Interspecies Differences and Scaling for the Pharmacokinetics of Xanthine Derivatives

Pharmacokinetic characteristics of the new xanthine bronchodilators, enprofylline and 1-methyl-3-propylxanthine (MPX), were investigated in mice, rats, guinea-pigs, rabbits and dogs. The possibility of an interspecies pharmacokinetic scale was also evaluated. The concentration of these two drugs in plasma and urine was determined by HPLC. Pharmacokinetic parameters were calculated using model-independent methods. The disappearance curves of the two drugs from plasma varied markedly among animal species. Interspecies differences in the plasma protein binding of each drug were observed for all animals in the study. Differences in the biotransformation of enprofylline and MPX were also confirmed among the various animal species: enprofylline is mainly excreted in an unchanged form in urine while MPX follows a non-renal route of elimination. In all animals, the renal clearance for enprofylline was greater than the glomerular filtration rate, indicating active tubular secretion. Significant allometric relationships were seen between the values of total body clearance and steady state volume of distribution for both total and unbound enprofylline and species body weight, but similar correlations could not be recognized for MPX. Renal clearance of enprofylline was also closely correlated with species body weight, suggesting no interspecies difference with relation to affinity and/or capacity for the active tubular secretion mechanism of enprofylline. Our findings suggest that xanthine derivatives, including enprofylline, are mainly eliminated via the kidney, and an estimate of the basic pharmacokinetics in man can be obtained from data in experimental animals.

Selective Bronchodilators from 1-(5′-Oxohexyl)xanthines

A series of twenty one 1-(5′-oxohexyl)xanthines substituted with alkyl chains at the N 3 and N 7 positions of the xanthine nucleus were prepared and their relaxant activity in guinea-pig isolated tracheal muscle and positive chronotropic activity in isolated right atrium of guinea-pig were compared. The tracheal relaxant activities were markedly increased with alkyl chain length at the N 3 position, but decreased by the N 7 alkylation. The positive chronotropic activities in the right atrium were increased by introduction of an n-propyl group at the N 3 position but decreased by substitution of longer alkyl chains, and the action on the heart was diminished by N 7 substitution. The activities of compounds on cAMP-phosphodiesterase (PDE) and binding of [3H]8-cyclopentyl-1,3-dipropylxanthine were measured in the homogenate of tracheal muscle and the membrane preparation of cerebral cortex, respectively. No relationship among tracheal muscle relaxant activity, cAMP-PDE inhibitory activity and adenosine antagonism of these xanthines was observed, and other action mechanisms should be considered for their relaxant activities. This study indicated that N 3 alkylation is important for the selectivity for tracheal muscle, while the introduction of long alkyl chains such as n-butyl and n-pentyl groups at the N 3 and N 7 positions diminished the potency for the right atrium in guinea-pigs. 3-n-Pentyl- and 7-methy]-3-n-pentyl-1-(5′-oxohexyl)xanthines showed much higher bronchoselectivity than oxpentifylline and theophylline.

Use of circulating tumor cells to predict response to chemotherapy in patients with advanced gastric cancer

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Background: The purpose of this study was to quantify circulating tumor cells (CTCs) in advanced gastric cancer (AGC) patients, and to demonstrate the role of CTCs in cancer therapy. The purpose of this study was to identify CTC threshold proposal for determining response to chemotherapy in AGC.

Methods: From November 2007 to June 2009, fifty-two patients with AGC were enrolled into a prospective study. All patients were enrolled using institutional review board-approved protocols at the Cancer Institute Hospital and provided informed consent. The study population consisted of patients of aged 18 years or older with histologically proven AGC. Other inclusion criteria were Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 2; adequate organ function. The subjects were five patients treated with S-1 (40 mg/m2, twice daily, days 1-28, repeated every 6 weeks), twenty-six patients treated with S-1 plus CDDP (S-1 40 mg/m2, twice daily, days 1-21, CDDP 60 mg/m2, day 8, repeated every 5 weeks), and twenty-one patients treated with paclitaxel (80 mg/m2, weekly). CTCs of whole blood at baseline, two weeks and four weeks after initiation of chemotherapy, were isolated and enumerated using immunomagnetics.

