Hemodynamic characterization of arterialized and nonarterialized liver transplants in the rat

Persistent hyperkinetic circulation after liver transplantation has been described in humans, but similar changes have not been well characterized in the rat model. This study aimed to investigate the hemodynamics of the systemic and splanchnic circulations in both arterialized and nonarterialized hepatic allografts. Orthotopic liver transplantation was performed in four groups of Sprague-Dawley rats. Group A comprised sham-operated rats with hepatic artery ligation that did not receive transplants; group B comprised rats that received transplants without arterialization; group C comprised sham-operated rats with intact hepatic artery that did not receive transplants; and group D comprised rats that received transplants with arterialization. Blood flow measurements were performed three weeks after the surgical procedure, using the radioactive microsphere method. The results showed that rats that received transplants exhibited a significantly higher cardiac index and lower systemic vascular resistance than the control rats. Splanchnic hyperemia was also present with increased mesenteric blood flow. However, there was no difference in hemodynamics between rats that received arterialized transplants and those that received nonarterialized transplants. Arterial collateral vessels from adjacent tissues were observed in the nonarterialized grafts; this was confirmed histologically. It is concluded that rats that undergo orthotopic liver transplantation exhibit hyperdynamic circulation, regardless of the arterial reconstruction procedure, possibly due to extensive collateral formation in the hepatosplanchnic circulation.

Esophageal cancer

Accurate pretherapy staging for esophageal cancer is important for stage-directed therapy. Precise staging is also essential for quality control and ensuring the validity of clinical trials. Endoscopic ultrasound is currently the best technique in local regional staging. Various investigators have attempted to overcome the problems of nontraversable lesions and restaging after neoadjuvant therapy. Positron emission tomography scan was shown to be especially useful in identifying distant metastases. Its more widespread use is likely to impact on treatment strategies. Surgical resection remains the mainstay of treatment of esophageal cancer. Improvement in immediate postoperative morbidity, mortality, and long-term survival was shown by various reports to relate to experience and volume. The concept of three-field dissection was further defined by illustrating the importance of lymphadenectomy around the recurrent laryngeal nerves. Multimodality treatments continue to receive attention. Several studies have established the patterns of practice in the United States in treating esophageal cancer. Chemoradiation programs are gaining a more important role and are widely used, although their exact roles are uncertain. Closely related to this area of research is the search of molecular markers of favorable response to such therapies. Concerning palliative treatment for esophageal cancer, self-expanding metallic stents have a definite role in patients with malignant dysphagia. Their results and complications are reviewed. Lastly, quality-of-life issues have assumed more importance in studies in oncology. Prospective quality-of-life data should be evaluated in future studies on different treatment methods for this deadly disease.

Improving survival results after resection of hepatocellular carcinoma: a prospective study of 377 patients over 10 years

OBJECTIVE

To investigate whether the survival results after resection of hepatocellular carcinoma (HCC) have improved within the past decade by an analysis of a prospective cohort of patients over a 10-year period.

SUMMARY BACKGROUND DATA

The surgical death rate after resection of HCC has greatly improved in recent years, but the long-term prognosis remains unsatisfactory. It remains unknown whether the survival results after resection of HCC have improved within the past decade.

METHODS

The clinicopathologic and follow-up data of 377 patients who underwent curative resection of HCC between January 1989 and January 1999 were prospectively collected. These patients were categorized according to two time periods: before 1994 (group 1, n = 136) and after 1994 (group 2, n = 241). The two groups were compared for clinicopathologic data and survival results. The prognostic factors for disease-free survival were further analyzed to identify the factors that might have led to improved survival outcomes.

RESULTS

The overall and disease-free survival results were significantly better in group 2 compared with group 1. Patients in group 2 had significantly higher proportions of subclinical presentation, small tumors, and tumors of early pTNM stage. There were also significantly lower frequencies of histologic margin involvement, less intraoperative blood loss, and a lower transfusion rate in group 2. By multivariate analysis, early pTNM stage, subclinical HCC, and no perioperative transfusion were independent favorable prognostic factors for disease-free survival.

CONCLUSIONS

Significant improvement of overall and disease-free survival results after resection of HCC has been achieved within the past decade as a result of advances in the diagnosis and surgical management of HCC. Earlier diagnosis of HCC by better imaging modalities, increased detection of subclinical HCC by screening of high-risk patients, and a reduced perioperative transfusion rate were identified as the major contributory factors for the improved outcomes.

Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer

BACKGROUND

Leakage from esophageal anastomoses is higher than that for other gastrointestinal anastomoses. An intrathoracic anastomotic leak is a potentially catastrophic event.

