Feasibility study of postoperative management based on ERAS of patients with gastrectomy

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Background: Although the usefulness of the postoperative management based on Enhanced Recovery After Surgery (ERAS) program of patents with colectomy is shown, there are a few papers concerning ERAS program for gastric cancer patients. The aim of the present study was to examined whether a new postoperative management based on ERAS was feasible for pts with gastrectomy.

Methods: From September 2009 to April 2010, we have adopted the new clinical pathway (CP) based on ERAS and oral rehydration therapy (ORT) for 30 consecutive gastric cancer patients who underwent curative gastrectomy. These pts began a oral rehydration solution (ORS) on the first postoperative day, and after the volume of ORS got 1,000 ml, we stopped intravenous transfusion. The incidence of adverse events, postoperative pt's activity score, which pt's daily activity was evaluated with, and total infusion volume of these pts were compared with 30 pts with the previous CP that were enrolled as a control group.

Results: There were no significant differences in the clinical and operative factors between the two groups. The post operative patient's activity score of ERAS group was significantly higher up to 7th postoperative day (POD). Total infusion volume was significantly little besides, in most cases, infusion therapy was substituted for ORT with OS-1 within 2 POD. There was no difference in the hospitalized days, and the incidence of adverse events were statistically no significance between two groups.

Conclusions: Our CP based on ERAS and ORT is feasible for patients with gastrectomy.

No significant financial relationships to disclose.

Infusion requirements and reversibility of rocuronium at the corrugator supercilii and adductor pollicis muscles

BACKGROUND

The aim of this study is to compare the infusion rates required to maintain a constant neuromuscular block and the reversibility of rocuronium at the corrugator supercilii muscle (CSM) and the adductor pollicis muscle (APM).

METHODS

We randomly allocated 30 female patients into two groups of 15 patients each to monitor neuromuscular block at either the CSM or the APM. After induction of anaesthesia and laryngeal mask insertion, contraction of the CSM to the facial nerve stimulation or that of the APM to the ulnar nerve stimulation was quantified using an acceleromyograph during 1.0-1.5% end-tidal sevoflurane anaesthesia. All the patients received a bolus of 1 mg/kg rocuronium. When the first twitch (T1) of train-of-four (TOF) recovered to 10% of the control, rocuronium infusion was commenced and maintained at T1 of 10% of the control at the CSM or APM for 120 min. Immediately after rocuronium infusion was discontinued, the time required for 0.04 mg/kg neostigmine-facilitated recovery to a TOF ratio of 0.9 was recorded.

RESULTS

Rocuronium infusion dose after a lapse of 120 min was significantly larger in the CSM than in the APM [7.1 (2.3) vs. 4.7 (2.6) microg/kg/min; P=0.001]. The time for facilitated recovery was shorter in the CSM than in the APM [11.4 (3.8) vs. 16.2 (6.0) min; P=0.016].

CONCLUSION

A larger rocuronium infusion dose was required to maintain a constant neuromuscular block at the CSM. Neostigmine-mediated reversal was faster at the CSM.

Presenilin enhancer-2 (PSENEN), a component of the gamma-secretase complex, is involved in adipocyte differentiation

This study was conducted to identify genes expressed during adipocyte differentiation of bovine intramuscular fibroblast-like cells using differential display reverse-transcriptase polymerase chain reaction. The presenilin enhancer-2 (PSENEN) gene was found to be down-regulated during adipocyte differentiation of bovine intramuscular fibroblast-like cells. The ectopic expression of bovine PSENEN in 3T3-L1 reduced adipogenesis and the inhibition of endogenous PSENEN by siRNA induced adipogenesis on d 4 of adipocyte differentiation of 3T3-L1 cells. Interestingly, the expression of gamma-secretase complex gene-related Notch signaling was decreased at d 2 and d 4 during adipocyte differentiation. In addition, expression of the Notch-signaling genes (Notch-1, Hes-1, Pref-1, adipsin) was regulated during adipocyte differentiation by regulation of PSENEN expression. These results suggest that PSENEN plays an important role in adipocyte differentiation and that Notch signaling is involved in adipogenesis.