Results: Patients with ≥4 CTCs at two-week points and four-week points had a shorter median PFS (1.4, 1.4 months, respectively), than those with the median PFS of <4 CTCs (4.9, 5.0 months, respectively) (p<0.001, p<0.001, respectively). Patients with ≥4 CTCs at two-week points and four-week points had shorter median OS (3.5, 4.0 months, respectively) than those with the median PFS of <4 CTCs (11.7, 11.4 months, respectively) (p<0.001, p=0.001, respectively). In univariate analysis, PS, treatment regimen, Line of chemotherapy, and CTC levels at 2 weeks and 4 weeks predicted PFS and OS. In order to evaluate the independent predictive effect of chemotherapy, multivariate Cox regression analysis was carried out. CTC levels at 2 weeks and 4 weeks were the strongest predictors.

Conclusions: A threshold of lower than 4 CTC/7.5 ml at 2 weeks and 4 weeks was a significant predictor of the outcome for AGC patients treated with S-1 based regimen or paclitaxel regimen.

No significant financial relationships to disclose.

Coagulo-fibrinolytic activity as a predictor of efficacy in bevacizumab-combined chemotherapy in metastatic colorectal cancer patients

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Background: The combination of bevacizumab (BV) and chemotherapy in the first-line and second-line treatment of metastatic colorectal cancer (mCRC) has been shown to improve survival. Bevacizumab is a recombinant, humanized monoclonal antibody against vascular endothelial growth factor. However, the relationship between coagulo-fibrinolytic activity factors and treatment efficacy remains to be clarified. The aim of this study was to determine potential coagulo-fibrinolytic activity markers impacting survival.

Methods: Among 119 consecutive patients included in the study, 85 received first-line FOLFOX4 plus BV 5 mg/kg and 34 received second-line FOLFIRI plus BV 5 mg/kg until progression of disease or unmanageable toxicity occurred. Coagulo-fibrinolytic activity factors, including D-dimer, thrombin antithrombin complex (TAT) and carbohydrate antigen 125 (CA125) encoded by the MUC16 mucin gene were evaluated as candidate predictors of outcome.

Results: In first-line treatment, overall response, median progression-free survival (PFS) and two-year survival rate were 61.9%, 518 days and 67.3%, respectively. In second-line treatment, overall response, median PFS and median overall survival (OS) were 23.5%, 248 days and 651 days, respectively. The outcomes of the univariate analysis were as follows: normal D-dimer and CA125 levels at baseline were associated with better PFS and OS in first-line treatment; normal TAT and CA125 levels at baseline were associated with better PFS and OS in second-line treatment. According to the results of the multivariate analysis, normal D-dimer level was associated with longer PFS in first-line treatment, and only CA125 level at baseline was an independent predictor of both PFS and OS in second-line treatment.

Conclusions: The results suggest that coagulo-fibrinolytic activity factors such as TAT, D-dimer or CA125 may be useful predictors of outcome in mCRC patients receiving BV in combination with chemotherapy.

No significant financial relationships to disclose.

Insufficient lymph node dissection is an independent risk factor for postoperative cancer death in patients undergoing surgery for stage II colorectal cancer

BACKGROUND

Surgical resection is the most effective treatment for patients with stage II colorectal cancer (CRC). However, a few patients with early-phase CRC suffer postoperative cancer death.

AIMS

To investigate the risk factors for postoperative cancer death in patients who undergo surgery for stage II CRC.

METHODS

Prognostic significance was analyzed by χ(2) test, univariate analyses, Kaplan-Meier analysis and log-rank test using clinicopathological factors from the database.

RESULTS

A total of 205 patients with stage II CRC were evaluated. Age (≤ 65/>65 years), venous invasion (negative/positive), number of dissected lymph nodes (≤ 9/≥ 10), grade of lymph node dissection (sufficient/insufficient) and albumin level (< 3.5/≥ 3.5 g/dl) were associated with shorter overall survival. Univariate analysis of the clinicopathological factors revealed that only the grade of lymph node dissection (sufficient/insufficient) was associated with postoperative cancer death (odds ratio 2.993, 95% confidence interval 1.216-7.368, p = 0.017).Kaplan-Meier analysis and log-rank test revealed that the group with insufficient lymph node dissection had a higher incidence of postoperative cancer death than the group with sufficient dissection (p < 0.001).

CONCLUSIONS

Insufficient lymph node dissection is an independent risk factor for postoperative cancer death in patients who undergo surgery for stage II CRC.

