Short coupling with high burden of atrial ectopy in twenty-four hour holter recording predicts recurrence of atrial arrhythmia after atrial fibrillation ablation

Background

Atrial arrhythmia recurrence is experienced in up to 20% of patients after initially receiving a catheter ablation for atrial fibrillation (AF). Therefore, it is important to define predictors of atrial arrhythmia recurrence. Atrial ectopy (AE) with short coupling interval (S-AE) has been reported to be a trigger of AF. On the other hand, high burden of AE has been reported to be a useful predictor of atrial arrhythmia recurrences after AF ablation. Thus, the combination of the incidence of S-AE and AE burden during a 24-hour Holter recording could be a useful predictor of atrial arrhythmia recurrence after AF ablation.

Purpose

To investigate this hypothesis, we performed a retrospective case-controlled study.

Methods

We enrolled 180 patients who underwent their first catheter ablation procedure for AF and performed a 24-hour Holter recording between 90 to 365 days after their ablation procedure. Patients who performed an additional ablation procedure before the Holter recording were excluded. Finally, we analyzed 173 patients (age: 65±10 years, female: 28.3%, non-paroxysmal: 27.7%). The Holter recordings were analyzed by the same experienced technicians. We defined AE as a narrow QRS complex occurring >25% than prior R-R interval, and S-AE as AE occurring >55% earlier than expected. The relationship between the characteristics of AE during the Holter recording and atrial arrhythmia recurrences was investigated.

Results

The Holter recordings were performed at a median of 103 (IQR: 98–138) days after ablation. The median number of AE were 144 (IQR: 54–699) beats per day, and S-AE was recorded in 49 patients (28.3%). Forty-two patients (24.3%) had a recurrence of atrial arrhythmia during a median 488-day follow up period. Patients with S-AE had a recurrence of atrial arrhythmia more frequently than those without S-AE (44.9% vs 16.1%, p<0.001). We found the cut-off point of AE burden as 241 beats per day by the receiver operating characteristic curve with 74% sensitivity and 70% specificity to predict atrial arrhythmia recurrence. We divided the patients into four groups according to the presence or absence of S-AE and high AE burden. In the Kaplan-Meier analysis, patients with S-AE and high AE burden had the highest atrial arrhythmia recurrence rate (Log-rank test: p<0.001). In the Cox multivariate analysis, S-AE with high AE burden was an independent predictor of atrial arrhythmia recurrence (HR: 4.27, 95% CI: 2.32–7.85, p<0.001).

Conclusion

For AF patients who underwent their first catheter ablation, S-AE (>55% earlier than expected) with high AE burden (>241 beats per day) during the 24-hour Holter recording predicted recurrences of atrial arrhythmia. These results can help to develop follow-up strategies after AF ablation.

Funding Acknowledgement

Type of funding source: None

[Gastrectomy of a GIST with Diaphragmatic Repair Utilizing the Fascia Lata-A Case Report]

A 73-year-old man was admitted with the chief complaint of upper abdominal discomfort.After close examination, he was diagnosed with a huge stomach gastrointestinal stromal tumor(GIST)that occupied the upper left abdomen with a maximum diameter of 150 mm.The patient was referred to our department for surgery.The border between the tumor and spleen was unclear on CT images.As the diaphragm was thinned due to compression by the tumor, gastrectomy with splenectomy and partial resection of the diaphragm was planned.For the diaphragmatic defects, a simple closure was considered at first. However, artifacts have a high risk of infection when the defect holes are too large.Therefore, in this case, we attempted to repair the diaphragm hole with the autologous fascia lata.Intraoperatively, while the tumor was resected with 1 more layer of the diaphragm, the diaphragm itself was thinned, resulting in a defect hole of about 60×80 mm.Therefore, an 80×110mm fascia lata was harvested, and the diaphragm was repaired.Fascia lata can be conveniently harvested as a free graft.In addition, the fascia of the thigh has the advantage of being more resistant to infection than artificial materials.In addition, there was no functional failure due to collection, and special plastic surgery techniques and tools were unnecessary.Thus, it is a useful reconstruction material for general surgeons.Here we report the details of the surgery along with a review of the literature.

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?

Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.

Huge rectovesical fistula due to long-term retention of a rectal foreign body: A case report and review of the literature

•

A long-term retained rectal foreign body is rare, compared to other foreign bodies.

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We describe a foreign body in the rectum for 5 months.

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This resulted in a huge rectovesical fistula and requireing emergency laparotomy.

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These rare foreign bodies could result in a large fistula or diffuse inflammation.

•

In these cases, we should prepare for surgical treatment of multiple pelvic organs.