METHODS

Patients with and without thoracic anastomotic leakage were compared for predisposing factors. Leak-related mortality was analyzed.

RESULTS

Of 475 patients, there were 17 leaks (3.5%). Predisposing technical factors occurred significantly more frequently in patients who leaked. Sixteen such events were identified as contributory in 11 patients. The hospital mortality for patients who leaked was significantly higher (35% versus 9%, P = 0.005). Inadequate drainage and persistent sepsis accounted for 4 of the 6 deaths. The need for inotropic support postoperatively correlated with leak-related mortality (66% versus 0%, P = 0.006), while leak size, time to diagnosis, or method of drainage did not.

CONCLUSIONS

Thoracic anastomotic leaks are largely preventable. Leak-related mortality for the series was 1% and was most commonly related to inadequate drainage.

Clinicopathologic features of long-term survivors and disease-free survivors after resection of hepatocellular carcinoma: a study of a prospective cohort

PURPOSE

This study aims to clarify the clinicopathologic features of long-term survivors and disease-free survivors after resection of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

The clinicopathologic features of 5-year survivors and disease-free survivors were elucidated in a cohort of 230 patients prospectively observed for > 5 years (64 to 192 months) after curative resection of HCC.

RESULTS

The incidence of 5-year overall and disease-free survivors were 37% (85 of 230) and 20% (45 of 230), respectively. Clinicopathologic features associated with 5-year survivors included female sex (P =.024), preoperative serum albumin > or= 40 g/L (P =.033), AST < 50 u/L (P =.001), tumor < 5 cm (P =.001), solitary tumor (P =.035), encapsulated tumor (P =.021), no venous invasion (P =.001), no microsatellite nodule (P =.001), and early pathologic tumor-node-metastasis (pTNM) stage (I or II, P <.001). Features favoring 5-year disease-free survivors were preoperative serum AST < 50 u/L (P =.007), tumor < 5 cm (P =.005), encapsulated tumor (P =.007), no venous invasion (P <.001), no microsatellite nodule (P =.001), and early pTNM stage (I or II, P <.001). By multivariate analysis, pTNM stage was the only significant predictive factor for both overall and disease-free survival.

CONCLUSION

This study shows that long-term disease-free survival > 5 years after resection of HCC can be achieved in patients with favorable tumor characteristics. Early pTNM stage was the most reliable predictor of both long-term overall and disease-free survivors.

Pathological features and BRCA1 mutation screening in premenopausal breast cancer patients

PURPOSE

Risk calculations for carrying BRCA1/BRCA2 mutations are based on family history and the age of onset of cancers. However, women may carry these deleterious mutations without a strong family history. Additional criteria for risk estimation would be of value. It has been recently established that BRCA1-associated breast cancers are associated with poor tumor differentiation (TD3) and estrogen receptor (ER) negativity. The aim of this study is to determine whether morphological features of breast cancers in premenopausal patients (age < 45 years) could determine additional women who may benefit from BRCA1 screening.

EXPERIMENTAL DESIGN

In a prospective, systematic study of 76 consecutive breast cancer patients (age < 45 years), genomic DNA was obtained from peripheral blood, and eight mutations in BRCA1 (10.5%) were found. Archival paraffin-embedded breast cancer specimens were then analyzed for tumor differentiation and ER status.

RESULTS

In patients < 45 years of age, 25% (6 of 24) of ER-negative and TD3 breast cancers were found to harbor mutations in BRCA1. Only 5.6% (2 of 36) of BRCA1-associated breast cancers did not have this morphological profile, compared with 94.4% (34 of 36) patients without BRCA1 mutations, giving an odds ratio of 5.67 (95% confidence interval, 1.04-32; P = 0.05). Finally, only one patient with BRCA1 mutations had a significant family history.

CONCLUSIONS

In patients with early-onset breast cancer, the use of morphological criteria provides an additional strategy to determine those patients who might benefit from genetic testing.

Synchronous gastric adenocarcinoma and mucosa-associated lymphoid tissue lymphoma in association with Helicobacter pylori infection: comparing reported cases between the East and West

The association of Helicobacter pylori infection with synchronous gastric adenocarcinoma and mucosa-associated lymphoid tissue (MALT) lymphoma is rare. Three Chinese patients (M:F = 1:2) who were 71, 58, and 75 yr of age were diagnosed to have gastric adenocarcinoma (2 patients) and gastric lymphoma (1 patient) on endoscopic biopsies. Distal gastrectomy was performed in all of them. Histological study of the three resected specimens revealed synchronous gastric adenocarcinoma and MALT lymphoma. H. pylori infection was found in two patients. A literature search revealed another 29 patients with synchronous tumors in whom H. pylori status was examined. Overall, H. pylori infection was found in 78% of 32 patients. The majority of lymphoma was low grade (75%) and was larger than carcinoma (81%). The majority of carcinoma (65.6%) was early. This suggested lymphoma might develop before carcinoma or the presence of MALT lymphoma might increase the risk of developing carcinoma.

