Combined use of paravertebral block and general anesthesia for breast cancer surgery

BACKGROUND: Thoracic paravertebral block (TPVB) is reportedly a useful alternative of general anesthesia (GA) for patients undergoing major breast surgery. To provide surgical anesthesia by TPVB alone, however, demands considerable patient's discomfort during neural block and during surgery. This study was undertaken to investigate if TPVB adds to patient satisfaction when combined with GA for breast cancer surgery. METHODS: In 26 women (ASA I * II) undergoing modified radical mastectomy with axillary dissection, TPVB was performed at T 1 level and 15 ml of 0.5% ropivacaine was injected prior to induction of general anesthesia. After surgery, VAS (visual analogue scale, 0-100 mm) pain scores and postoperative medication were recorded. These data with TPVB were compared with those of 17 patients who had previously undergone similar surgical procedure without TPVB in our hospital. RESULTS: The VAS scores in patients with TPVB were 34 +/- 45 mm (mean +/- SD) on admission to the recovery room and 15 +/- 5 mm next morning. Frequency of postoperative administration of analgesics in patients with TPVB was significantly less than those without TPVB. CONCLUSIONS: Above findings suggest that combined use of TPVB and GA may be a preferable choice of anesthesia for patients undergoing major breast cancer surgery.     

Development of Bile Acid Metabolism in Neonates during Perinatal Period | Part 2. Mass screening of congenital biliary atresia by radioimmunoassay using dried blood spot

Inour country, congenital biliary atresia (CBA) has occurred in approximately 1 of 10,000 live births, but its prognosis has been extremely poor. In the mass screening of this disease, glycocholic acid (GCA) or chenodeoxycholic acid (CDCA) level in dried blood spots on filter paper in5-day-old neonates was determined by radioimmunoassay (RIA).
To determine GCA in dried blood spots on filter paper, the procedures in this experiment were modified using commercial kit for serum.
The mean GCA level of controls (n=391) was 5.88±4.28 nM/ml and that of CBA (n=22) was 14.1 ±3.1 nM/ml. On the other hand the mean CDCA level of controls (n=86) was 5.86 ±3.07 pM/l disc that of CBA (n=22) was 30.0 ±35.9 pM/l disc. When the criterion is assumed to be more than 16 nM/ml of GCA level or 10 pM/l disc of CDCA level, false negative diagnoses of CBA are 31.8% and 18.2% respectively. On the other hand false positive diagnoses of CBA are 6.9% and 3.5% respectively. It was thought that false negative diagnosis on mass screening with GCA level would decrease using fresh dried blood spot within 2 weeks after taking blood.
In 22 CBA cases, the GCA levels in dried blood spots on filter paper were not always parallel with the CDCA levels.     

Molecular mechanisms involved in the adaptive response to cadmium-induced apoptosis in human myelomonocytic lymphoma U937 cells

We examined the molecular mechanisms involved in the adaptive response to cadmium (Cd)-induced apoptosis in human myelomonocytic lymphoma U937 cells. When U937 cells were treated with 50 μM cadmium chloride (CdCl₂) for 12 h, significant apoptosis occurred. This was associated with an increase in intracellular reactive oxygen species (ROS), sustained phosphorylation of JNK, activation of caspase-3, a decrease in Mcl-1 (anti-apoptotic Bcl-2 proteins), and increases in Bim, Noxa and tBid (a pro-apoptotic protein under the Bcl-2 family). No apoptosis occurred when the cells were treated with 1 μM CdCl₂ for 72 h. However, pretreatment with low-dose CdCl₂ dramatically altered the sensitivity of the cells to 50 μM CdCl₂ with inhibition of apoptosis. Concomitantly, there were significant decreases in the generation of intracellular ROS and the activation of JNK. Pretreatment with 1 μM CdCl₂ also attenuated the decrease in Mcl-1 and the increases in Bim, Noxa and tBid induced by 50 μM CdCl₂. In conclusion, pretreatment with low-dose Cd inhibited apoptosis induced by high-dose Cd. The mechanism involves inhibition of intracellular ROS generation and JNK activation, and modulating the balance between the expression of Mcl-1 and its binding partners, Bim, Noxa and tBid.     

Incremental prognostic value of the SYNTAX score to late gadolinium-enhanced magnetic resonance images for patients with stable coronary artery disease

The prognostic significance of the SYNTAX (Synergy between PCI with Taxus and cardiac surgery) score has recently been demonstrated in patients with stable multivessel or left main coronary artery disease (CAD). The present study determines whether adding the SYNTAX score to Framingham risk score (FRS), left ventricular ejection fraction (LVEF) and presence of myocardial infarction (MI) by late gadolinium enhancement (LGE) magnetic resonance imaging can improve the risk stratification in patients with stable CAD. We calculated the SYNTAX score in 161 patients with stable CAD (mean age: 66 ± 10 years old). During a mean follow-up of 2.3 years, 56 (35 %) of 161 patients developed cardiovascular events defined as cardiovascular death, non-fatal MI, cerebral infarction, unstable angina pectoris, hospitalization due to heart failure and revascularization. Multivariate Cox regression analysis selected triglycerides [hazard ratio (HR): 1.005 (95 % confidence interval (CI): 1.001–1.008), p < 0.008], presence of LGE [HR: 6.329 (95 % CI: 2.662–15.05), p < 0.001] and the SYNTAX score [HR: 1.085 (95 % CI: 1.044–1.127), p < 0.001] as risk factors for future cardiovascular events. Adding the SYNTAX score to FRS, EF and LGE significantly improved the net reclassification index (NRI) [40.4 % (95 % CI: 18.1–54.8 %), p < 0.05] with an increase in C-statistics of 0.089 (from 0.707 to 0.796). An increase in C-statistics and significant improvement of NRI showed that adding the SYNTAX score to the FRS, LVEF and LGE incrementally improved risk stratification in patient with stable CAD.     