Introduction

Most patients with foreign bodies in their rectums present to medical institutions within a few days. In this report, we describe a foreign body in the rectum in situ for 5 months that resulted in a huge rectovesical fistula 4 cm in diameter, requiring emergency laparotomy.

Presentation of case

A 59-year-old man, who had undergone rectal foreign body extraction via the anal canal without any complications 7 years previously, presented with abdominal pain and diarrhea. Computed tomography revealed a cup-shaped rectal foreign body and huge rectovesical fistula. We performed an emergency laparotomy. There was no contaminated ascites. The adhesion around the fistula was too stiff to be dissected. We incised the rectal wall, excised the ceramic cup-shaped foreign body, and detected a fistula approximately 4 cm in diameter. We performed sigmoid colostomy, and the incised rectal wall and the bladder wall were sutured, and the residual rectum was supposed to function as a part of the bladder. After the surgery, no severe complications occurred. The patient told us that he inserted the foreign body himself 5 months earlier, and urine had appeared in the stool in the previous month.

Discussion

A long-term retained rectal foreign body is very rare and could create an abnormal huge fistula between the pelvic organs because of prolonged pressure on the walls of the pelvic organs.

Conclusion

In patients with a long-term retained rectal foreign body, we should prepare for surgical treatment of not only the rectum but also the other pelvic organs.

Adult intussusception: a retrospective review

BACKGROUND

Intussusception is common in children but rare in adults. The goal of this study was to review retrospectively the symptoms, diagnosis, and treatment of intussusception in adults.

METHODS

From 1997 to 2013, we experienced 44 patients of intussusception in patients older than 18 years. The patients were divided into enteric, ileocolic, ileocecal, and colocolonic (rectal) types. The diagnosis and treatment of these patients were reviewed.

RESULTS

Of the 44 patients of adult intussusception, 42 were diagnosed with abdominal ultrasonography and abdominal computed tomography. There were 12 patients of enteric intussusception, six patients of ileocolic intussusception, 16 patients of ileocecal type intussusception, and 10 patients of colonic (rectal) intussusception. Among them, 77.3 % were associated with a tumor. Among 12 patients of enteric intussusception, three were associated with a metastatic intestinal tumor, and one was associated with a benign tumor. Among six patients of ileocolic intussusception, two patients were associated with malignant disease. Also, 93.8 % of ileocecal intussusceptions were associated with tumors, 80.0 % of which were malignant. Similarly, 90.0 % of colonic intussusceptions were associated with malignant tumors. Intussusception was reduced before or during surgery in 28 patients. Surgery was performed in 41 patients, and laparoscopy-assisted surgery was performed for ab underlying disease in 12 patients.

CONCLUSIONS

Preoperative diagnoses were possible in almost all patients. Reduction greatly benefited any surgery required and the extent of the resection regardless of the underlying disease and surgical site.

Broad ligament hernia successfully treated by laparoscopy: Case report and review of literature

We report a case of a 36-year-old woman with a history of caesarean section who presented with small bowel obstruction. Abdominal multi-detector CT showed discontinuity of the small bowel near the broad ligament on the left. We made a provisional diagnosis of an internal hernia through a defect in the broad ligament and performed laparoscopic exploration, which revealed a viable ileal loop incarcerated by the broad ligament. Multi-detector CT may be useful for diagnosing this type of defect preoperatively, whereby open surgery can be avoided.

Characterization of ASKP1240, a fully human antibody targeting human CD40 with potent immunosuppressive effects

Blocking the CD40-CD154 interaction is reported to be effective for transplantation management and autoimmune disease models in rodents and nonhuman primates. However, clinical trials with anti-CD154 mAbs were halted because of high incidence of thromboembolic complications. Thus, we generated and characterized a fully human anti-CD40 mAb ASKP1240, as an alternative to anti-CD154 mAb. In vitro ASKP1240 concentration-dependently inhibited human peripheral blood mononuclear cell proliferation induced by soluble CD154. In addition, ASKP1240 did not destabilize platelet thrombi under physiological high shear conditions while mouse anti-human CD154 mAb (mu5C8) did. And ASKP1240 itself did not activate platelet and endothelial cells. In vivo administration of ASKP1240 (1 or 10 mg/kg, intravenously) to cynomolgus monkeys, weekly for 3 weeks, significantly attenuated both delayed-type hypersensitivity and specific antibody formation evoked by tetanus toxoid. The immunosuppressive effect was well correlated with the CD40 receptor saturation. Thus, these results suggest that ASKP1240 is immunosuppressive but not prothromboembolic, and as such appears to be a promising therapeutic candidate for the management of solid organ transplant rejection and autoimmune diseases therapy.