A prospective longitudinal study of quality of life after resection of hepatocellular carcinoma

HYPOTHESIS

Hepatic resection improves quality of life (QOL) in patients with resectable hepatocellular carcinoma (HCC).

DESIGN

A prospective longitudinal study.

SETTING

A university teaching hospital.

PATIENTS

Sixty-six consecutive patients undergoing resection of HCC, and 10 patients with unresectable HCC found after surgical exploration who were subsequently treated with transarterial chemoembolization (control group).

MAIN OUTCOME MEASURE

Serial measurements of preoperative and postoperative QOL using the Functional Assessment of Cancer Therapy-General (FACT-G) Questionnaire for up to 2 years after surgery (at 3, 6, 9, 12, 18, and 24 months).

RESULTS

Among the 66 patients with resectable HCC, the mean postoperative QOL scores at 3 months after surgery were significantly higher than the mean preoperative QOL scores in domains related to physical, social, and emotional well-being and relationship with physicians. The mean total QOL score increased from 83.5 (SD, 9.4) before surgery to 94.1 (SD, 7.7) at 3 months after surgery (P <.001). No significant change of QOL scores at 3 months after surgery was observed in the control group. Twenty patients in the resected group died of early recurrence within 2 years after surgery, but their mean postoperative QOL scores remained higher than the preoperative QOL scores for most assessment times. In contrast, in the control group, the mean total QOL scores became significantly lower than the preoperative scores, starting 9 months after surgery. Forty-six patients in the resected group completed all QOL assessments. At all postoperative assessments, their mean QOL scores were higher than preoperative scores. Recurrence developed in 13 of the 46 patients within the 2-year study, and there was significant deterioration of QOL over time among these 13 (P <.001), whereas no significant change in QOL over time was observed among the 33 recurrence-free patients. Of various clinicopathologic factors, only advanced pTNM stage was significantly predictive of deterioration of QOL over time after resection of HCC.

CONCLUSIONS

Hepatic resection results in significant enhancement of QOL in patients with HCC. Development of recurrence is the main factor leading to deterioration in QOL over time after resection of HCC.

Soluble E-cadherin is a valid prognostic marker in gastric carcinoma

BACKGROUND

Gastric cancer remains a major cause of cancer mortality globally but no good prognostic tumour marker is available. Soluble fragment of E-cadherin protein has been reported to increase in the sera of patients with cancer and recently was found to be elevated in 67% of patients with gastric cancer.

AIMS

To investigate if serum soluble E-cadherin is a valid prognostic marker in gastric cancer.

METHODS

Concentrations of soluble E-cadherin from 116 patients with histologically confirmed gastric adenocarcinoma and 40 healthy subjects were measured using an immunoenzymometric method with a commercially available sandwich ELISA kit based on monoclonal antibodies.

RESULTS

The logarithm of the means of soluble E-cadherin concentration was significantly higher in patients with gastric cancers (mean 3.85 (SD 0.28)) than in healthy subjects (3.71 (0.18)) (p=0.001), and in palliative/conservatively treated cancers (3.91 (0.35)) than in operable cancers (3.78 (0.19)) (p=0.015). The logarithm of the concentrations correlated with tumour size (p=0.032) and carcinoembryonic antigen concentrations (p=0.001). The cut off value calculated from discriminant analysis on operability and inoperability/palliative treatment was 7025 ng/ml. Soluble E-cadherin concentrations higher than this cut off value predicted tumour (T4) depth invasion (p=0.020, confidence interval (CI) 1.008-1.668) and palliative/conservative treatment (p=0.023, CI 1.038-2.514). In contrast, the relative risks for lymph node (N2) metastasis, distant metastasis, and stage III/IV disease were 1.41, 1.33, and 1.55 respectively, despite not reaching statistical significance.

CONCLUSION

Serum soluble E-cadherin is a potential valid prognostic marker for gastric cancer. A high concentration predicts palliative/conservative treatment and T4 invasion.