Right internal jugular vein is recommended for central venous catheterization

BACKGROUND

The internal jugular vein (IJV) is one of the recommended sites for safe insertion of a central venous catheter (CVC). Although CVC insertion via the IJV has a lower risk of severe complications such as pneumothorax and arterial bleeding than insertion via the subclavian vein, few reports have provided concrete evidence for the safety of a right-sided approach.

PURPOSE

To examine whether a right-sided approach, rather than a left-sided one is superior for CVC insertion via the IJV.

METHODS

A retrospective study was performed to compare the right IJV with the left in terms of characteristics such as vertical and horizontal diameters, depth from the skin, and the relationship between the IJV and the common carotid artery (CCA) using the same computed tomography axial slice.

RESULTS

From April 2006 to September 2008, 100 patients (50 male and 50 female) who underwent CVC insertion via the IJV before surgery for colorectal cancer were enrolled. Vertical and horizontal diameters of the right IJV were significantly larger than those of the left IJV [right: left (cm), 1.51 +/- 0.41 vs 1.13 +/- 0.34, p <.0001, 1.54 +/- 0.36 vs 1.08 +/- 0.33, p <.0001], respectively. The right IJV runs more superficially than the left IJV [right: left (cm), 1.74 +/- 0.60 vs 1.87 +/- 0.56, p <.0001].

CONCLUSIONS

Because the right IJV has a much wider diameter and runs more superficially than the left IJV, a right-sided approach is more acceptable than a left-sided one for CVC insertion via the IJV.

Characterization of nestin expression in the spinal cord of GFP transgenic mice after peripheral nerve injury

Many studies have shown that activation and increase in the number of astrocytes and microglia in the spinal cord participate in the initiation and maintenance of neuropathic pain, but little attention has been paid to the responses of neural progenitor cells to peripheral nerve injury. Nestin, a class VI intermediate filament protein, is expressed both in neuronal and glial progenitors as well as in their common precursors; and nestin-positive cells appear in the brain and spinal cord following various forms of damage to these regions. To clarify the responses of neural progenitor cells to nerve injury, we applied L5 spinal nerve transection (L5-SNT) to nestin-promoter GFP (pNestin-GFP) transgenic mice to narrow the target to them. While pNestin-GFP expression was strongly retained in the ependyma lining the central canal of the transgenic spinal cord even in adulthood, it was markedly reduced in the dorsal horn during postnatal development by day 7. Increases in pNestin-GFP expression and labeling by the proliferation marker 5-bromodeoxyuridine were broadly found in the dorsal horn of adult mice on day 3 after L5-SNT. On the other hand, the activation and increase in number of microglia and astrocytes are restricted to the superficial layer of the dorsal horn, the central terminal of injured primary afferent fibers. Purinergic P2X agonist α, β-MeATP increased [Ca(2+)]i in nestin-positive cells in the superficial layer ipsilateral to nerve injury and P2 receptor antagonists suramin and pyridoxalphosphate-6-azophenyl-2,4-disulphonic acid (PPADS) blocked the expression and elongation of pNestin-GFP fibers in the slice culture of the spinal cord. These results with pNestin-GFP transgenic mice demonstrate that nestin-positive cells proliferate in the dorsal horn in response to peripheral nerve injury and suggest that ATP may contribute to the expression of nestin and activation of neural progenitor cells after nerve injury.

Effect of maternal stress on fetal heart rate assessed by vibroacoustic stimulation

This study was designed to determine whether maternal stress levels, state and trait anxiety levels, and stress hormones affect fetal heart rate (FHR) patterns after vibroacoustic stimulation (VAS) at 30 weeks of gestation. A total of 24 healthy pregnant women with a single fetus pregnancy were enrolled. Corticotropin releasing hormone (CRH) and adrenocorticotropic hormone in maternal plasma and cortisol, and chromogranin A in saliva were measured. The FHR patterns after VAS were divided into three types: type I, a long period of acceleration or one acceleration lasting > 1 min or at least two accelerations lasting > 15 s; type II, a biphasic response with acceleration followed by deceleration; and type III, no response or prolonged deceleration. In the high trait anxiety group, CRH levels were significantly higher than in the low trait anxiety group, and FHR patterns after VAS showed mostly a type II response pattern. These findings suggest that stress in pregnant women with high trait anxiety may influence FHR patterns after VAS.