Reappraisal of the vascular anatomy of the colon and consequences for the definition of surgical resection

INTRODUCTION

Databases of information on surgical treatment for colorectal cancer have been created in various countries and data have started to be released. The most important facets of research for statistical processing include the methodology and firm definitions of content. However, for trials involving colorectal cancer, the applicable terminology has not been defined, and much bias is frequently encountered. Starting from definitions of the colon and vascular system of the colon, we propose definitions of surgical procedures for colorectal cancer.

METHODOLOGY

This paper reviews the colon segments and vascular anatomy of the colon. If surgical treatment of colon cancer is considered from this perspective, we can see that definitions for these surgical procedures are lacking. The definition of surgical treatment would also allow clarification of the range of lymph node dissection. In general, surgical procedures and the area of surgical lymph node dissection are both defined according to the basic structure of the associated arteries. However, the existing descriptions are not based on a definition of the arteries. We therefore tried to establish the most useful nomenclature for the arterial system of the large intestine for colorectal surgeons and reviewed the frequency of important arterial variations. Using the resulting definitions, we provided consistent definitions for colon cancer surgery.

CONCLUSION

The segments of the colon need to be defined. In surgery, procedures are performed using the arteries as indicators, so vessels originating from the superior and inferior mesenteric arteries are referred to as arteries, with others are referred to as branches. Surgical treatment of colon cancer can be defined from the relationship between these arteries. For the first time, this may allow proper application of statistics for the treatment of colon cancer.

Small bowel metastasis of uterine cervical adenocarcinoma

A few cases of small bowel metastasis from uterine cervical cancer have been previously reported. All reported cases were connected to squamous cell carcinoma, while none were associated with cervical adenocarcinoma. This report is of a rare case of cervical adenocarcinoma that haematogenously metastasised to the small intestine, and which caused a perforation and small bowel obstruction metachronously. An 84-year-old woman was admitted to our hospital with vaginal bleeding. She was diagnosed with FIGO stage III cervical adenocarcinoma by imaging and pathohistological examinations. Three months after receiving radiation therapy to control the bleeding, surgery was performed twice; the first operation for small bowel perforation and the second for small bowel obstruction. She was then diagnosed with haematogenous metastasis of cervical adenocarcinoma to the ileum according to the operative, histopathological and immunopathological findings.

Differentiating a large abdominal cystic lymphangioma from multicystic mesothelioma: report of a case

We report a case of retroperitoneal cystic lymphangioma in a 30-year-old woman who presented with abdominal distention and pain. Imaging studies revealed a large, thin-walled multicystic mass occupying the whole abdomen. Based on a preoperative diagnosis of multicystic mesothelioma, we performed laparotomy, which revealed a tumor arising from the gastropancreatic ligament in the posterior wall of the omental bursa. We resected the tumor completely, without the adjacent viscera. The final pathological diagnosis was cystic lymphangioma, based on the immunohistochemical findings of positive CD31 and CD34 expression, the presence of smooth muscle confirmed by smooth muscle antigen and desmin, and negative calretinin, WT-1 and cytokeratins 5/6 expression. Multicystic mesotheliomas and cystic lymphangiomas are so similar in morphology that immunohistochemical staining should be fully utilized to differentiate them.

Pinch-off syndrome: transection of implantable central venous access device

As the population of people with cancer increases so does the number of patients who take chemotherapy. Majority of them are administered parentally continuously. Implantable central venous catheter device is a good choice for those patients; however, severe complication would occur concerning the devices. Pinch-off syndrome is one of the most severe complications. The authors report a severe case of pinch-off syndrome. The patient with the implantable central venous device could not take chemotherapy because the device occluded. Further examination revealed the transection of the catheter. The transected fragment of the catheter in the heart was successfully removed by using a loop snare placed through the right femoral vein.

Pinch-off syndrome: transection of implantable central venous access device

As the population of people with cancer increases so does the number of patients who take chemotherapy. Majority of them are administered parentally continuously. Implantable central venous catheter device is a good choice for those patients; however, severe complication would occur concerning the devices. Pinch-off syndrome is one of the most severe complications. The authors report a severe case of pinch-off syndrome. The patient with the implantable central venous device could not take chemotherapy because the device occluded. Further examination revealed the transection of the catheter. The transected fragment of the catheter in the heart was successfully removed by using a loop snare placed through the right femoral vein.

Quality of life in patients with chronic anal fissure after topical treatment with diltiazem

AIM: To assess the physical and mental health of fissure patients before and after topical treatment with diltiazem.

METHODS: Consecutive patients were enrolled prospectively into the study. Quality of life was measured with the short-forum 36 health survey (SF-36) before and after 6-wk treatment with diltiazem. Patients scored symptoms of pain, bleeding, and irritation using numeral rating scales at the initial and follow-up visits. Fissure healing was assessed and side effects were noted.