Detection of genetic alterations in esophageal squamous cell carcinomas and adjacent normal epithelia by comparative DNA fingerprinting using inter-simple sequence repeat PCR

In this study, we screened 19 esophageal squamous cell carcinomas (ESCCs) for the detection of genetic alterations using inter-simple sequence repeat PCR, a DNA fingerprinting approach. Three simple repetitive unanchored primers representing tri- and tetranucleotide repeats [(GTG)(5), (GACA)(4), and (GATA)(4)] were used, and evidence of gains and losses of chromosomal sequences were detected in all tumors (19 of 19 cases) for at least one of the primers. In 13 of these cases, apparently normal marginal epithelia adjacent to the tumors were also collected and examined. Eight of the 13 (62%) patients showed matching somatic mutations in the marginal epithelia adjacent to the tumors. Five of these 8 (63%) marginal epithelial samples were histologically normal, two were dysplastic, and one had extremely rare tumor cells. In 3 of these 13 (23%) cases, the profile bands were also seen to quantitatively increase in intensity, progressing from normal epithelia to marginal epithelia to tumors. Ten profile bands showing gains and one profile band showing loss in tumors compared with the corresponding normal epithelia were cloned, and their origins were determined by sequencing. The DNA sequence of one of the profile bands showing gain in the tumor could be matched to an expressed sequence tag sequence that has been mapped to the 7q22 region, a genomic amplification novel to ESCC. The sequence of the other profile band showing gain in the tumor could be matched to a nonexonic sequence of chromosome 20, whereas the sequences of the remaining profile bands could not be matched with any known sequences after comparison with the genomic sequence data in the European Molecular Biology Laboratory and GenBank databases. The bona fide nature of the gains or losses of 11 profile bands in the original cases was confirmed by direct genomic PCR amplification. The frequencies of these specific gene alterations in tumors were then analyzed in a total of 60 ESCCs, which included 41 additional cases of ESCC. Significantly, 26 of 60 (43%) tumors showed the DNA amplification for the expressed sequence tag sequence of chromosome 7, whereas the frequency of other individual gene alterations ranged from 7% to 15%. It is concluded that the inter-simple sequence repeat PCR strategy is adequate for the detection of somatic mutations in tumors, most of which are quantitative alterations in anonymous genomic sequences. This approach is also suitable for detection of somatic mutations preceding the onset of morphologically detectable neoplasia in ESCC.

The effect of anastrozole on the single-dose pharmacokinetics and anticoagulant activity of warfarin in healthy volunteers

AIMS

The aims of this study were to determine the effects of the nonsteroidal, selective aromatase inhibitor, anastrozole, at steady-state concentrations, on the pharmacokinetics and pharmacodynamics of warfarin, and to assess whether or not anastrozole alone has any anticoagulant activity.

METHODS

This was a randomized, double-blind, placebo-controlled, two-way crossover trial conducted at a single centre. The study comprised two treatment periods of 11 days, separated by a 3 week washout. Healthy male volunteers (n = 16, median age 28.5 years) were randomized to receive either anastrozole (7 mg loading dose on day 1, followed by 1 mg daily on days 2-11) in the first treatment period and placebo in the second treatment period, or vice versa. In addition to their randomized treatment, all volunteers received a single dose of 25 mg warfarin on day 3 of each treatment period. Blood samples for pharmacokinetic and pharmacodynamic assessment were taken at frequent intervals during each treatment period. The safety of volunteers was monitored throughout the study.

RESULTS

Administration of anastrozole resulted in no clinically significant changes in the pharmacokinetics of either R- or S-warfarin compared with placebo for AUC (ng ml-1 h) (glsmean, R-warfarin; anastrozole 93619.9, placebo 91127.91, 95%CI 0.988-1.068; S-warfarin; anastrozole 57129.21, placebo 55676.34, 95%CI 0.979-1.076), CL/F (ml min-1) (glsmean, R-warfarin; anastrozole 2.23, placebo 2.29, 95%CI 0.937-1.012; S-warfarin; anastrozole 3.65, placebo 3.74, 95%CI 0.929-1.021) and t1/2 (h) (lsmean, R-warfarin; anastrozole 55.40, placebo 55.15, 95%CI-2.083-2.592; S-warfarin; anastrozole 39.38, placebo 40.98, 95%CI-6.189-2.996). In addition, anastrozole had no clinically significant effect on the pharmacodynamic effects of warfarin, as assessed 240 h after warfarin dosing by measurement of prothrombin time (s) (glsmean, anastrozole 11.56, placebo 11.31, 95%CI 0.987-1.059), thrombin time (s) (glsmean, anastrozole 19.06, placebo 18.75, 95%CI 0.980-1.054) activated partial thromboplastin time (s) (glsmean, anastrozole 29.94, placebo 29.74, 95%CI 0.968-1.047) and factor VII (%) (glsmean, anastrozole 97.81, placebo 107.26, 95%CI 0.821-1.012). Anastrozole alone had no effect on these indicators of the clotting process.