Factors influencing 3D-MRI diagnosis in preoperative breast cancer patients

620

Background: We presented 3D-MRI will be the useful breast imaging tool in diagnosing intraductal spread and tumor size in breast cancer patients. (ASCO 2008).To do breast conserving surgery, careful management was needed in cases with widely ductal spreading and multifocal lesion. This study was to evaluate factors influencing false negative diagnosis and multifocal types of 3D-MRI, retrospectively. Methods: From July 2000, pre-operative 3D-MRI was underwent 488 cases and images were obtained 479 cases (98%). These patients could be divided into three groups according to 3D-MRI images: pattern 1) localized type (273 cases), 2) widely enhanced type (106 cases) and 3) multi-focal type (100 cases). From April 2005, resected specimen was serially step cut and total specimens were microscopically evaluated. Tumor size in 3D-MRI was 1cm over smaller than resected specimens were defined false negative cases. Investigated factors influencing 3D-MRI were age, patterns of 3D-MRI images, presence of pre-operative chemotherapy, histological type, histological grade, microscopical invasive tumor size (mm) and presence of ductal spreading. Results: The rate of histological confirmed intraductal spread were seen in 58% (158/273cases), 89% (94/106 cases) of patients with 3D-MRI pattern 1) and 2), respectively. Tumor size was correlated between MRI and specimens, significantly (n = 162, r = 06706, p < 0.001). Factors influencing false negative diagnosis of 3D-MRI were presence of pre-operative chemotherapy (p < 0.05), presence of ductal spreading (p < 0.001) and patterns of 3D-MRI images (p < 0.05). In the cases with multi-focal 3D- images, there were only 11(11/41, 26%) cases with true multifocal lesions by total specimens examination. Selection for breast conserving surgery and margin width were based by 3D-MRI images. The proportion of breast-conserved surgery were obtained 90% (437/488 cases) and local failure seen only 6 cases (local failure rate 1.4%) in 3D-MRI guided surgery. (median follow up 52 months). Conclusions: These results suggest that MRI will be the useful breast imaging tool, but caution will be needed in cases with pre-operative systemic therapy, cases expected intraductal spread by imaging tools and cases with multi-focal 3D- images.

No significant financial relationships to disclose.

Association of pharmacokinetics and germ-line mutations in EGFR and ABC transporters with erlotinib toxicity in patients with non-small cell lung cancer (NSCLC)

2506

Background: Erlotinib demonstrates substantial inter-individual differences in response and the development of skin rash (grade≥2) was correlated with efficacy. Erlotinib interacts with its target EGFR and the efflux transporter ABCB1 and ABCG2. EGFR CA repeat is associated with incidence of skin rash. A 421C>A SNP in ABCG2 and 1236C>T, 2677 G>(T/A), and 3435C>T SNPs in ABCB1 are associated with reduced protein expression. The aim of this study was to evaluate the effects of these variants and pharmacokinetics of erlotinib on toxicity grade in Japanese patients treating single agent erlotinib. Methods: Twenty-two patients with NSCLC received erlotinib orally at 150 mg/day and plasma levels of erlotinib were measured on days 1(D1), 8(D8), and stable phase (>day 14) by high-performance liquid chromatography. DNA from plasma was screened for SNPs in the EGFR, ABCB1, and ABCG2 genes using direct nucleotide sequencing or TaqMan assay. Eligibility criteria included: performance status (PS) < 3, age < 75, stage IIIB-IV, and written informed consent. Results: The mean Cmax (±SD) of D1 and D8 were 1.8 ± 1.0 and 3.1 ± 1.4 μg/ml, respectively. Trough concentration (Cmin) at D1 and steady state were 0.9 and 1.7 μg/ml, respectively. Grade 1–2 skin rash or diarrhea occurred in 95% of patients. One patient (Cmax at D1, 3.0 μg/ml) developed interstitial lung disease after continuous treatment with erlotinib for 3 days. The area under curves and Cmax on D1 were correlated with the severity of skin rash (p=0.05 and 0.01), however, Cmin were not correlated. Patients with homozygous variant and heterozygous for ABCB1 1236C>T, 2677 G>(T/A), and 3435C>T genotype as compared to patients carrying the wild-type were associated with higher Cmin at steady state (2.4 vs 1.2 μg/ml, p=0.01). EGFR CA repeat and AGCG2 421C>A genotype were not associated with any pharmacokinetic parameters. All Patients (n=4) with homozygous variant for ABCB1 1236TT- 2677TT/TA/AA-3435TT developed grade≥2 skin rash or diarrhea. Conclusions: The present study suggests that ABCB1 gene polymorphism is associated with the variable toxicity and pharmacokinetics to erlotinib treatment.