RESULTS: Fissures healed in 21 of 30 (70%) patients. There were significant reductions in the scores of pain, bleeding, and irritation after 1 wk of treatment, respectively. Four patients experienced perianal itching and one patient reported headache. When measured at baseline, pain and irritation showed a negative impact on two of the eight subscales on the SF-36, respectively (bodily pain and social functioning for pain; vitality and mental health for irritation). Repeating the SF-36 showed an improvement in bodily pain (P = 0.001). Patients whose fissures healed reported an improvement in bodily pain, health-perception, vitality, and mental health (P < 0.05).

CONCLUSION: Successful treatment of chronic anal fissure with topical diltiazem leads to improvement in health-related quality of life.

Granular cell tumor of the common bile duct: A Japanese case

Granular cell tumor (GCT) of the biliary system is rare. It is reported that it occurs more commonly in young black women. We report here our seldom experience of a Japanese case in whom icterus was found as a first symptom just after a caesarean operation. A 36-year-old Japanese woman developed icterus after delivery by the Caesarean operation. A surgical operation was performed without can deny that there was a tumor-related change in a bile duct as a result of examination for various images. As a result of pathological evaluation, GCT was diagnosed. By the preoperative organization biomicroscopy result, it was not able to be attachd a right diagnosis. It was thought that this tumor, although rare, should be considered as one of the causes of biliary stenosis in the younger population.

Randomized controlled trial of bipolar diathermy vs ultrasonic scalpel for closed hemorrhoidectomy

AIM: To compare hemorrhoidectomy with a bipolar electrothermal device or hemorrhoidectomy using an ultrasonically activated scalpel.

METHODS: Sixty patients with grade III or IV hemorrhoids were prospectively randomized to undergo closed hemorrhoidectomy assisted by bipolar diathermy (group 1) or hemorrhoidectomy with the ultrasonic scalpel (group 2). Operative data were recorded, and patients were followed at 1, 3, and 6 wk to evaluate complications. Independent assessors were assigned to obtain postoperative pain scores, oral analgesic requirement and satisfaction scores.

RESULTS: Reduced intraoperative blood loss median 0.9 mL (95% CI: 0.8-3.7) vs 4.6 mL (95% CI: 3.8-7.0), P = 0.001 and a short operating time median 16 (95% CI: 14.6-18.2) min vs 31 (95% CI: 28.1-35.3) min, P < 0.0001 was observed in group 1 compared with group 2. There was a trend towards lower postoperative pain scores on day 1 group 1 median 2 (95% CI: 1.8-3.5) vs group 2 median 3 (95% CI: 2.6-4.2), P = 0.135. Reduced oral analgesic requirement during postoperative 24 h after operation median 1 (95% CI: 0.4-0.9) tablet vs 1 (95% CI: 0.9-1.3) tablet, P = 0.006 was observed in group 1 compared with group 2. There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications.

CONCLUSION: Bipolar diathermy hemorrhoidectomy is quick and bloodless and, although as painful as closed hemorrhoidectomy with the ultrasonic scalpel, is associated with a reduced analgesic requirement immediately after operation.

The future of NOTES from the conservative point of view

Recently, the unfamiliar term "natural orifice transluminal endoscopic surgery (NOTES)" appeared in my field. Actually, I am hesitant to accept this technique in my surgical practice. In this paper, I will review some references and try to establish my position toward NOTES. The author has been skeptical and ironical about the clinical potentiality of NOTES since hearing the presentation about NOTES for the first time. I have been concerned about making a puncture in the gastrointestinal tract as an old surgeon who believes that intestinal injury must not occur during surgery. However, recent advances in the research of NOTES are changing my stubborn belief. What I have to do is to avoid interrupting or disturbing young surgeons' challenges to develop NOTES. I remember that some senior surgeons were against us when we started laparoscopic surgery around 1990. Senior surgeons and physicians must be generous, considerate, helpful and supportive to our followers. I have been enthusiastic about the development and spread of laparoscopic surgery since 1987 and have been doing various surgical procedures myself, including those involving the biliary tract, pancreas, spleen, upper and lower gastrointestinal tract, adrenal, kidney and gynecologic organs. Recently, the unfamiliar term "NOTES" appeared in my field. Actually, I am hesitant to accept this technique in my surgical practice. In this paper I will review some references and try to establish my position toward NOTES.

