Background: Carotid ultrasonography can be used as a minimally invasive method of evaluating systemic hemodynamics. We investigated carotid artery flow velocity during one-lung ventilation (OLV) to test our hypothesis that the measured values from carotid ultrasonography would positively correlate with global hemodynamic values, blood pressure, and arterial pressure-based cardiac output (APCO). Methods: The study group comprised 43 consecutive patients who underwent pulmonary surgery between April and September 2017. Common carotid artery measurements on the same side as the non-dependent lung were obtained at 8 time points: before induction of general anesthesia, after tracheal intubation, after positional change, at 15, 30, 60, and 90 minutes after initiation of OLV, and 15 minutes after OLV. We measured peak systolic velocity (PSV) of the common carotid artery. Non-invasive systolic blood pressure (NISBP), non-invasive mean blood pressure (NIMBP), non-invasive diastolic blood pressure (NIDBP), systolic arterial pressure (SAP), mean arterial pressure (MAP), and diastolic arterial pressure (DAP), and APCO were recorded at the same points. Results: PSV increased significantly after a change to the lateral decubitus position. Multiple regression analysis showed PSV was affected by APCO, SAP, age, and history of hypertension (R2 = 0.23). APCO was the most affective factor (β = 8.35, SE = 1.60, t = 5.22, P < 0.0001). The second was SAP (β = ‒0.37, SE = 0.08, t = ‒4.75, P < 0.0001). Conclusions: Carotid ultrasonography may be useful for evaluating systemic hemodynamics during pulmonary surgery.
Objective: We investigated the safety and validity of laparoscopic palliative resection of the primary lesion in cases of Stage IV colorectal cancer. Patients and methods: We retrospectively compared patient characteristics, intraoperative and postoperative courses, and outcomes of patients with a symptomatic primary Stage IV colorectal cancer lesion treated either by laparoscopic surgery (n=41, LA group) or open surgery (n=18, OP group). Results: Symptoms related to the primary lesion, particularly anemia and stenosis, did not differ significantly in prevalence between the two groups. Patients in both groups, but significantly more in the OP group (8 patients [44%] vs. 5 patients [12%], respectively; P=0.013) required bowel decompression. cT4b cancers existed only in the OP group (n=4) (P=0.006). Operation time was significantly longer in the LA group than in the OP group (218.5 [±69.4] vs. 142.5 [±60.5] minutes, respectively; P<0.001). Blood loss volume was significantly lower in the LA group (106.6 [±199.5] vs. 422.5 [±720.9] mL, respectively; P=0.0056). The hospital stay did not differ significantly (19.2 [±10.4] days vs. 20.1 [±6.3] days, respectively). Postoperative chemotherapy was initiated in 36 patients (87%) in the LA group and 13 patients (72%) in the OP group, without a significant difference in number, but the period preceding the chemotherapy was significantly shorter in the LA group (24.5 [±12.1] vs. 35.6 [±25.2] days, respectively; P=0.03). Median survival was significantly longer in the LA group than in the OP group (36 vs. 20 months, respectively; P=0.00167). Conclusion: We conclude that laparoscopic resection of a primary, symptomatic Stage IV colorectal tumor is indicated in patients without bowel obstruction or after bowel decompression and when the rectal tumor has not invaded adjacent organs. Laparoscopic surgery appears to be safer than open surgery in such cases, and chemotherapy can be initiated earlier. The resulting prolonged survival reinforces the validity of this treatment.
Wearable 3-axis accelerometers have been used to analyze kinetic data in patients with motor disability. We aimed to investigate whether the kinetic properties of turnover movements in bed are different between Parkinson’s disease (PD) and hemiplegic stroke using accelerometer-based overnight monitoring. Patients with PD and hemiplegic stroke whose modified Rankin Scale (mRS) score ranged from 1 to 4 were prospectively enrolled. Patients were allocated to the slight disability group (mRS = 1 or 2) and moderate disability group (mRS = 3 or 4). In total, 45 PD patients and 39 hemiplegic stroke patients were enrolled. Total number of turnover movements in bed was similar between the PD and hemiplegic stroke patients. However, the number of turnovers to the affected side was higher in the hemiplegic stroke patients (p = 0.013). Directional preponderance in turnover movement was observed in hemiplegic stroke patients (p = 0.004). Among the hemiplegic stroke patients, all kinetic properties were significantly different between patients with slight disability and moderate disability, but not in the PD patients. Interaction of disease type, i.e.. PD or hemiplegic stroke, on the difference in number of turnover movements between slight and moderate disability was significant (p = 0.003). Our study showed that patients with hemiplegic stroke, but not PD, tend to rotate to their affected side when turning over. Estimation of night time motor disability by mRS scores, i.e.. daytime disability, may be feasible in hemiplegic stroke but not in PD. Thus accelerometer-based overnight kinetic analysis is needed to evaluate night time disability in PD.