Valve system does not reduce the catheter-related bloodstream infection

BACKGROUND

The Groshong catheter (GC) is considered to have a lower risk of central venous catheter-related bloodstream infection (CVC-RBSI) than conventional catheters because of its valve system (closed-end) for preventing blood reflux. However, few studies have compared the GC with conventional (open-end) catheters in terms of catheter-related complications.

PURPOSE

To compare the incidence of catheter-related complications including CVC-RBSI between the GC and the Argyle catheter (AC).

METHODS

The GC and the AC were inserted in the same way from the internal jugular vein. Catheter-related complications were evaluated from the database retrospectively.

RESULTS

Two hundred seventy GCs were inserted in 123 patients, and 251 ACs were inserted in 135 patients. There were no significant differences in patient background factors between GC and AC use, except for the following two parameters. Use of GC was associated with a longer catheter insertion length and a younger patient age. Univariate analysis revealed that neither type of catheter reduced the incidence of CVC-RBSI. Kaplan-Meier analysis and log rank test revealed no significant difference between the GC and the AC in the period from insertion to development of complications.

CONCLUSIONS

The GC has no superiority over the conventional AC for preventing CVC-RBSI.

Effects of dietary glycine supplementation and fish meal on inflammatory responses in broiler chicks

1. The effect of dietary protein source and glycine (Gly) supplementation on inflammatory responses was investigated using broiler chicks. Birds (7 d of age) were fed on a maize-soybean meal based (CS) diet with or without 20 g fish meal (FM)/kg and/or 10 g Gly/kg for 14 d. 2. Inflammatory responses were assessed by determining changes in the plasma concentrations of nitrate plus nitrite (NO(x)), caeruloplasmin (Cer) and alpha-1 acid glycoprotein (AGP), and changes in the expression of mRNA encoding substances related to the inflammatory response, such as interleukin (IL)-1 beta and -6, tumour necrosis factor like ligand (TL)1A, inducible nitrite synthase (iNOS), interferon(IFN)-gamma, following lipopolysaccharide (LPS) injection. 3. IL-1 beta and TL1A mRNA expression in chicks fed on the FM diet was higher than in chicks fed on the CS diet. 4. Supplementing the CS diet with Gly resulted in smaller increases in the plasma concentrations of NO(x), Cer and AGP after LPS injection than were observed for chicks fed on the CS diet alone. In addition, 2 h after LPS challenge the expression of encoding inflammatory response-related substances was lower in the spleens of those chicks fed on the Gly-supplemented diet than in those fed the CS diet. 5. Supplementation of the FM diet with Gly reduced the plasma AGP concentration and IL-1 beta and TL1A expression. 6. These results suggest that modulation of inflammatory responses by dietary Gly supplementation is affected by dietary composition; Gly supplementation has different effects on the cytokine responses dependent on the diet.

Influence of inflammation-based prognostic score on mortality of patients undergoing chemotherapy for far advanced or recurrent unresectable colorectal cancer

11084

Background: Recent studies have revealed that the Glasgow prognostic score (GPS), an inflammation-based prognostic score that includes only C-reactive protein (CRP) and albumin, is a useful tool for predicting postoperative outcome in cancer patients. However, few studies have investigated the GPS in patients undergoing chemotherapy for far advanced or recurrent unresectable colorectal cancer (AR-UCRC). Objective: To demonstrate the influence of the GPS for prognostication of patients undergoing chemotherapy for AR-UCRC. Methods: The GPS was calculated as follows: patients with both an elevated level of CRP (>1.0 mg/dl) and hypoalbuminemia (<3.5 g/dl) were allocated a score of 2, and patients showing one or none of these blood chemistry abnormalities were allocated a score of 1 or 0, respectively. Results: One hundred twelve patients who had undergone chemotherapy for AR-UCRC with regimens such as such as FOLFIRI (5-fluorouracil [5-FU]/l-leucovorin [LV]/irinotecan hydrochloride [CPT-11]) or FOLFOX (5-FU/LV/oxialiplatin [L-OHP]) were evaluated retrospectively. Kaplan-Meier analysis and log rank test revealed that GPS2 predicted a higher risk of mortality than GPS0 or 1 (P <0.0001). Univariate analyses revealed that the neutrophil ratio (P = 0.0411), CA19–9 (P = 0.0473), CRP (P = 0.0477), albumin (P = 0.0043) and GPS (0,1/2) (P < 0.0001) were associated with mortality. Multivariate analyses using these five factors revealed that only GPS (0,1/2) (odds ratio, 6.071; 95% C.I., 1.625–22.68; P = 0.0073) was an independent risk factor of mortality. Conclusions: GPS is considered the most important and independent predictor of mortality in patients undergoing chemotherapy for AR-UCRC.