Octopus gonadotrophin-releasing hormone: a multifunctional peptide in the endocrine and nervous systems of the cephalopod

The optic gland, which is analogous to the anterior pituitary in the context of gonadal maturation, is found on the upper posterior edge of the optic tract of the octopus Octopus vulgaris. In mature octopus, the optic glands enlarge and secrete a gonadotrophic hormone. A peptide with structural features similar to that of vertebrate gonadotrophin-releasing hormone (GnRH) was isolated from the brain of octopus and was named oct-GnRH. Oct-GnRH showed luteinising hormone-releasing activity in the anterior pituitary cells of the Japanese quail Coturnix coturnix. Oct-GnRH immunoreactive signals were observed in the glandular cells of the mature optic gland. Oct-GnRH stimulated the synthesis and release of sex steroids from the ovary and testis, and elicited contractions of the oviduct. Oct-GnRH receptor was expressed in the gonads and accessory organs, such as the oviduct and oviducal gland. These results suggest that oct-GnRH induces the gonadal maturation and oviposition by regulating sex steroidogenesis and a series of egg-laying behaviours via the oct-GnRH receptor. The distribution and expression of oct-GnRH in the central and peripheral nervous systems suggest that oct-GnRH acts as a multifunctional modulatory factor in feeding, memory processing, sensory, movement and autonomic functions.

[A case of multiple lung metastases of sigmoid colon cancer responding well to oral UFT+leucovorin therapy]

Chemotherapy combining 5-fluorouracil (5-FU) with leucovorin is now used as a standard regimen for chemotherapy of inoperative, recurrent or distantly-metastasized colorectal carcinoma. We recently treated a patient with multiple metastases of sigmoid colon cancer by sigmoidectomy and oral drug therapy using a combination of Uzel (dl-leucovorin) and UFT (uracil and tegafur). Three courses of this therapy were administered, with each course consisting of treatment for 4 consecutive week (UFT 400 mg/day, Uzel 75 mg/day) and a one week interval between successive courses. The therapy resulted in marked reduction of tumor and this response was rated as PR (partial response). The lower lobe of the right lung, which showed the largest tumor (34.5 x 35.7 mm), was resected, and the upper lobe of the same lung, showing a small metastastic tumor (4.4 x 4.6 mm), was partially resected. Oral chemotherapy, which had begun before surgery, was continued after lobectomy and partial pneumonectomy. To date (January 15, 2005), the patient has received 5 courses of this therapy and has shown no signs of tumor exacerbation. Because this therapy has allowed satisfactory control of metastatic tumor for about one year since surgery without causing any adverse reaction or requiring re-hospitalization, it is fair to say that the therapy has successfully maintained the quality of life (QOL) of this patient.

Techniques for difficult cases of laparoscopic cholecystectomy

Our basic techniques for the management of difficult cases of laparoscopic cholecystectomy (LC) are presented in this article. If access to Calot's triangle cannot be gained safely, dissection should be started at the fundus or body of the gallbladder (GB), rather than the neck (fundus-first method). In cases with a short and wide cystic duct, a transfixing suture should be applied for ligation instead of clipping. EndoGIA is useful for ligating and transecting this case to avoid a subsequent stricture caused by normal method of ligation. Intraoperative cholangiography should be performed near the neck of the GB in cases in which orientation is lost during dissection. More dissection should be performed in the direction of the junction of the bile ducts after orientation is regained. In cases with GB filled with stones accompanied by severe fibrosis, part of the GB is incised to remove the stones and expose the lumen of the GB. Confluence stones can be removed by placing an incision on the GB side of the junction of the duct. The incised part is closed with suture. A cystic tube (C-tube) is placed in the common bile duct through the cystic duct for decompression. In more difficult cases in which dissection cannot be started safely at any location, the body and the fundus of the GB are excised, and a drain is placed at the neck of the GB. Dissection can be carried out from the main surgeon's or the assistant's side depending on the situation, and cooperation between the two surgeons is mandatory to achieve safe LC in difficult cases. When performing the LC, one must have a low threshold for converting to open surgery if injuries cannot be managed safely.

Laparoscopic pancreatic surgery: its indications and techniques: from the viewpoint of limiting the indications

Indications in the field of pancreatic surgery should be limited considering the technical difficulties and the characteristics of pancreatic diseases. Benign or low-grade malignant tumors, including pseudocysts, islet tumors, and cystic tumors, are indications for distal pancreatectomy. Islet tumors such as insulinomas are good candidates for this procedure when they are located near splenic vessels or the main pancreatic duct and enucleation is considered inappropriate. Techniques of laparoscopic distal pancreatectomy with/without splenectomy and laparoscopy-assisted distal pancreatectomy indicated in low-grade malignant tumors such as mucinous cystadenoma are described. Insulinoma is one of the best candidates for enucleation because many of the cases are solitary and benign. The technique of enucleation is also described.

Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis

BACKGROUND

This meta-analysis was performed to determine the degree to which improvements in open hernia repair (OHR) in the last decade have altered the relative benefit of laparoscopic hernia repair (LHR).

METHODS

Twenty-seven comparative trials including 4,688 randomized patients were evaluated.

RESULTS

Within the control OHR, patients with routine mesh repair returned to work earlier than a sutured repair (16.4 versus 27.3 days, P = 0.010). During the study period, the increased use of mesh in OHR (3 of 12 initially versus 9 of 15 subsequent studies) was associated with an earlier return to work (25.9 to 16.8 days, P = 0.017); there was no significant improvement with corresponding LHR.

CONCLUSIONS

Although LHR was associated with an earlier return to work compared with conventional sutured OHR, more recent mesh OHRs provide equivalent outcomes but at lower costs and potentially less severe complications, supporting an open technique using preperitoneal mesh prostheses as the optimal hernia repair.

The first isolable pentacoordinate 1,2 lambda 5-azaphosphetine: synthesis, X-ray crystallographic analysis, and dynamic behaviour

Cycloaddition reaction of an iminophosphorane bearing the Martin ligand with an alkyne gave the first stable 1,2 lambda 5-azaphosphetine, whose structure was determined by X-ray crystallographic analysis, and variable temperature NMR spectroscopy revealed the existence of equilibrium with the corresponding alpha-iminoalkylidenephosphorane.

Synthesis, crystal structure, and thermolysis of the first tetracoordinate 1lambda4,2-selenazetidines: aziridine formation reaction from a four-membered heterocycle bearing highly coordinate selenium

[structure: see text]. The first tetracoordinate 1lambda4,2-selenazetidines were synthesized by taking advantage of the Martin ligand and characterized by X-ray crystallographic analysis. The selenazetidines gave the corresponding aziridine and the cyclic selenenate on their thermolysis, which indicates the possibility that a highly coordinate 1,2-heterachalcogenetane may provide the corresponding heteracyclopropane regardless of the heteroatoms.

The time-course of acid excretion, levels of fluorescence dependent on cellular nicotinamide adenine nucleotide and glycolytic intermediates of Streptococcus mutans cells exposed and not exposed to air in the presence of glucose and sorbitol

The aim of this study was to examine glucose and sorbitol metabolism in Streptococcus mutans cells exposed and not exposed to air at the coexistence of these compounds by measuring acid excretion, levels of fluorescence dependent on cellular NADH and glycolytic intermediates. An aliquot of bacterial cells grown under strictly anaerobic conditions (anaerobic cells) was exposed temporarily to air (aerobic cells). When glucose was added to the anaerobic cells metabolizing sorbitol, the acid excretion was increased. The level of NADH decreased initially and then increased to the higher plateau level than that during glucose metabolism. The aerobic cells neither metabolized sorbitol nor contained glycolytic intermediates. However, 2 min after glucose was added in the presence of sorbitol, the acid excretion was started slowly and the intermediates appeared. The level of NADH was decreased at first and then increased. These results suggested that the anaerobic S. mutans cells metabolized glucose and sorbitol simultaneously, and that in the presence of sorbitol the aerobic cells could start to metabolize glucose 2 min after glucose was added, as the intermediates (phosphoenopyruvate potential) for the glucose transport were accumulated.

[A study of institutional medical care of female victims of sexual assault and violence]

OBJECTIVE

The purpose of the study is to clarify the present situation of medical care for victims of sexual assault and violence. Medical facilities in two wards in Tokyo were studied in order to know what problems regarding medical care exist and how to support female victims.

METHODS

In April 1998, we distributed questionnaires to 338 medical facilities covering all the clinics and hospitals, that had more than only otorhinolaryngology and ophthalmology, in Kouto-ku and Sumida-ku, Tokyo. The questionnaire included questions about individual experience of consulting with sexual assault and violence against women, the number of victims in the last year, and their understandings for victims.

RESULT

1) 76 of the respondents completed the answer sheet by themselves. The mean age of the subjects was 57.4 years old, 16.3% of them had seen sexual assault victims, and about 36.8% had cared for victims of violence. 2) 67 victims of sexual assault and violence were reported in the previous year. 36% of victims of sexual assault were reported by facilities related to obstetrics, and 85% of victims of violence were reported by general medical facilities. 3) As for understandings for victims, those who thought the victims were responsible for the sexual assault also regarded violence as caused by carelessness of victims.

CONCLUSION

Medical facilities may be an important place to care for victims of sexual assault and violence against women. There are few data available as to how many women suffer from sexual violence. This study showed for the first time the reality of sexual assault and violence from the viewpoints of medical facilities in Japan, although it had some limitations. It is necessary for more discussion about roles of medical care for female victims of sexual assault and violence.