CONCLUSIONS

Overall, there was no evidence to suggest that anastrozole has any clinically relevant effects on the pharmacokinetics of warfarin. Anastrozole had no effect on clotting mechanisms or on the pharmacodynamic activity of warfarin, as assessed by prothrombin time, thrombin time, activated partial thromboplastin time, and factor VII.

Pharyngolaryngeal morbidity with the laryngeal mask airway in spontaneously breathing patients: does size matter?

BACKGROUND

Currently, the manufacturer of the laryngeal mask airway (LMA; Laryngeal Mask Company, Ltd., Northfield End, Henley on Thames, Oxon, United Kingdom) recommends using as large a mask size as possible. The aim of this study was to compare the incidence of pharyngolaryngeal morbidity after the use of a large (size 5 in males and size 4 in females) or small (size 4 in males and size 3 in females) LMA in spontaneously breathing patients.

METHODS

A total of 258 male and female patients were randomly assigned to insertion of a large or small LMA while breathing spontaneously during general anesthesia. After insertion of the LMA, a "just-seal" cuff pressure was obtained, and intracuff pressure was measured at 10-min intervals until just before removal of the LMA. The 2- and 24-h incidence of postoperative sore throat, pain, hoarseness, dysphagia, and nausea and vomiting was assessed. Complications after LMA removal, including body movement, coughing, retching, regurgitation, vomiting, biting on the LMA, bronchospasm, laryngospasm, or the presence of blood on the LMA, were recorded.

RESULTS

The use of a large LMA was associated with a higher incidence of sore throat in both sexes (20% vs. 7% in men, 21% vs. 5% in women; P < 0.05) and a higher incidence of hoarseness in male patients at 2 h postoperatively (21% vs. 9%, P < 0.05). There was a higher incidence of sore throat in male patients at 24 h postoperatively with the use of a large LMA (26% vs. 12%, P < 0.05). There was no difference in the incidence of complications of LMA removal orother pharyngolaryngeal morbidity, such as difficulty swallowing, drinking, and eating, or nausea and vomiting, between male or female groups at any time period with the use of a large LMA.

CONCLUSIONS

Selection of a small laryngeal mask airway (size 4) in spontaneously breathing male patients may be more appropriate to limit the occurrence of sore throat on the first postoperative day. All patients had a fourfold increased risk of developing sore throat when a large LMA was used.

Pyloroplasty in gastric replacement of the esophagus after esophagectomy: one-layer or two-layer technique?

Pyloroplasty is our routine drainage procedure performed when the stomach is used as the esophageal substitute after esophageal resection for cancer. The technique of pyloroplasty varies among surgeons and effectiveness has not been studied. Thirty-four patients with a gastric conduit whose pyloroplasty was constructed with a one-layer technique (group 1) were compared with a historical cohort of 31 patients treated with a two-layer method (group 2). Patients who had an abnormal pyloroduodenal region were excluded from the study. Perioperative morbidity and post-operative gastrointestinal symptoms within the first 6 months were evaluated. Patient demographics and the types of surgical procedures did not differ between the two groups. The median daily output from the nasogastric tube was 119 mL in group 1 and 115 mL in group 2 (p = 0.49). In 40 out of 65 patients (62%), the nasogastric tube was removed at a median of 3 days after the operation in both groups. There was no leakage from the pylorus or the esophagogastric anastomosis in this study. In both groups, the patients could resume a semisolid diet at a median of 8 days after surgery. One patient in group 1 and two patients in group 2 developed gastroparesis clinically. No patient, however, required reoperation. There was no significant difference in cardiopulmonary complications attributable to the technique of pyloroplasty. The incidence of gastrointestinal symptoms within the first 6 months after surgery did not differ. Regurgitation was the most common symptom, affecting 10 patients in each group, 29% and 32% in group 1 and group 2 respectively (p = 1.0). Pyloroplasty was an effective gastric drainage procedure after esophagectomy whether the one or two-layer method was used. The authors prefer the one-layer method, which is safe and simple.

Treatment of inguinodynia after laparoscopic herniorrhaphy: a combined laparoscopic and fluoroscopic approach to the removal of helical tackers

Laparoscopic inguinal herniorrhaphy has become a popular operation for the treatment of inguinal hernia. However, injury and entrapment of the cutaneous nerves of the lumbar plexus by the staples or tackers used for mesh fixation have been described. Laparoscopic removal of the staples or tackers in the inguinal region has been attempted with variable success. The success of the laparoscopic approach for removal of helical tackers in particular is sometimes limited by the fact that the offending tackers are deeply embedded in the preperitoneal tissues and not readily located with a simple laparoscopic view. The authors report a case in which fluoroscopy was used to help identify tackers that could not be visualized laparoscopically. The neuralgia disappeared after successful removal of the offending tackers with no neurologic deficit. Liberal use of fluoroscopic guidance in the laparoscopic removal of helical tackers in similar cases is recommended.