No significant financial relationships to disclose.

Transnasal fine gastrointestinal fiberscope-guided long tube insertion for patients with small bowel obstruction

BACKGROUND

The use of a transnasal fine gastrointestinal fiberscope (TNF-GIF) has been rapidly disseminating in Japan. However, there has been no trial of long tube insertion (LTI) using the TNF-GIF for patients with small bowel obstruction (SBO).

PURPOSE

To examine whether TNF-GIF-guided LTI is superior to conventional LTI for patients with clinically diagnosed SBO.

METHODS

The time required for LTI was determined prospectively in each group of patients who underwent the conventional method (group 1, n = 10) and the TNF-GIF-guided method (group 2, n = 10) between March 2007 and November 2007. Insertion time was compared between groups 1 and 2.

RESULTS

Insertion time in group 2 was significantly shorter than that in group 1 (group 1, 22 +/- 16 min versus group 2, 9.2 +/- 5.4 min; P = 0.03).

CONCLUSIONS

Novel TNF-GIF-guided LTI is useful and superior to the conventional method.

Is long-term tocolysis effective for threatened premature labour?

There is some controversy regarding the optimum duration of tocolysis. This retrospective multicentre study was performed to evaluate whether long-term (> 2 days) tocolysis is effective in treating threatened premature labour. A total of 1147 eligible patients were grouped according to whether or not tocolytics were given, and according to route of administration and whether or not ritodrine (the standard tocolytic regimen in Japan) or other tocolytic was given. They were then further stratified into three subgroups, using the Baumgarten and Gruber tocolysis index (TI), to assess the efficacy of tocolysis treatment according to the risk of premature labour. Prolongation of gestation was significantly longer in patients treated with tocolytics for > 2 days compared with the unmedicated, bed-rest group. In women receiving tocolysis, the mean duration of prolonged gestation was 2.2 times longer in the intermediate-risk TI group and 3.1 times longer in the high-risk TI group compared with the unmedicated group. In the patients who received tocolysis, IV ritodrine was used in 86% of cases and was considered safe and effective for prolonging gestation in cases of threatened premature labour.

Surface tension and elasticity of gel studied with laser-induced surface-deformation spectroscopy

The laser manipulation technique was effectively used for agarose solutions and the frequency specstrum of the surface response to the periodical laser irradiation yielded shear elasticity G and surface tension sigma in the gel. The laser spot size, from 60 mum to 200 mum in radius, was chosen so that either the Rayleigh waves or the capillary waves, selectively excited, associated with G or sigma , respectively. The result of G showed a dependence on the agarose concentration that is consistent with the theoretical prediction of the percolation model, while sigma has little dependence on the concentration. The surface state of 0.2 wt.% agarose solution was controlled with sodium-dodecyl-sulfate (SDS) additives, and sigma of the gel and the sol was observed at different SDS concentrations: The result showed (i) sigma decreased with increasing SDS concentration up to 39 x 10-3 mol/l and kept a constant value thereafter, and (ii) the gel and the sol have the same value of sigma and the same dependence on the concentration. These results were considered from a viewpoint of surface pressure and a partially quantitative discussion was made on the surface adsorbed with SDS and agarose molecules.

The chondrogenic repair response of undifferentiated mesenchymal cells in rat full-thickness articular cartilage defects

OBJECTIVE

The aim of this study is to develop a rat model of full-thickness articular cartilage defects that is suitable for detailed molecular analyses of the regenerative repair of cartilage.

MATERIALS AND METHODS

The V-shaped full-thickness defects (width: 0.7 mm; depth: 0.8 mm; and length: 4mm) were created in the femoral patellar groove of 6 weeks old male rats using a custom-built twin-blade device. Prior to starting the repair experiments, our device was examined for its accuracy and reliability in generating defects. Then, the time course of the repair response in these cartilage defects was examined using a semi-quantitative histological grading scale. The expression of chondrogenic differentiation markers in the reparative regions was examined with immunohistochemistry and in situ hybridization.

RESULTS

Our device creates full-thickness articular cartilage defects uniformly. In these defects, undifferentiated mesenchymal cells filled the defect cavities (4 days) and initiated chondrogenic differentiation at the center of the defect (7 days). Cartilage formation was observed in the same region (2 weeks). Finally, hyaline-like articular cartilage and subchondral bone layers were reconstituted in their appropriate locations (4 weeks).