No significant financial relationships to disclose.

Increased insulin demand promotes while pioglitazone prevents pancreatic beta cell apoptosis in Wfs1 knockout mice

AIMS/HYPOTHESIS

The WFS1 gene encodes an endoplasmic reticulum (ER) membrane-embedded protein called Wolfram syndrome 1 protein, homozygous mutations of which cause selective beta cell loss in humans. The function(s) of this protein and the mechanism by which the mutations of this gene cause beta cell death are still not fully understood. We hypothesised that increased insulin demand as a result of obesity/insulin resistance causes ER stress in pancreatic beta cells, thereby promoting beta cell death.

METHODS

We studied the effect of breeding Wfs1 ( -/- ) mice on a C57BL/6J background with mild obesity and insulin resistance, by introducing the agouti lethal yellow mutation (A ( y ) /a). We also treated the mice with pioglitazone.

RESULTS

Wfs1 ( -/- ) mice bred on a C57BL/6J background rarely develop overt diabetes by 24 weeks of age, showing only mild beta cell loss. However, Wfs1 ( -/- ) A ( y ) /a mice developed selective beta cell loss and severe insulin-deficient diabetes as early as 8 weeks. This beta cell loss was due to apoptosis. In Wfs1 ( +/+ ) A ( y ) /a islets, levels of ER chaperone immunoglobulin-binding protein (BiP)/78 kDa glucose-regulated protein (GRP78) and phosphorylation of eukaryotic translation initiation factor 2, subunit alpha (eIF2alpha) apparently increased. Levels of both were further increased in Wfs1 ( -/- ) A ( y ) /a murine islets. Electron micrography revealed markedly dilated ERs in Wfs1 (-/-) A ( y ) /a murine beta cells. Interestingly, pioglitazone treatment protected beta cells from apoptosis and almost completely prevented diabetes development.

CONCLUSIONS/INTERPRETATION

Wfs1-deficient beta cells are susceptible to ER stress. Increased insulin demand prompts apoptosis in such cells in vivo. Pioglitazone, remarkably, suppresses this process and prevents diabetes. As common WFS1 gene variants have recently been shown to confer a risk of type 2 diabetes, our findings may be relevant to the gradual but progressive loss of beta cells in type 2 diabetes.

Factors influencing false negative diagnosis of 3D-MRI in pre-operative breast cancer patients