Spinal anesthesia improves the early recovery profile of patients undergoing ambulatory knee arthroscopy

PURPOSE

We compared the recovery profiles, postoperative complications, perioperative OR utilization times, and times to discharge of patients undergoing ambulatory knee arthroscopy under spinal anesthesia (SA) or general anesthesia (GA).

METHODS

In this randomized, prospective study, 84 ASA I-II patients were randomized to receive either SA with 50 mg of 1% lidocaine, or a standardized GA. Postoperative pain, nausea and vomiting, sedation, OR utilization, postanesthesia care unit (PACU), and ambulatory surgical unit (ASU) recovery were compared.

RESULTS

Patients in the GA group had more pain in the PACU than the SA group (61% vs 15%, P <0.01), and a higher incidence of PACU analgesic use (59% vs 7.5%, P <0.01). Patients in the SA group were able to drink and eat sooner than the GA group (83 +/- 23 vs 95 +/- 22 min, P <0.05 and 88 +/- 27 vs 105 +/- 29 min, P <0.01, respectively). The times to sit, walk, and void were similar. The length of PACU and ASU stay between the GA and SA groups were similar (67 +/- 17 vs 60 +/- 19 min, P >0.05 and 122 +/- 27 vs 127.9 +/- 31 min, P >0.05, respectively). The incidence of backache was higher in the SA group (35 vs 13.6%, P <0.05) than the GA group. However, the incidence of sore throat was higher in the GA compared to the SA group (25% vs 2.5%, P <0.01).

CONCLUSIONS

SA with 50 mg of 1% lidocaine provides an improved recovery profile for ambulatory knee arthroscopy. Discharge times were similar, and with the exception of backache and sore throat, the incidence of complications was similar.

American ginseng (Panax quinquefolius L.) attenuates postprandial glycemia in a time-dependent but not dose-dependent manner in healthy individuals

BACKGROUND

We previously showed that 3 g American ginseng administered 40 min before an oral glucose challenge significantly reduces postprandial glycemia in subjects without diabetes. Whether this effect can be replicated with doses <3 g and administration times closer to the oral glucose challenge is unclear.

OBJECTIVE

Our objective was to study the dosing and timing effects of American ginseng on postprandial glycemia.

DESIGN

In a random crossover design, 12 healthy individuals [X +/- SEM age: 42 +/- 7 y; body mass index (BMI; in kg/m2): 24.1 +/- 1.1] received 16 treatments: 0 (placebo), 1, 2, or 3 g American ginseng at 40, 20, 10, or 0 min before a 25-g oral glucose challenge. Capillary blood was collected before administration and at 0, 15, 30, 45, 60, and 90 min after the start of the glucose challenge.

RESULTS

Two-way analysis of variance showed that the main effects of treatment and administration time were significant (P < 0.05). Glycemia was lower over the last 45 min of the test after doses of 1, 2, or 3 g ginseng than after placebo (P < 0.05); there were no significant differences between doses. The reductions in the areas under the curve for these 3 doses were 14.4 +/- 6.5%, 10.6 +/- 4.0%, and 9.1 +/- 6%, respectively. Glycemia in the last hour of the test and area under the curve were significantly lower when ginseng was administered 40 min before the challenge than when it was administered 20, 10, or 0 min before the challenge (P < 0.05).

CONCLUSIONS

American ginseng reduced postprandial glycemia in subjects without diabetes. These reductions were time dependent but not dose dependent: an effect was seen only when the ginseng was administered 40 min before the challenge. Doses within the range of 1-3 g were equally effective.

Endovascular stenting of superficial femoral artery stenosis and occlusions: results and risk factor analysis

PURPOSE

To determine the early and midterm results of femoro-popliteal angioplasty with adjunctive stenting and to identify factors affecting early and continuing success.

METHODS

Sixty-nine consecutive balloon angioplasty procedures on the superficial femoral artery (SFA) were performed in 60 limbs and 55 patients in the operating theater. Fifty-two percent of lesions were occlusions, and 87% involved the distal half or the whole segment of the SFA. Immediate endovascular stenting was used in all procedures, involving the placement of 105 stents, with a mean stented length of 13.8 cm. Twenty-nine procedures (43%) were performed for critical ischemia. Three-monthly duplex ultrasound was used for follow up assessment, with stenosis of > 50% defined as the endpoint for failure. The patient demographic and biochemical data, and procedural details were correlated with success criteria according to Society of Vascular Surgery standards.

