Effects of Nicorandil Versus Nitroglycerin on Arterial Oxygenation During Two-Lung Ventilation and One-Lung Ventilation in Patients With Risk Factors for Myocardial Ischemia: A Prospective, Randomized, Double-Blind Study

OBJECTIVES

To compare the effects of nicorandil and nitroglycerin on arterial oxygenation during two-lung ventilation (TLV) and one-lung ventilation (OLV) in patients with risk factors for myocardial ischemia.

DESIGN

A prospective, randomized, double-blind study.

SETTING

A tertiary care hospital.

PARTICIPANTS

Fifty-six patients scheduled for elective video-assisted thoracic surgery were assigned randomly to either the nicorandil group or the nitroglycerin group.

INTERVENTIONS

Patients in the nicorandil group received a bolus dose of nicorandil, 0.08 mg/kg during induction of anesthesia, followed by a continuous infusion at a rate of 0.08 mg/kg/h. Patients in the nitroglycerin group received a continuous infusion of nitroglycerin at a rate of 1 µg/kg/min from the induction of anesthesia.

MEASUREMENTS AND MAIN RESULTS

Arterial blood gas analysis was performed at the following points: before induction of anesthesia; during TLV; at 5, 10, 20, and 30 minutes after the initiation of OLV. PaO₂ at TLV (479.7 ± 57.1 v 408.2 ± 70.9 mmHg, p < 0.001); and at 5 minutes (344.8 ± 85.1 v 282.6 ± 85.8 mmHg, p = 0.012), 20 minutes (215.7 ± 103.0 v 158.2 ± 74.5 mmHg, p = 0.027), and 30 minutes (198.8 ± 103.5 v 147.5 ± 64.1 mmHg, p = 0.039) after OLV was significantly higher in the nicorandil group than in the nitroglycerin group.

CONCLUSION

This study demonstrated that oxygenation during TLV and OLV was significantly higher in patients receiving nicorandil than in those receiving nitroglycerin.

Prerequisites to Salvage Profound Biventricular Failure Patients with Ventricular Assist Devices

We conducted chronic experiments to determine how to treat profound biventricular failure systematically with ventricular assist devices (VADs) and to analyze the factors that affect prognoses for this condition. Anoxic arrest was induced in ten goats by aortic cross-clamping under normothermic conditions (38.5° C) for 30 (n= 3), 45 (n= 1), and 60 (n= 6) minutes. A left ventricular assist device (LVAD) was implanted in eight animals, and a biventricular assist device (BVAD) was used in two. Three goats — two of which had undergone anoxic arrest for 30 minutes and one for 60 minutes — whose right atrial pressure (RAP) was approximately 18 mm Hg during the acute stage, recovered in two to three weeks, and the pumps were successfully removed. Pathological findings in these animals showed scattered areas of surviving myocardium, with connective tissue replacing the degenerated myocardium. The remaining five LVAD goats required higher RAPs to maintain circulation and died from various causes. Maintaining circulation without volume loading, even in the presence of arrhythmias, was easier with the BVAD. One BVAD animal that underwent 45 minutes of anoxic arrest recovered from right ventricular failure, and the right pump was removed. The second goat (anoxic arrest, 60 min) on the BVAD failed to recover. Autopsy of the myocardium revealed a thin ventricular wall. Our studies show that the use of VADs allows time for a failing heart to recover, but the potential for healing is affected by the severity of myocardial damage prior to VAD application. We believe that although LVADs can maintain circulation with high RAPs, the use of BVADs might be more beneficial for maintaining systemic organ function in cases of persistent biventricular failure.

Treatment of Acute Myocardial Infarction with Cardiogenic Shock using Left Ventricular Assist Device

We have treated ten cardiogenic shock patients after acute myocardial infarction (AMI) with a left ventricular assist device (LVAD). These patients were later divided into three groups: the first group with ventricular septal perforation, the second with aorto-coronary bypass grafting (ACBG) before LVAD implantation and the third group without ACBG. LVAD maintained the systemic circulation in each group, and cardiac function recovered enough to remove LVAD in 70% of the total patients. Two of three patients in the first group were discharged from hospital. Two weaned cases in the second group died of multiple organ failure and one was discharged, and hemorrhagic necrosis was seen in the bypassed area of the myocardium. One patient of the third group could not be weaned from LVAD because of respiratory failure though his heart function began to recover. Another case in the third group underwent bypass grafting after removal of LVAD. However ACBG surgery should be done very carefully because a patient in shock is occasionally intolerant to major surgery. In all groups, the major cause of death was multiple organ failure which was probably caused by the prolonged low output condition prior to LVAD application. In the light of this experience, it appears that LVAD should be applied before irreversible damage occurs to major organs, including the heart itself. To ensure the timely application of LVAD, some way must be found to introduce systematic application of LVAD into the normal course of AMI treatment.