Prognostic value of cardiovascular magnetic resonance derived right ventricular function in patients with interstitial lung disease

Background

Cardiovascular magnetic resonance (CMR) provides non-invasive and more accurate assessment of right ventricular (RV) function in comparison to echocardiography. Recent study demonstrated that assessment of RV function by echocardiography was an independent predictor for mortality in patients with interstitial lung disease (ILD). The purpose of this study was to determine the prognostic significance of CMR derived RV ejection fraction (RVEF) in ILD patients.

Methods

We enrolled 76 patients with ILD and 24 controls in the current study. By using 1.5 T CMR scanner equipped with 32 channel cardiac coils, we performed steady-state free precession cine CMR to assess the RVEF. RV systolic dysfunction (RVSD) was defined as RVEF ≤45.0% calculated by long axis slices. Pulmonary hypertension (PH) was defined as mean pulmonary artery pressure (mPAP) of more than 25 mmHg at rest in the setting of pulmonary capillary wedge pressure ≤15 mmHg.

Results

The median RVEF was 59.2% in controls (n = 24), 53.8% in ILD patients without PH (n = 42) and 43.1% in ILD patients with PH (n = 13) (p < 0.001 by one-way ANOVA). During a mean follow-up of 386 days, 18 patients with RVSD had 11 severe events (3 deaths, 3 right heart failure, 3 exacerbation of dyspnea requiring oxygen, 2 pneumonia requiring hospitalization). In contrast, only 2 exacerbation of dyspnea requiring oxygen were observed in 58 patients without RVSD. Multivariate Cox regression analysis showed that RVEF independently predicted future events, after adjusting for age, sex and RVFAC by echocardiography (hazard ratio: 0.889, 95% confidence interval: 0.809 – 0.976, p = 0.014).

Conclusions

The current study demonstrated that RVSD in ILD patients can be clearly detected by cine CMR. Importantly, low prevalence of PH (17%) indicated that population included many mild ILD patients. CMR derived RVEF might be useful for the risk stratification and clinical management of ILD patients.     

Environmental chemical tributyltin augments adipocyte differentiation

Scientific attention has been drawn to environmental factors that affect obesity and type II diabetes. Previously, acute organotin toxicosis was reported to induce hyperglycemia without morphological abnormalities in islet tissue, suggesting that these compounds have a direct effect on adipose tissue. Therefore, we investigated the effect of tributyltin (TBT) on adipocyte differentiation. When confluent 3T3-L1 cells were incubated with TBT for 2 days in the presence or absence of isobutyl methylxanthine, dexamethasone and insulin (MDI), the lipid accumulation in adipocytes was greatly enhanced. These morphological changes induced by TBT were accompanied by the expression of a differentiation marker for adipocytes in a dose-dependent manner. Co-treatment with the peroxisome proliferator-activated receptor (PPAR)gamma antagonist GW9662 did not inhibit the effect of TBT, suggesting that the observed effect of TBT may not be PPARgamma-dependent. Although TBT was reported to exert androgenic effects and inhibit the activity of aromatase, treatments with dihydrotestosterone or 17beta-estradiol did not influence the aP2 expression in 3T3-L1 cells, suggesting that the TBT effect does not occur via sex-steroids. These findings indicate that TBT may be one of the environmental chemicals that lead to excessive accumulation of adipose tissue, which can result in obesity.     

Present situation and future perspectives on newborn hearing screening system in Japan

Childhood hearing impairment is a serious and relatively common condition. The earlier childhood hearing impairment is diagnosed, the less developmentally disadvantaged children become. Newborn hearing screening (NBS) programs have been implemented in Japan. NBS is important for identifying hearing loss at an early age and for adequate intervention at an early developmental stage. According to a survey questionnaire by the Japan Association of Obstetricians and Gynecologists, 62% of the newborn babies were audiologically and medically examined. The average age of examinees has become younger since the beginning of NBS. Here, we summarized the NBS programs in Japan including behavioral audiometry and examinations of auditory brainstem response, auditory-steady state response, and otoacoustic emissions. NBS can lead to advantages in terms of language developmental outcome for children with hearing impairment. However, there is no sufficient support system existing for children who are advised to undergo further auditory diagnostic tests after NBS. It is necessary for government agencies, medical and educational institutions to communicate together for clarifying their responsibilities in order to support the children with hearing impairment.