RESULTS

Initial technical success by intent to treat was 92%, with four procedure-related complications and no deaths. Initial success by anatomic, hemodynamic and clinical criteria were 98.3, 96.7 and 93.3% respectively (92.2, 90.6 and 87.5% by intent to treat). Cumulative primary patency at 6, 12, and 24 months was 73.1, 62.6 and 53.8%, and secondary patency 84.9, 72.1 and 72.1% correspondingly. Significant factors relating to inferior patency were occlusions, stented segment length > 10 cm, procedure in claudicants, and the use of the Memotherm stent.

CONCLUSIONS

Angioplasty and stenting of the superficial femoral artery has acceptable primary and secondary patency rates even in the presence of long stenosis and occlusions. A duplex surveillance program is recommended for early detection and timely treatment of restenosis.

Anomalous overexpression of p27(Kip1) in sporadic pancreatic endocrine tumors

BACKGROUND

Little is known about the cellular defects and molecular mechanisms leading to pancreatic endocrine tumors (PETs). p27(Kip1) is a universal cyclin-dependent kinase inhibitor (CDKI), which acts as a tumor suppressor and a negative regulator of cell cycle. From previous reports, quiescent cells show high levels of p27(Kip1) expression while neoplastic and proliferating cells show no detectable p27(Kip1) expression. We hypothesize that in malignant sporadic PETs, p27(Kip1) expression would be decreased compared with benign PETs and normal pancreatic tissue.

METHODS

Western analysis was performed on 28 PETs (7 malignant, 21 benign), 2 nonendocrine cell lines, and 5 endocrine cell lines. Signal intensities were quantitated using densitometry and standardized to normal pancreas.

RESULTS

Unexpectedly, increased p27(Kip1) expression as compared with control was seen in both benign and malignant tumors, as well as in all four pancreatic islet tumor cell lines, but not fibroblast or pituitary cell lines, evaluated. There was no difference in p27(Kip1) level between benign and malignant tumors.

CONCLUSION

This represents the first report of anomalous p27(Kip1) overexpression in sporadic PETs, and is part of a growing literature describing the paradoxical overexpression of p27(Kip1) in human tumors that includes other endocrine tumors. These studies suggest a unique molecular pathway leading to endocrine tumorigenesis.

Laparoscopic versus open bowel resection for Crohn's disease

BACKGROUND

Laparoscopic bowel resection is an alternative to open surgery for patients with Crohn's disease requiring surgical resection. The present report describes a seven-year experience with the laparoscopic treatment of Crohn's disease compared with the open technique in a tertiary Canadian centre.

PATIENTS AND METHODS

A retrospective analysis of 61 consecutive patients undergoing elective resection for Crohn's disease was carried out between October 1992 and June 1999. This analysis included 32 laparoscopic resections (mean age 33 years) and 29 open resections (mean age 42 years). Patient demographics were compared, as well as short and long term outcomes after surgery (mean follow-up 39 months).

RESULTS

Patients in the laparoscopic group were younger and had fewer previous bowel surgeries than patients who had open resections. Indications for surgery and operative times were similar between the groups. Patients who underwent laparoscopic resections required fewer doses of narcotic analgesics. The resumption of bowel function after surgery, and tolerance of a clear liquid and solid diet was quicker in the laparoscopic group. Patients who underwent laparoscopic resections had significantly shorter hospital stays than those who underwent open resections. Fifteen patients (48.4%) in the laparoscopic group experienced recurrence of disease compared with 13 patients (44.8%) in the open group. In both groups, the most common site of recurrence was at the anastomosis. The disease-free interval was the same length for both groups (23.9+/-17.3 months for the laparoscopic resection patients compared with 23.9+/-20.2 months for the open resection patients; P=1.00).

CONCLUSIONS

Laparoscopic resection for Crohn's disease can be performed safely and effectively. Quicker resumption of oral feeds, less postoperative pain and earlier discharge from hospital are advantages of the laparoscopic method. No differences in the recurrence rate or the disease-free interval were noted.

Automated chemical synthesis: from resins to instruments

Solid-phase organic synthesis is now a prevalent activity in drug discovery. In keeping with this keen interest is the need to develop reliable automated synthesis instrumentation as well as polymeric supports and linkers suitable for the full range of organic synthesis applications. In this paper, we review our activities in the development of new and enabling tools for automated chemical synthesis, including the following: (i) new solid supports such as ArgoGel (PS-PEG-based) and Argo-X203 (PS-based); and (ii) the Nautilus 2400 system, a fully closed and inert automated chemistry development workstation. Selected chemistry optimization and synthesis examples performed on the Nautilus and new solid supports will be described.

