation informing the drive for the provision of supportive care services for patients and their families. The work on patient access, barriers to participation, and service evaluation are providing some insights that can help guide practitioners in their efforts to ensure that services designed to meet psychosocial need reach and involve the appropriate individuals. However, this direction is presently in its infancy leaving many questions unanswered. This article makes a contribution to advancing and strengthening this line of research through a fresh perspective on the topic provided by consumer research with individuals diagnosed with a hematological malignancy. The research was initiated and funded by the Leukaemia Foundation of Queensland (LFQ) with the aim of exploring the experience of survivorship for individuals diagnosed with a hematological malignancy to inform supportive care service provision and development. The findings from the research posit the notion of “receptivity” as an important new concept that can contribute to the deepening of our understanding of the myriad of factors associated with effectively engaging with individuals in supportive care service provision.     

Associations between cytochrome P4502E1 genotype, mutagen sensitivity, cigarette smoking and susceptibility to lung cancer

Cytochrome P4502E1 (CYP2E1) is involved in the metabolic activation of carcinogenic N-nitrosoamines. We therefore assessed the genotype frequencies of PstI or RsaI CYP2E1 restriction fragment length polymorphisms and another susceptibility marker, mutagen sensitivity, in 137 lung cancer cases (92 African American and 45 Mexican American) and 206 controls (114 African American and 92 Mexican American) identified in a molecular epidemiological study of lung cancer. The CYP2E1 c1/c1 genotype was found in 86.7% of Mexican American cases, 70.6% of Mexican American controls, 89.1% of African American cases and 86.8% of African American controls. By multivariate analysis, this genotype was found to be associated with a 14.0-fold increased risk of lung cancer in Mexican Americans but not in African Americans; a 9.9- fold increased risk of lung cancer in Mexican American former smokers, but not in non-smokers or current smokers; a 15-fold increased risk of lung cancer in Mexican American males, but not in females. Patients with the susceptible genotype appeared to have developed cancer at an earlier age and with lower cigarette pack-year of exposure than did patients with the c1/c2 or c2/c2 genotypes. Stratified analysis suggested a greater than multiplicative interaction between cigarette smoking and CYP2E1 c1/c1 genotype, although not statistically significant. The odds ratios (ORs) for the CYP2E1 c1/c1 genotype, cigarette smoking and both risk factors combined were 1.3, 6.7 and 16.3, respectively. The association between CYP2E1 c1/c1 genotype and pack-years of smoking followed the same pattern. The interaction between mutagen sensitivity and CYP2E1 c1/c1 genotype was especially strong in former smokers (the ORs for the CYP2E1 c1/c1 genotype, mutagen sensitivity and both risk factors combined were 3.9, 5.4 and 23.0, respectively). Therefore, the data suggest that individuals who lack a c2 allele might be at higher risk for developing lung cancer.      

Impaired vision in the elderly: a preventable condition

BACKGROUND: Vision is thought to deteriorate with age as a number of factors in later life endanger eyesight. Assessment of the visual acuity of the elderly and identification of endangering factors help in detecting those with impaired vision which in turn impairs daily activities. OBJECTIVE: This study measured the visual acuity of the senior citizens and identified those with impaired vision. The probable contributing factors for impaired vision were studied with the aim of preventing visual impairment. METHOD: The study was part of a screening campaign for elderly glaucoma in the community. A convenience sample of ambulatory senior citizens from stratified localities had their visual acuity measured with a standard Snellen's chart. The test was repeated with pinholes if the visual acuity was less than 0.5. Those without improvement after pinhole were considered as having impaired vision. People with elevated intraocular pressure by the Pulsair were selected for examination by an ophthalmologist for ocular pathology. RESULTS: For the ambulatory population aged > or = 65 the mean visual acuity of either eye before pinhole was 0.3. Nearly 72% had impaired vision (visual acuity not corrected above 0.5 with pinhole). There was a significant association between this impairment and female sex, history of diabetes mellitus or glaucoma, cataract, and infrequent eye examination. CONCLUSION: Impaired vision is highly prevalent in the elderly ambulatory population, a condition which is preventable by tight surveillance of predisposing factors and regular simple measurement of visual acuity. The primary care setting is most suitable for these activities.      