Aims: The prognostic impact of in-stent restenosis (ISR) detected upon routine follow-up coronary angiography (RFU-CAG) after percutaneous coronary intervention (PCI) has been unclear. The aim of our study was to compare the clinical outcomes after RFU-CAG between patients with and without ISR detected upon RFU-CAG. Methods and results: A total of 824 patients who underwent PCI and RFU-CAG were analysed. Patients were divided into two groups: those with ISR (n=112) and those without (n=712). Outcomes were compared between patients with ISR and those without detected upon RFU-CAG. The study patients were followed up for a median of 1,323 (709 to 2,130) days. The incidence of a major adverse cardiac event (MACE), defined as all-cause death, any myocardial infarction, stroke, revascularisation for de novo lesion(s) or hospitalisation for heart failure was significantly higher in patients with ISR than in those without (45.5% vs. 24.4%, respectively; p<0.01). Specifically, patients with ISR had a higher incidence of all-cause death (16.1% vs. 6.2%, respectively; p<0.01) and revascularisation for de novo lesion(s) (28.6% vs. 16.2%, respectively; p<0.01). Even after adjustment for possible confounders, ISR detected upon RFU-CAG was an independent predictor for MACE (Hazard ratio: 2.13; 95% confidence interval: 1.55 to 2.92: p<0.01) Conclusions: ISR detected upon RFU-CAG were independently associated with an increased MACE, which was mainly driven by an increased incidence of all-cause death and revascularisation for de novo lesion(s).
The hypothesis of the “development origins of health and diseases” addresses the risk of chronic kidney disease in adulthood. This study aimed to investigate whether prenatal glucocorticoid (GC) administration is associated with fetal kidney maturation. We investigated the effects of prenatal GC administration on the expression of the prorenin receptor (PRR) and extracellular signal-regulated kinase (ERK) required for development in the fetal rat. Dexamethasone (DEX) was administered to pregnant rats for 2 days on days 17 and 18 or days 19 and 20 of gestation, and the kidney tissues of 19- and 21-day fetuses and 1-day-old neonates were analyzed by immunohistochemistry. The viability of human embryonic kidney (HEK)293 cells exposed to DEX for 24 h was determined by MTT assay, and mRNA and protein expressions of the PRR, ERK, and phospho(p)-ERK were analyzed using real-time PCR and Western blotting. ERK-positive areas were observed in primitive perivascular mesenchymal cells and immature glomeruli of the fetal rats. ERK-positive areas were significantly increased in the kidneys of 21-day fetuses compared with those of 19-day fetuses. DEX tended to increase ERK- and p-ERK-positive areas in the kidney of 19-day fetuses, and their levels tended to reach the expression levels of 21-day fetuses. Although the number of PPR-positive areas did not change with DEX administration, they were localized in ureteric bud branches and collecting ducts. DEX also significantly increased the mRNA and protein levels of ERK, p-ERK, and PRR in HEK293 cells. Taken together, these results indicate that prenatal DEX administration may contribute to kidney development through an increase in ERK in the immature fetal rat.
This report documents simultaneous laparoscopic resection of a small bowel gastrointestinal stromal tumor (GIST) and transverse colon cancer that were diagnosed preoperatively and concomitantly. The patient was an 88-year-old man who was referred to us when computed tomography (CT) performed as follow-up for prostate cancer revealed what appeared to be a small bowel tumor. Abnormal tracer uptake in the small bowel and transverse colon was observed on FDG-positron emission tomography/CT images, so we performed lower gastrointestinal endoscopy and discovered a type 2 transverse colon cancer. Laparoscopic partial colectomy and partial small bowel resection were performed for a pathological lesion suspected of being GIST, following which a definitive histopathological diagnosis of transverse colon cancer and small bowel GIST were confirmed. Although GIST can be complicated by other malignant tumors, complication by colorectal cancer is uncommon. A literature search revealed only 8 patients who had undergone simultaneous resection for small bowel GIST and colorectal cancer, and 5 of the 8 were treated by open surgery. There are scattered reports indicating that, as in our case, laparoscopy was performed. We present a rare case of concomitant small bowel laparoscopic resection and review the relevant literature.
Dexmedetomidine is a useful sedative drug that does not cause severe respiratory depression but sometimes causes hypotension or bradycardia. We encountered a case in which asystole occurred during transurethral lithotomy (TUL) that was performed under spinal anesthesia with administration of dexmedetomidine. The patient was a 73-year-old man whose medical history included radiation therapy for prostate cancer and TUL, which had been performed under spinal anesthesia without incident. Results of preoperative examination were unremarkable, and electrocardiography (ECG) showed sinus rhythm with heart rate of 74 bpm. Spinal anesthesia was administered with 3.4 mL of 0.5% hyperbaric bupivacaine, and upper level sensory loss was confirmed at T10. Ten minutes after injection of the bupivacaine, dexmedetomidine was administered for sedation at a loading dose of 3 μg/kg/h over 10 minutes; it was continued at 0.4 μg/kg/h. The patient’s vital signs were stable, but because his SpO2 on room air decreased to 93%, oxygen inhalation was started, and the dexmedetomidine was reduced to 0.2 μg/kg/h. Upon completion of the operation, 115 minutes after the bupivacaine injection, the patient groaned, and almost simultaneously, his heart rate decreased to 30 bpm and progressed to asystole. The dexmedetomidine infusion was stopped, and 0.5 mg of atropine was injected intravenously. Before chest compressions were started, sinus rhythm returned, and the patient regained consciousness. No ECG abnormalities were found. Upper level sensory block at T10 was reconfirmed. The patient was discharged the next day without complications. We reasoned that the asystole resulted as an adverse effect of the dexmedetomidine, from a vagal reflex, and from the spinal anesthesia. Our case illustrates both the importance of avoiding the administration of dexmedetomidine above the recommended dose during spinal anesthesia and the need for careful ECG monitoring and observation of hemodynamics in patients undergoing TUL.