CONCLUSIONS

We have successfully developed a rat model containing identically sized full-thickness defects of articular cartilage that can undergo chondrogenic repair in a reproducible fashion.

A magnetic fluid microdevice using insect wings

A magnetic fluid microdevice using Diptera insect wings is proposed and constructed. The magnetic fluid device is composed of insect wings, a small permanent magnet, coil, and kerosene-based magnetic fluid. First, the structural properties of insect wings are studied through measurements of certain morphological parameters. Secondly, the novel type of microwind energy converter is constructed. Thirdly, the power generation characteristics of the magnetic fluid microdevice using insect wings are examined. It is found that the output power is roughly proportional to the cube of the airflow velocity.

Involvement of stem cell factor and its receptor tyrosine kinase c-kit in pain regulation

The c-kit receptor tyrosine kinase is expressed in a subpopulation of small- and medium-sized neurons of the dorsal root ganglia (DRG) and in the superficial layer of the spinal cord. Stem cell factor (SCF), a ligand of the c-kit receptor, induces neurite outgrowth from DRG and supports the survival of c-kit-expressing neurons. To clarify the possible function of the SCF/c-kit receptor system in the adult animal, we investigated the expression of c-kit receptor in the spinal cord and DRG in relation to pain by using H2C7, a newly developed anti-c-kit monoclonal antibody. S.c. and intrathecal injection of SCF markedly reduced the paw withdrawal threshold to mechanical stimuli and intrathecal SCF at 10 pg maximally induced mechanical allodynia in conscious mice. Intrathecal SCF also reduced the paw withdrawal latency to heat stimuli significantly but transiently. The c-kit receptor was co-expressed in 58.4% of calcitonin gene-related peptide (CGRP) -positive, but only 5.1% of isolectin B4-positive, DRG neurons. In the spinal cord, the c-kit receptor was detected in the superficial layer of the dorsal horn and co-localized there with CGRP in central terminals of DRG neurons. Selective elimination of unmyelinated C-fibers by neonatal capsaicin treatment resulted in marked reduction of the c-kit receptor and CGRP expression in the superficial layer of the spinal cord. Cell-size profiles showed that c-kit receptor expression was significantly up-regulated and down-regulated in medium-sized DRG neurons after neonatal capsaicin treatment and nerve injury, respectively. These results suggest that the c-kit receptor is mainly expressed in peptidergic small-sized DRG neurons and may be involved in pain regulation both peripherally and centrally.

POSSUM is an optimal system for predicting mortality due to colorectal perforation

BACKGROUND/AIMS

The purpose of this study was to determine the most useful predictive scoring system for the postoperative mortality of patients with colorectal perforation using the Acute Physiological and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Physiological and Operative Severity Score for the enUmeration of Mortality (POSSUM).

METHODOLOGY

First, the 3 scoring systems were applied to all patients, and the efficacy of these systems was compared between survivors and non-survivors. Second, using receiver operating characteristic (ROC) curve analysis, optimal cut-off values were determined for each system and patients were divided into another two groups (high score group and low score group). Then statistical analyses were performed, respectively.

RESULTS

All scoring systems gave significantly lower scores for survivors than for non-survivors. POSSUM was the most sensitive system for predicting operative mortality (POSSUM: sensitivity 87.5%). Kaplan-Meier analysis and log rank test revealed that there were significant differences between the high score group and the low score group, except for APACHE II. Multivariate logistic regression analysis revealed that only POSSUM was an independent predictor (odds ratio, 0.858; 95% C.I.; 0.736-1,000; p = 0.0498).

CONCLUSIONS

POSSUM is an optimal predictor of mortality following emergency surgery for colorectal perforation.