Telomere length determined by the fluorescence in situ hybridisation distinguishes malignant and benign cells in cytological specimens

BACKGROUND

Telomeres are tandem repeats of TTAGGG at the end of eukaryotic chromosomes that play a key role in preventing chromosomal instability. The aim of the present study is to determine telomere length using fluorescence in situ hybridisation (FISH) on cytological specimens.

METHODS

Aspiration samples (n = 41) were smeared on glass slides and used for FISH.

RESULTS

Telomere signal intensity was significantly lower in positive cases (cases with malignancy, n = 25) as compared to negative cases (cases without malignancy, n = 16), and the same was observed for centromere intensity. The difference in DAPI intensity was not statistically significant. The ratio of telomere to centromere intensity did not show a significant difference between positive and negative cases. There was no statistical difference in the signal intensities of aspiration samples from ascites or pleural effusion (n = 23) and endoscopic ultrasound-guided FNA samples from the pancreas (n = 18).

CONCLUSIONS

The present study revealed that telomere length can be used as an indicator to distinguish malignant and benign cells in cytological specimens. This novel approach may help improve diagnosis for cancer patients.

Diagnostic Accuracy of Neuroimaging to Delineate Diffuse Gliomas within the Brain: A Meta-Analysis

BACKGROUND

Brain imaging in diffuse glioma is used for diagnosis, treatment planning, and follow-up.

PURPOSE

In this meta-analysis, we address the diagnostic accuracy of imaging to delineate diffuse glioma.

DATA SOURCES

We systematically searched studies of adults with diffuse gliomas and correlation of imaging with histopathology.

STUDY SELECTION

Study inclusion was based on quality criteria. Individual patient data were used, if available.

DATA ANALYSIS

A hierarchic summary receiver operating characteristic method was applied. Low- and high-grade gliomas were analyzed in subgroups.

DATA SYNTHESIS

Sixty-one studies described 3532 samples in 1309 patients. The mean Standard for Reporting of Diagnostic Accuracy score (13/25) indicated suboptimal reporting quality. For diffuse gliomas as a whole, the diagnostic accuracy was best with T2-weighted imaging, measured as area under the curve, false-positive rate, true-positive rate, and diagnostic odds ratio of 95.6%, 3.3%, 82%, and 152. For low-grade gliomas, the diagnostic accuracy of T2-weighted imaging as a reference was 89.0%, 0.4%, 44.7%, and 205; and for high-grade gliomas, with T1-weighted gadolinium-enhanced MR imaging as a reference, it was 80.7%, 16.8%, 73.3%, and 14.8. In high-grade gliomas, MR spectroscopy (85.7%, 35.0%, 85.7%, and 12.4) and ¹¹C methionine-PET (85.1%, 38.7%, 93.7%, and 26.6) performed better than the reference imaging.

LIMITATIONS

True-negative samples were underrepresented in these data, so false-positive rates are probably less reliable than true-positive rates. Multimodality imaging data were unavailable.

CONCLUSIONS

The diagnostic accuracy of commonly used imaging is better for delineation of low-grade gliomas than high-grade gliomas on the basis of limited evidence. Improvement is indicated from advanced techniques, such as MR spectroscopy and PET.

Cytological diagnostic clues in poorly differentiated squamous cell carcinomas of the breast: Streaming arrangement, necrotic background, nucleolar enlargement and cannibalism of cancer cells

OBJECTIVE

Squamous cell carcinoma (SCC) is a rare histological type of breast cancer. The cytological diagnosis of non-keratinising, poorly differentiated SCC is often difficult, and distinguishing it from invasive ductal carcinoma or apocrine carcinoma (AC) is especially challenging. We aimed to define the diagnostic cytological features of poorly differentiated SCC of the breast.

METHODS

We studied the cytological findings of poorly differentiated SCC (n=10) and compared them to those of IDC (n=15) and AC (n=14). The following six cytological features were evaluated: streaming arrangement, nucleolar enlargement, dense nuclei, cannibalism, atypical keratinocytes and necrotic background.

RESULTS

SCC exhibited significantly higher frequencies of streaming arrangement (70% vs 6.7%, P=.002), nucleolar enlargement (80% vs 27%, P=.02), and necrotic background (80% vs 36%, P=.002) than invasive ductal carcinoma. The detection of two or three of these features yielded a higher sensitivity (80%) and specificity (93%) for the diagnosis of SCC. Streaming arrangement (70% vs 0%, P<.001), cannibalism (60% vs 0%, P=.002), and a necrotic background (80% vs 36%, P=.047) were all significantly more frequent in SCC than in AC. When distinguishing SCC from AC, the presence of two or three of these features yielded a high sensitivity (80%) and specificity (100%).

CONCLUSIONS

Cytological features such as a streaming arrangement, a necrotic background, nucleolar enlargement and cannibalism are useful indicators for the diagnosis of SCC of the breast. As such, greater attention should be paid to these morphological features in daily clinical practice.