Abstract #4005

Introduction: We presented 3D-MRI will be the useful breast imaging tool in diagnosing intraductal spread and tumor size in breast cancer patients (ASCO 2008). But, false negative cases were very important in breast conserving surgery and careful management was needed in 3D-MRI guided surgery. This study was to review imaging diagnosis using 3D-MRI and to evaluate factors influencing false negative diagnosis of 3D-MRI, retrospectively. Material and methods: From July 2000, pre-operative 3D-MRI was underwent 433 cases of breast cancer patients. Images were obtained 426 cases (98%). Tumor size between 3D-MRI and resected specimens were evaluated retrospectively. Cases with tumor size difference between 3D-MRI and resected specimens less than 1cm were defined related cases and cases with tumor size in 3D-MRI was 1cm more smaller than resected specimens were defined false negative cases. Investigated factors influencing false negative diagnosis of 3D-MRI were age, patterns of 3D-MRI images, presence of pre-operative chemotherapy, histological type, histological grade, microscopical invasive tumor size (mm) and presence of ductal spreading. From April 2005, the entire specimen was serially step cut and evaluated. Results: Tumor diameter from nipple side to lateral margin were measured by MRI and specimens, tumor size was correlated between MRI and specimens, significantly (n=118, r=07186, P &lt; 0.001). On Multivariate analysis revealed that factors influencing 3D-MRI diagnosis were presence of ductal spreading (p=0.0002), patterns of 3D-MRI images (p=0.06) and presence of pre-operative chemotherapy (P=0.04). Factors influencing false negative diagnosis of 3D-MRI were presence of pre-operative chemotherapy (P&lt;0.05), presence of ductal spreading (P&lt;0.01) and infiltration of lymphocyte in the edge of ductal spreading (P&lt;0.05). Selection for breast conserving surgery and margin width were based by 3D-MRI images. The proportion of breast-conserved surgery were obtained 89% (380/426 cases) and local failure seen only 6 cases (local failure rate 1.4%) in 3D-MRI guided surgery. (6-94 months, median follow up 51 months).&#x2028; Conclusion: These results suggest that MRI will be the useful breast imaging tool in diagnosing intraductal spread and tumor size in breast cancer patients. But, caution will be needed in cases with pre-operative systemic therapy and cases expected ductal spreading by other imaging tools.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4005.

Minimally invasive video-assisted thoracoscopic lobectomy for better clinical outcomes in peripheral T1NO lung cancer

It is an unresolved issue whether various thoracotomies affect clinical outcomes. In addition, a wide variety of technical approaches of video-assisted thoracic surgery depend on the facility. We reviewed 152 consecutive patients with clinical T1N0M0 lung cancer that underwent three types of lobectomy with systematic mediastinal lymphadenectomy in a single institute: 46 conventional thoracotomies (OPEN), 50 anterolateral small thoracotomies mainly using the thoracoscope as a light guide (ASSIST), and 56 minimum thoracotomies in which only a thoracoscope view was used (PURE). Total discharge from the chest drainage tube, length of hospital stay, and post-thoracotomy pain were significantly less in PURE than in OPEN and ASSIST. The results of mediastinal lymphadenectomy were equivalent. The 3-year survival rates were also similar among the three groups. We conclude that good clinical outcomes, especially reduced post-thoracotomy pain, seemed to correlate with the lesser degree of destruction of the chest wall with the identical quality as an acceptable cancer operation in PURE.

Epidurally administered mepivacaine delays recovery of train-of-four ratio from vecuronium-induced neuromuscular block

BACKGROUND

The aim of this study was to examine the efficacy of epidurally administered mepivacaine on recovery from vecuronium-induced neuromuscular block.

METHODS

Eighty patients were randomly assigned to one of two study groups. They were either given epidurally a bolus of 0.15 ml kg(-1) of mepivacaine 2%, followed by repetitive injections of 0.1 ml kg(-1) h(-1) throughout the study, or were not given epidurally. General anaesthesia was induced and maintained with fentanyl, propofol and nitrous oxide. Neuromuscular block was induced with vecuronium 0.1 mg kg(-1) and monitored using acceleromyographic train-of-four (TOF) at the adductor pollicis. Patients in each treatment group were randomized to receive neostigmine 0.04 mg kg(-1) at 25% recovery of the first twitch of TOF or to recover spontaneously to a TOF ratio of 0.9. The effect of epidural mepivacaine on speed of spontaneous and facilitated recovery of neuromuscular function was evaluated.

RESULTS

The time from administration of vecuronium to spontaneous recovery to a TOF ratio of 0.9 was significantly longer in the epidural mepivacaine group [105.4 (14.2) min] as compared with the control group [78.5 (9.1) min, P < 0.01]. Neostigmine administered at 25% of control in T1 shortened recovery from neuromuscular block, however the time required for facilitated recovery to a TOF ratio of 0.9 in the epidural group was significantly longer than that in the control group [7.6 (1.6) min vs 5.8 (2.1) min, P < 0.01].

CONCLUSIONS

In clinical anaesthesia, it should be recognized that epidurally administered mepivacaine delays considerably the TOF recovery from neuromuscular block.