Tritium incorporation into functional materials by applying OT-for-OH exchange reaction

In order to reveal (1) the behavior of the tritium-labeled hydroxyl group (i.e., OT group) and (2) the effect of temperature on the dissociation equilibrium of tritiated water, the OT-for-OH exchange reaction in a homogeneous system was observed (1) using ion-exchange resins and HTO water, and (2) using hydrogen oxides and HTO water. Consequently, the following four conclusions were obtained: (1) The OT-for-OH exchange reaction occurred between each anion-exchange resin (or each metal hydroxide) and HTO water. (2) The higher the temperature is, the smaller the activity of both anion-exchange resin and metal hydroxide will be, and the activity of cation-exchange resin is large when the temperature is high. (3) The larger the degree of crosslinking in each Biorad AG1 resin is, the lower the activity of the resin will be. (4) The exchange rate for the OT-for-OH exchange reaction is small when the electronegativity of the metal ion in the metal hydroxide is large.

Direct transfer of bovine embryos frozen-thawed in the presence of propylene glycol or ethylene glycol under on-farm conditions in an integrated embryo transfer program

An integrated bovine embryo transfer program was conducted in collaboration with 11 Japanese prefectural livestock experiment stations. The program was conducted to evaluate the practicability of the direct transfer method for bovine embryos frozen-thawed in the presence of propylene glycol (PG) or ethylene glycol (EG) under on-farm conditions. Embryos at the compacted morula to expanded blastocyst stages were collected from superovulated donors on Day 7 or 8 after estrus and equilibrated in 1.6 M PG or 1.8 M EG in Dulbecco's phosphate-buffered saline (DPBS) supplemented with 20% heat-inactivated calf serum. Embryos were then loaded individually into a 0.25-ml straw and placed directly into a cooling chamber of a programmable freezer precooled to -7 degrees C. After 2 min, the straw was seeded, maintained at -7 degrees C for 8 min more, and then cooled to -30 degrees C either at 0.3 degree C/min or 0.5 degree C/min before being plunged into liquid nitrogen. Embryos at the same stages were also frozen in the presence of 1.4 M glycerol (GLY) by a conventional method, which served as a control. The frozen embryos were thawed by allowing the straws to stand in air for 5 to 10 sec and then immersing them in a 30 degrees C water bath. Embryos frozen-thawed in the presence of PG or EG were nonsurgically transferred into the uterine horn without diluting the cryoprotectant. Embryos frozen-thawed in the presence of GLY were nonsurgically transferred after removing GLY either by the stepwise method (GLY-I) or by in situ dilution with 0.3 M sucrose solution (GLY-II). A total of 1,273 (PG: 400, EG: 418, GLY-I: 177, GLY-II; 278) frozen-thawed embryos was transferred into recipients, yielding 545 pregnancies (overall: 42.8%, PG: 36.0%, EG; 44.7%, GLY-I; 48.6%, GLY-II; 46.0%). The pregnancy rate with PG was significantly lower than that with EG or GLY-II (P < 0.05). The pregnancy rate was affected by the type of cryoprotectant, the region where the embryo transfer program was carried out, the developmental stage of the embryos, the parity of the recipients, and corpus luteum (CL) quality of the recipients. There were no differences in rates of abortion and stillbirth among the 3 cryoprotectants. The present study demonstrates that EG can be effectively used as a cryoprotectant for freezing and direct transfer of bovine embryos, and that the direct transfer method is applicable under on-farm conditions.

[A study on autonomy in hospital-based midwifery practices in New York]

The purpose of this study was to identify the reality and understanding of American midwives in hospitals by focusing on autonomy as a profession. The method was conducted by interview and participant observation to 13 nurse-midwives in four hospitals. The data indicated that midwifery services belonged to obstetric and gynecology departments in three hospitals. Nurse-midwives had midwifery clinics and had responsibility to normal women antepartally, intrapartally, and postpartally. They distinguished midwifery as a profession from medicine and nursing. However, some midwives stated conflicts with doctors and nurses. Most of them had been motivate to be a midwife directly. It was said that nurse-midwives in New York City have struggled to gain autonomy in hospital systems.