Adjunctive donepezil in attention deficit hyperactivity disorder youth: case series

Despite well-documented improvement in attention deficit hyperactivity disorder (ADHD) in youths with the available single and combined pharmacologic agents, a number of youths remain with residual symptomatology causing impairment in multiple domains. Recent work has suggested a potential cognitive-enhancing role of cholinergic agents in ADHD. We describe five cases of ADHD youths aged 8-17 years being treated for ADHD with the acetylcholinesterase inhibitor donepezil (Aricept), all of whom demonstrated improvement.

Liver transplantation in rats using small-for-size grafts: a study of hemodynamic and morphological changes

BACKGROUND

Damage to a small-for-size liver graft after reperfusion is frequently observed but the mechanism of injury remains unclear.

HYPOTHESIS

Injury to a small-for-size liver graft is related to the changes of portal pressure and blood flow.

MAIN OUTCOME MEASURES

Survival rates, portal hemodynamics, microcirculatory changes, and morphological changes (by light microscopy and electron microscopy).

SETTING

A rat model of nonarterialized orthotopic liver transplantation comparing 2 groups of rats transplanted with whole grafts (100% of recipient liver weight) and small-for-size grafts (30% of recipient liver weight).

RESULTS

Median survival of the rats with small-for-size grafts was 30 hours (range, 27-37 hours). During the first 15 minutes after reperfusion, mean arterial pressure of the small-for-size graft group was significantly lower than that of the whole graft group (10-minute: 100 vs 132 mm Hg, P =.04; 15-minute: 96 vs 127 mm Hg, P =.04). Portal pressure (in centimeters of water) of the small-for-size graft group was significantly higher in the first 20 minutes after reperfusion than the level before the anhepatic phase (5-minute: 15.1 vs 9.3, P =.02; 10-minute: 16.1 vs 9.3, P =.03; 15-minute, 13.5 vs 9.3, P =.03; 20-minute: 13.4 vs 9.3, P =.03) and was significantly higher than that of the whole graft group in the first 10 minutes after reperfusion (5-minute: 15.1 vs 9.6, P =.02; 10-minute: 16.1 vs 10.3, P =.04). Hepatic microcirculatory blood flow (in milliliters per minute per 100 g) was also significantly higher in the small-for-size graft group during the first 40 minutes after reperfusion (5-minute: 16.3 vs 9.3, P =.02; 10-minute: 14.9 vs 6.6, P =.02; 15-minute: 14.8 vs 5.5, P =.02; 20-minute: 13.1 vs 7.0, P =.02; 30-minute: 13.2 vs 8.8, P =.04; 40-minute: 14.6 vs 7.1, P =.02). Light and electron microscopy showed normal morphological features of whole graft up to 24 hours after reperfusion. The small-for-size graft, however, showed sinusoidal congestion, tremendous swelling of mitochondria of hepatocytes, irregular large gap of sinusoidal lining cells, and collapse of the space of Disse.

CONCLUSIONS

In a rat model, the portal hemodynamic changes in small-for-size grafts are transient. Progressive damage of the graft may result from microcirculatory failure due to irreversible endothelial injury after reperfusion.

Novel demonstration of a physiologic/pharmacologic role of insulin-like growth factor-1 in ovulation in rats and action on cumulus oophorus

Gonadotropins are well known to be the most important stimulus for ovarian follicular development. More recently, there is indirect evidence that insulin-like growth factor-1 (IGF-1) is also a very important autocrine/paracrine factor in folliculogenesis. We had access to an analog of IGF-1, LR3IGF-1, which binds very poorly to IGF-1 binding proteins and therefore was shown by previous investigators to have biologic effects. We studied rats that were superovulated with the use of gonadotropins. We showed that the addition of LR3IGF-1 by infusion further increased the ovulation rate (statistically significant) and increased the ovarian weight in two of three strains of rats. We demonstrated that infusion of LR3IGF-1 or injection of equine chorionic gonadotropin or a combination of these two were associated with oocytes with reduced number of cumulus cells (statistically significant). We conducted an experiment to determine whether in vitro culturing with varying dosage of IGF-1 may stimulate cumulus cell replication to improve the quality of oocyte cumulus complex. IGF-1 did not show any change in this respect. Through these physiologic (pharmacologic) studies, we have shown that IGF-1 (analog) can further increase the ovulation rate induced by gonadotropins.