Clinical application of carbon fibre reinforced plastic leg orthosis for polio survivors and its advantages and disadvantages

A prospective study was carried out on the clinical application and features of a carbon fibre reinforced plastic leg orthosis (carbon orthosis) for polio survivors. The subjects comprised 9 polio survivors, and 11 carbon knee-ankle-foot orthoses (KAFOs) were prescribed, fabricated, and checked out at the authors' post-polio clinic. Walking was classified based on the functional ambulatory category, and the features of walking with a carbon orthosis were self-evaluated by using a visual analogue scale. The period from modelling a cast to completion was 55 +/- 25 days; the weight of a carbon KAFO was 27.8% lighter than that of the ordinary KAFO; the standard carbon KAFO was 50% more expensive than the ordinary KAFO. The carbon KAFO remained undamaged for at least 2 years. It improved the scores in the functional ambulation categories, but there was no difference between walking with an ordinary and with a carbon KAFO. The self-evaluation of walking with a carbon KAFO revealed that the subjects using a carbon KAFO were satisfied with their carbon KAFO. The carbon KAFO is lightweight, durable, slim and smart, and is positively indicated for polio survivors.

Effects of various anti-asthmatic agents on mite allergen-pulsed murine bone marrow-derived dendritic cells

BACKGROUND

Dendritic cells (DCs) play an important role in the immune response and are critically involved in asthma. beta2-agonists could potentially exacerbate type 2 T helper (Th2) cell-mediated immune response.

OBJECTIVES

To determine the effects of various anti-asthmatic agents on DCs function both in vitro and in vivo.

METHODS

Murine bone marrow-derived DCs were pulsed with mite allergen in the presence of pranlukast, salbutamol, salmeterol or fluticasone. These DCs were then inoculated intranasally into naïve mice to induce allergic airway inflammation in vivo.

RESULTS

Pranlukast reduced IL-10 and increased IL-12, while fluticasone reduced both IL-10 and IL-12 production by mite allergen-pulsed DCs. Allergic airway inflammation in pranlukast- and fluticasone-treated and mite allergen pulsed DCs-harbouring mice was attenuated and such response was associated with inhibition of Th2 response in the airway. Salbutamol did not alter cytokine production, while salmeterol reduced IL-12 production by mite allergen-pulsed DCs. Lung pathology in beta2-agonist-harbouring mice was comparable with those of mite allergen-pulsed DCs-harbouring mice.

CONCLUSIONS

Our results indicate that leukotriene receptor antagonists and corticosteroids inhibit DCs-induced Th2 skewed immune response, and that short- and long-acting beta2-agonists do not modify DCs-induced allergic airway inflammation.

Normalization of acceleromyographic train-of-four ratio by baseline value for detecting residual neuromuscular block

BACKGROUND

This study was designed to recognize the importance of normalizing postoperative acceleromyographic train-of-four (TOF) ratio by the baseline TOF value obtained before neuromuscular block for ensuring adequate recovery of neuromuscular function.

METHODS

In 120 patients, TOF responses of the adductor pollicis to the ulnar nerve stimulation were monitored by acceleromyography (AMG) during anaesthesia using propofol, fentanyl and nitrous oxide. Control TOF stimuli were administered for 30 min. A TOF ratio measured at the end of control stimulation was regarded as a baseline value. Neuromuscular block was induced with vecuronium 0.1 mg kg(-1) and was allowed to recover spontaneously. Duration to a TOF ratio of 0.9 as calculated by AMG (DUR-raw 0.9) was compared with that of 0.9 as corrected by the baseline TOF ratio (i.e. 0.9 x baseline TOF ratio; DUR-real 0.9).

RESULTS

Baseline TOF ratios ranged from 0.95 to 1.47. The average TOF ratios observed every 5 min were constant throughout control stimulation from at time zero mean (SD) [range]; 1.11 (0.09) [0.94-1.42] to at 30 min 1.13 (0.11) [0.95-1.47]. The DUR-real 0.9 was 91.0 (18.0) [51.3-131.0] min and was significantly longer than the DUR-raw 0.9 (81.2 (16.3) [41.3-123.0] min).