[Participation in the IEC Workshop on Adolescent Sexual Health--a challenge to protect reproductive health/right in Latin America and Caribbean Region]

In order to explore the possibility of new global activity in nursing/midwifery to be performed by the WHO Collaborating Center for Nursing Development in Primary Health Care at St. Luke's College of Nursing, the center sent two faculty members to attend the IEC Workshop on Adolescent Sexual Health held in November 1996 in Mexico. The two representatives took part as resource persons and reported to the workshop on the activities of nurses and midwives for adolescent sexual health in Japan. During the session, they obtained information on the actual situation of adolescent sexual health in Latin America and Caribbean region and the novel strategies which were carried out in cooperation between governmental and non governmental organizations. The workshop also provided a good opportunity for international communication and information exchange with health workers in the region about adolescent sexual health. By participating in the workshop, we obtained first-hand information on various aspects of cooperation in international health.

[An experiment in a new method of nursing education--the problem-based learning for prenatal nursing]

At the opening of lectures in 1995 on the Science of maternity Nursing in the Special Subjects of Nursing, a problem-based learning was tried as a new educating method in the unit of "Prenatal Nursing." In the present paper, reviewing the introduction/implementation of the method, subjects in the future are described. This process contained two major flows, one was the training of tutors in problem-based learning, including participating the workshop held at McMaster University, and the other was the preparation for the class at the introduction of the new educational method, such as the overall subject composition and the development of teaching materials of prenatal nursing and resources, etc. according to the procedures of the problem-based learning. As the results of the actual implementation, various different reactions in comparison with the lecture method were observed both in tutors and students. As the subjects hereafter, the following three points have been clearly elucidated, that is, in order to proceed the problem-based learning under the present condition that it is not in the comprehensive curriculum, to prevent the overload and conflict in the student learning, considering and adjusting the relationship with contents and methods of concurrent subjects and units, to establish the system for tutorial assessment and evaluation, and to insure tutors and fulfill their training system.

[Tissue concentration of 5-FU after intra-operative arterial infusion]

The aim of this study was to measure the tissue concentration of anti-cancer agents administered by arterial infusion. After the abdominal cavity was opened, 250 mg of 5-FU diluted in 20 ml saline was infused into the feeding artery in 16 patients with colonic cancer. After the affected lesion was resected, specimens were obtained at the tumor, at sites 5 and 10 cm from the center of the tumor, and at the adjacent nodes. The concentration of 5-FU was higher in the tumor and the adjacent lymph nodes than in the normal colon near the lesion. This suggests that 5-FU has a more favorable distribution profile in tumor tissue than in normal tissue. Patients with a high concentration of 5-FU in the tumor also demonstrated high levels in the other tissue. Blood flow volume and the length of time between the injection of 5-FU and harvest of the specimen may account for differences in the tissue concentration of the agent after administration of the same dose.

[A case report of far advanced gastric cancer with multiple liver metastasis (H3) treated with transarterial intermittent chemotherapy and intradermal administration of low molecular lipopolysaccharide (LPSp) extracted from Pantoea agglomerans]

A case of far advanced gastric cancer with multiple liver metastasis (H3) was treated with transarterial intermittent chemotherapy (5-FU: 250 mg/week, Farmorubicin: 10 mg/4 weeks, MMC: 4 mg/2 weeks) and intradermal administration of low molecular lipopolysaccharide (LPSp) extracted from Pantoea agglomerans. The CT examination and endoscopy showed regression of the tumor and the patient was discharged from the hospital. LPSp was given at the concentration of 0.1 microgram initially, and the dose was gradually increased. Finally, the dose of LPSp was increased up to 70 micrograms. No serious side effect except fever was observed. The serum TNF-alpha levels were elevated and, histologically, CD 8(+) lymphocyte dominantly infiltrated around the tumor. These findings clearly indicated the immunological anticancer effect of LPSp. Intradermal administration of LPSp is a promising new adjuvant therapy to improve QOL without serious side effect.

[Correlation between tissue blood flow and tissue concentration of 5-FU and its metabolite in hepatic metastasis model for rats]

Correlation between 5-FU (20mg/kg) administrated via the peripheral vein and tissue concentration of its metabolite was studied in hepatic metastasis model prepared for rats. The measurement of tissue samples collected 30 min. after the 5-FU administration suggested a possible negative correlation between the F-dUMP concentration and the blood flow in the normal hepatic tissue of the control group and the tumor tissue in the metastasis group. In administering 5-FU, a time-dependent anticancer drug, to the tumor rich in the tissue blood flow, washing-off effect of the drug by blood outflow cannot be neglected. Some device of prolonging the exposure time of anti-cancer agent to the tumor tissue will be necessary.

Prevention of laparoscopic surgeon's thumb

Laparoscopic surgery is being used in an increasing number of operations today. We have been performing various types of laparoscopic techniques in our department. A problem we sometimes have encountered involves a ring of pressure that develops around the surgeon's thumb at the end of the procedure, which is accompanied by an area of paresthesia in the distribution of the lateral digital nerve. We report our own experience and a small review of the literature.