Usefulness of Groshong catheters for central venous access via the external jugular vein

This study was designed to evaluate the usefulness of central venous access via the external jugular vein (EJV) employing Groshong catheters, and to compare the complications with those of conventional internal jugular venous catheterization. Central venous access was achieved by insertion of a single-lumen 4.0 Fr Groshong catheter via the EJV or internal jugular vein (IJV) with a single puncture. Complications associated with insertion and central venous catheter-related bloodstream infection (CVC-RBSI) were evaluated from the database. Two hundred and twenty-five patients received 400 catheters for a total period of 5377 catheter-days. Ninety-six patients underwent 201 internal jugular venous catheter (IJV-C) procedures for 2381 catheter-days, and 129 patients underwent 199 external jugular venous catheter (EJV-C) procedures for 2996 catheter-days. Use of EJV-C was associated with a longer catheter insertion length (p < .01) and period (p < .01), a larger number of operations (p < .01), and more frequent use of total parenteral nutrition (TPN) (p < .01) and less frequent use of chemotherapy (p < .01) than for IJV-C. However, there were no significant differences (NS) in complications associated with insertion and CVC-RBSI between IJV-C and EJV-C. There were no significant differences such complications as malposition, oozing or hematoma formation of insertion site, arterial bleeding, nerve damage, pneumothorax, and phlebitis between IJV-C and EJV-C. Moreover, EJV-C was not associated with morbidities such as pneumothorax, arterial bleeding, and nerve damage. Thus the study concluded that EJV-C using Groshong catheters has no severe complications and has the same rates of CVC-RBSI as conventional IJV-C for central venous access.

Chronic headache after cranio-cervical trauma--hypothetical pathomechanism based upon neuroanatomical considerations

BACKGROUND

Chronic headache after whiplash injury is common, but the underlying mechanisms have not yet been elucidated. On the basis of human neuroanatomy, we hypothesize that rear-end collision can cause leakage of the cerebrospinal fluid (CSF) into the epidural space most frequently at the lumbosacral level, inducing chronic headache.

METHODS

We considered that the following phenomena would be evident in patients with chronic headache after rear-end collision: (1) orthostatic headache with early onset and long duration, (2) low intracranial pressure (ICP =or< 60 mm H2O), (3) CSF leakage mainly in the lumbosacral region on radioisotope-myelocisternography, and (4) diffuse pachymeningeal enhancement (DPE) on gadolinium enhanced magnetic resonant image (Gd-MRI). The clinical signs and symptoms, ICP and neuroimaging findings were analyzed retrospectively in 20 patients who complained of chronic headache after rear-end collisions.

RESULTS

Headaches were orthostatic and started on the day of the accident in 14 patients. The headaches lasted more than 3 months in all patients. Mean ICP was 120 +/- 30 cm H2O. Only one patient showed low ICP. RI-myelocisternography revealed signs of CSF leakage at the lumbosacral level in 10 patients. Gd-MRI showed no abnormalities known to be characteristic of spontaneous intracranial hypotension (SIH). Chronic headache disappeared or was diminished in all patients by epidural blood patching in the lumbosacral region.

CONCLUSION

This clinical study partly supports the validity of our verifiable hypothetical mechanism. The ICP is not low and DPE is not observed on Gd-MRI. Therefore, CSF leakage into the epidural space may not occur, but spinal CSF absorption may be over-activated. This condition may represent a new clinical entity.

[Mucoepidermoid carcinoma in a young man treated by bronchoplasty]

A 17-year-old man in whom mucoepidermoid carcinoma of the left upper lobe bronchus was successfully treated by bronchoplasty. The patient has been suffered from relapsing respiratory infections over the past 2 years. Bronchoscopic examination revealed a tumor at the orifice of the left upper lobe bronchus. Thus, left upper sleeve lobectomy was carried out. The tumor was 18 x 15 x 14 mm in size and obstructed left upper bronchus with mucoid impaction peripherally. Hystological examination confirmed a diagnosis of low grade malignant mucoepidermoid carcinoma without lymph node metastasis. The patient has been well and free from recurrence for 4 years postoperatively.

Rectal angiolipoma diagnosed after surgical resection: A case report

Angiolipoma is a common benign tumor with a characteristic vascular component that usually occurs in subcutaneous tissue. Although lipomas are frequently encountered at colonoscopy as submucosal tumors, angiolipomas are rarely found in the gastrointestinal tract including the large intestine. Here we report a 77-year old Japanese man who underwent transanal resection of a tumor that was diagnosed tentatively as a leiomyoma. Histologically, the tumor consisted of mature fat cells and blood vessels. Immunohistochemically, the tumor cells were negative for c-kit and HMB-45, which are consistently expressed in tumors such as gastrointestinal stromal tumor and angiomyolipoma. The tumor was therefore diagnosed as an angiolipoma. This is thought to be the first case report of a surgically resected angiolipoma of the rectum.