新型STAT3信号转导通路抑制剂WP1193在体外对脑肿瘤干细胞生物学特性影响的研究

背景与目的：恶性脑胶质母细胞瘤（glioblastoma Multiforme,GBM）是最常见的成人原发性脑肿瘤,预后仍不理想。近年来,肿瘤干细胞理论认为脑肿瘤干细胞是GBM进展及治疗耐受的主要原因,只有针对脑肿瘤干细胞的靶向治疗才能更加有效的治疗GBM。本研究旨在探讨新型STAT3信号转导通路抑制剂WP1193在体外对脑肿瘤干细胞生物学特性的影响。方法：从新鲜手术切除的GBM标本中,分离、培养及鉴定脑肿瘤干细胞。采用Western blot及RT-PCR法检测WP1193给药后,STAT3信号转导通路的变化。使用神经球形成实验评估WP1193对GBM干细胞形成神经球能力的影响。利用RT-PCR及流式细胞技术检测WP1193对CD133阳性细胞的影响。采用MTS及PI染色结合流式细胞技术检测WP1193对GBM干细胞增殖及细胞周期的影响。采用AnnexinV流式细胞术分析WP1193对GBM干细胞的凋亡诱导效应。结果：WP1193抑制GBM干细胞STAT3磷酸化及下游基因的表达。WP1193有效抑制GBM干细胞形成神经球的能力及增殖,并可将细胞阻滞于G1期。WP1193在体外通过改变Bax/Bcl-2比例诱导GBM干细胞凋亡。结论：WP1193通过抑制STAT3信号转导通路,有效的抑制GBM干细胞的增殖及形成神经球的能力,并能诱导凋亡。STAT3信号转导通路可作为GBM干细胞的治疗靶点。     

Vascular endothelial growth factor regulates myeloid cell leukemia-1 expression through neuropilin-1-dependent activation of c-MET signaling in human prostate cancer cells

Background

Nuclear factor-κB (NF-κB) is constitutively activated in many cancers and plays a key role in promoting cell proliferation, survival, and invasion. Our understanding of NF-κB signaling in thyroid cancer, however, is limited. In this study, we have investigated the role of NF-κB signaling in thyroid cancer cell proliferation, invasion, and apoptosis using selective genetic inhibition of NF-κB in advanced thyroid cancer cell lines.

Results

Three pharmacologic inhibitors of NF-κB differentially inhibited growth in a panel of advanced thyroid cancer cell lines, suggesting that these NF-κB inhibitors may have off-target effects. We therefore used a selective genetic approach to inhibit NF-κB signaling by overexpression of a dominant-negative IκBα (mIκBα). These studies revealed decreased cell growth in only one of five thyroid cancer cell lines (8505C), which occurred through a block in the S-G2/M transition. Resistance to TNFα-induced apoptosis was observed in all cell lines, likely through an NF-κB-dependent mechanism. Inhibition of NF-κB by mIκBα sensitized a subset of cell lines to TNFα-induced apoptosis. Sensitive cell lines displayed sustained activation of the stress-activated protein kinase/c-Jun NH2-terminal kinase (SAPK/JNK) pathway, defining a potential mechanism of response. Finally, NF-κB inhibition by mIκBα expression differentially reduced thyroid cancer cell invasion in these thyroid cancer cell lines. Sensitive cell lines demonstrated approximately a two-fold decrease in invasion, which was associated with differential expression of MMP-13. MMP-9 was reduced by mIκBα expression in all cell lines tested.

Conclusions

These data indicate that selective inhibition of NF-κB represents an attractive therapeutic target for the treatment of advanced thyroid. However, it is apparent that global regulation of thyroid cancer cell growth and invasion is not achieved by NF-κB signaling alone. Instead, our findings suggest that other important molecular processes play a critical role in defining the extent of NF-κB function within cancer cells.     

A protocol of selective antibiotic prophylaxis for Caesarean section based on risk factors

The aim of the study was to identify risk factors associated with increased risks of post Caesarean febrile morbidity from a retrospective epidemiological analysis, and to prospectively evaluate a protocol of selective antibiotic prophylaxis based on these risk factors. Caesarean section births over a three-year period--during which no antibiotic prophylaxis protocol was practised--were reviewed. Risk factors for febrile morbidity were identified using both univariate and multivariate analysis. A protocol of selective antibiotic prophylaxis, incorporating the significant risk factors identified, was then evaluated prospectively over a nine-month period. The incidence of febrile morbidity from the retrospective study was 16.9%. A logistic regression model, with febrile morbidity as the dependent variable, identified only the duration of labour over 10 hours as a significant factor. A protocol of antibiotic prophylaxis using intravenous ampicillin was then practised in the presence of these two factors. Evaluation of this protocol after nine months showed that the incidence of febrile morbidity was reduced significantly from 20% in those not given antibiotics to around 9.6% in those eligible for and given antibiotics. However, the overall incidence of febrile morbidity remained at around 16-18%.     

Suicide of older people in Asian societies: an international comparison

Objective : To verify in a systematic study if the Chinese tradition of venerating older people results in lower suicide rates compared to other countries. Method : The ratio between suicide rates in the older population and total population were calculated and used to compare 40 countries. Results : The highest male suicide ratios in the world were found in Urban China, Singapore, Rural China and Hong Kong. Singapore, Urban China and Hong Kong had the worst female suicide ratios. The highest rate of suicide among females was in Rural China, which also had the highest suicide rate among older people. Conclusion : These findings raise questions about the adequacy of support to older Asian people. It is surprising that high suicide rates are found in Hong Kong, Korea, Japan and Singapore, which are affluent societies. The possibility of this being the result of ageism is discussed. Country‐specific research is needed to improve suicide prevention measures, especially for older people.