Functional Anatomy of the Lateral Collateral Ligament Complex of the Elbow: Morphology and Strain

The anatomy of the lateral ulnar collateral ligament (LUCL) of the elbow was investigated in 26 fresh frozen cadavers. Two types of insertion of the LUCL were originally described but we found another type which is characterized by a broad single expansion along with a thin membranous fibre. Strain on the LUCL was measured in situ during extension and flexion with the forearm in supination, pronation and neutral. Strain in the proximal fibres started to occur at around 32° flexion and peaked at between 50° and 60° flexion. Strains measured in the distal fibres were smaller in magnitude. Forearm rotation had little effect on strain during extension to flexion. Based on these results, we conclude that the LUCL functions in unison with the annular ligament.

Magnetic Reversal of Electric Polarization with Fixed Chirality of Magnetic Structure in a Chiral-Lattice Helimagnet MnSb_{2}O_{6}

The correlation between magnetic and dielectric properties has been investigated for the single crystal of the chiral triangular-lattice helimagnet MnSb_{2}O_{6}. We found that the spin-spiral plane in the ground state has a considerable tilting from the (110) plane and that the sign of the spin-spiral tilting angle is coupled to the clockwise or counterclockwise manner of spin rotation and accordingly to the sign of magnetically induced electric polarization. This leads to unique magnetoelectric responses such as the magnetic-field-induced selection of a single ferroelectric domain as well as the reversal of electric polarization just by a slight tilting of the magnetic field direction, where the chiral nature of the crystal structure plays a crucial role through the coupling of the chirality between the crystal and magnetic structures. Our results demonstrate that crystallographic chirality can be an abundant source of novel magnetoelectric functions with coupled internal degrees of freedom.

Methods for immunoblot detection and electron microscopic localization of septin subunits in mammalian nervous systems

The minimal functional units of the mammalian septin system are diverse heterooligomers of SEPT1-14 subunits, which are most abundantly and differentially expressed in postmitotic neurons and glia. The subunit compositions of such heterooligomers are thought to differentiate their affinity for other proteins and lipids, and subcellular localization. Thus, high-precision quantification and mapping of each subunit is necessary to understand their subcellular functions and physiological roles. However, systematic information on the localization of individual septin subunits in the mammalian nervous system is limited. Here, we present our experimental workflows for the study of septin expression and localization in the rodent brain by immunoblot and serial section immunoelectron microscopy. Our protocols, based on standard methods, have been rigorously optimized and simplified for universality and reproducibility to aid non-experts in the field.

TORSADES DE POINTES ASSOCIATED WITH TAKOTSUBO CARDIOMYOPATHY IN AN ANOREXIA NERVOSA PATIENT DURING EMERGENCE FROM GENERAL ANESTHESIA

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a disease in which the patient exhibits transient, reversible left ventricular dysfunction that is triggered by physical or emotional stress. Prolongation of QT interval, a risk factor for arrhythmia and sudden death, has been reported to be prevalent among patients with Takotsubo cardiomyopathy and is also observed in those with severe anorexia nervosa. In this report, we describe the rare case of a 30-year-old female patient with anorexia nervosa who developed Torsades de Pointes associated with Takotsubo cardiomyopathy during emergence from general anesthesia for emergency exploratory laparotomy.

Polylactic acid nanosheets in prevention of postoperative intestinal adhesion and their effects on bacterial propagation in an experimental model

Background

Ultrathin films (nanosheets) adhere tightly to organ surfaces but prevent adhesion to other organs. The antiadhesive effect of nanosheets and their effect on bacterial propagation were investigated in a murine intestinal adhesion model.

Methods

Polylactic acid nanosheets (approximately 80 nm thick) were produced. Serosal defects were created by peeling off the intestinal serosa; these were left open or covered with nanosheets or Seprafilm® and the formation of intestinal adhesions was analysed. To examine bacterial propagation, a nanosheet or Seprafilm® was placed on intact murine jejunum followed by Escherichia coli inoculation at the site.

Results

Treatment both with nanosheets and with Seprafilm® reduced postoperative intestinal adhesion (mean adhesion score 0·67 for nanosheets, 0·43 for Seprafilm® and 2·87 for no antiadhesive treatment; P &lt; 0·001 for nanosheets or Seprafilm® versus no adhesive treatment). Nanosheet treatment did not affect bacterial propagation in the peritoneal cavity, whereas Seprafilm®-treated mice showed bacterial propagation, leading to increased mortality.

Conclusion

Nanosheets may be effective novel antiadhesive agents even in the presence of bacterial contamination. Surgical relevanceIntra-abdominal adhesions following surgical contamination can trigger postoperative complications and lead to deterioration in long-term quality of life. However, currently there are no effective antiadhesion materials to prevent the formation of adhesions.Treatment with ultrathin nanosheets effectively reduced postoperative intestinal adhesion in an experimental mouse model, and did not affect bacterial propagation in the peritoneal cavity.These nanosheets are potent novel antiadhesive materials that potentially can be applied even in contaminated conditions.