CONCLUSIONS

Baseline TOF ratios measured by AMG are usually more than 1.0 and vary widely among patients. Therefore a TOF ratio of 0.9 displayed postoperatively on AMG does not always represent adequate recovery of neuromuscular function and should be normalized by baseline value to reliably detect residual paralysis.

Effects of primary and secondary low-grade respiratory syncytial virus infections in a murine model of asthma

BACKGROUND

Respiratory syncytial virus (RSV) infection is known to develop and exacerbate asthma in young children. In adult, RSV causes recurrent but asymptomatic infections. However, the impact of asymptomatic RSV infection on adult asthma is yet to be determined. The present study is designed to determine the effects of primary and secondary low-grade RSV infections on allergic airway inflammation in a murine model of allergic asthma.

METHODS

A low-grade RSV (2 x 10(3) plaque-forming units/mouse) was inoculated, and this caused neither pulmonary inflammation nor symptoms but induced significant IFN-gamma production in thoracic lymph nodes. To investigate interaction between low-grade virus and Dermatophagoides farinae (Df), airway hyper-responsiveness, lung inflammation and cytokine production from thoracic lymph nodes were compared after primary and secondary low-grade RSV infections in four groups of mice; control, Df allergen-sensitized, RSV-infected and Df-sensitized RSV-infected mice. A direct comparison between low- and high-grade RSV infections was also performed in primary infection. To investigate the role of IL-5 during secondary RSV infection, anti-IL-5 monoclonal antibody (anti-IL-5 mAb) was injected in mice and similar parameters were compared in four groups of mice.

RESULTS

Primary high-grade RSV infection increased allergen-induced airway inflammation, while primary low-grade RSV infection attenuated allergen-induced airway inflammation concomitant with significant IFN-gamma production in lung-draining lymph nodes. In marked contrast, secondary low-grade RSV infection increased both IFN-gamma and IL-5 production, resulting in exacerbation of allergen-induced airway inflammation. Anti-IL-5 mAb treatment in secondary low-grade RSV infection and Df allergen-sensitized mice attenuated virus and allergen-induced airway inflammation.

CONCLUSIONS

Low-grade RSV infection per se does not cause pulmonary inflammation, whereas it induces a significant immunological response in the allergen-sensitized host. These results indicate that subclinical and recurrent RSV infection may play an important role in exacerbation and maintenance of asthma in adults, wherein IL-5 is critically involved.

Bronchial hyperresponsiveness and airway inflammation in adolescents with asymptomatic childhood asthma

BACKGROUND

About 70% of childhood asthmatics become free of asthma-related symptoms during adolescence. Little is known about bronchial hyperresponsiveness (BHR) and airway inflammation in young adults with "outgrown" childhood asthma.

METHODS

We studied 61 nonsmoking medical students (18 intermittent mild asthmatics, 23 students with outgrown childhood asthma but free of asthma-related symptoms for 10 years (asymptomatic asthmatics) and 20 healthy students). BHR and lung function were measured, and induced sputum samples analyzed for eosinophil count, eosinophilic cationic protein (ECP), granulocyte-macrophage colony stimulating factor (GM-CSF), and tumor necrosis factor-alpha (TNF-alpha).

RESULTS

BHR was still present in most asymptomatic asthmatics, but it was milder compared with healthy students. Only three subjects with previous asthma had no BHR and no signs of airway inflammation. Percentages of eosinophil, and ECP, TNF-alpha and GM-CSF concentrations in induced sputum of mild asthmatics and asymptomatic asthma groups were higher than in the healthy group. In asymptomatic asthmatics group, the duration of asthma, sputum eosinophil percentage, and the level of TNF-alpha in sputum correlated significantly with BHR.

CONCLUSIONS

Only a few subjects with longstanding asymptomatic asthma could be considered as cured; most asymptomatic asthmatics continued to exhibit BHR and signs of airway inflammation. The outcome of childhood asthma and BHR was associated with the degree of airway inflammation and the duration of childhood asthma.