Background: Ultrasonic devices have potential advantages over electrocautery surgical scalpels for muscle dissection, as they eliminate the risk of muscle contraction caused by electric currents. In this study, we investigated the outcomes of using both device types in subpectoral dissection for breast reconstruction. Methods: In this retrospective single-center study, we examined the electronic medical records of female patients with non-recurrent breast cancer who underwent breast reconstruction. The patients were treated with either Harmonic Focus+ Shears (HFS) or a Bovie electrocautery scalpel (BES) between January 2015 and April 2020. The primary clinical outcomes evaluated were total drainage volume, time to drainage tube removal, and operation time. To control for confounding, outcomes were stratified based on the type of tissue expander used—either Mentor or Natrelle. Results: The study included 303 patients; 155 (51.2%) were treated with HFS (mean age, 45.28±7.38 years) and 148 (48.8%) with BES (mean age, 44.41±9.37 years). Within each expander type, the frequency of drainage exceeding 30 cc per day after 21 postoperative days showed no statistical difference between the HFS and BES devices. The operation time was shorter for HFS in both the Mentor (85.13±19.81 minutes vs. 109.56±21.66 minutes, P<0.001) and Natrelle (88.09±20.64 minutes vs. 99.88±22.66, P<0.001) groups. Conclusions When controlling for the type of tissue expander as a confounding factor, HFS was associated with reduced operation time. Furthermore, it demonstrated superior clinical effectiveness compared to BES regarding operator convenience.

Because the most impcetant goal of anesthetic management is patient safety, it is accepted practice that pre-operative patients take nothing by mouth for at least 6 to 8 hours before surgery. However, recent studies have questioned this conventional pre-operative fasting, showing that a fixed volume of water at various time pre-operatively may either improve the characteristics of gastric contents, or else have no effect. The present study was designed to investigate the effect of aUowing patients unlimited access to oral water drinks regardless of time. Fifty-eight fit adult patients scheduled for elective surgery normally requiring endotracheal intubation were recruited. They were randomly allocated to two groups; "Fasters" and "Drinkers", and the effects on plasma osmolality, gastric contents and patient comfort were compared, respectively. This protocol was associated with a reduction in pre-operative anxiety, although the mechanism of this is not clear. No effects were found on plasma osmolality or on the volume or acidity of the gastric contents. No regurgitation occurred during induction and/or emergence in "Drinkers".
Adult ; Anxiety ; Drinking* ; Fasting ; Humans ; Intubation, Intratracheal ; Mouth ; Osmolar Concentration ; Patient Safety ; Plasma ; Water*

Phantom limb pain is a painful sensation from an absent limb. The onset of pain is generally early, with 75% of patients developing pain within the first few days after amputation. The frequency and duration of attacks tend to be reduced with time, although the prevalence and intensity remain constant. We report here a case of a 38-year-old man who exhibited the signs and symptoms of phantom limb pain due to the above-knee amputations of both legs. He was not responded to opioid therapy and a continuous intravenous infusion of ketamine, an N-methyl-D-aspatate receptor antagonist, reduced his severe pain.
Adult ; Amputation ; Extremities ; Humans ; Infusions, Intravenous* ; Ketamine* ; Leg ; Phantom Limb* ; Prevalence ; Sensation

BACKGROUND: In the present study, we examined the effect of morphine on NO- and peroxynitrite-induced cell death using a human neuroblastoma SH-SY5Y cell line which abundantly expresses micro, delta and K-opioid receptors. METHODS: The cultured cells were pretreated with morphine (100 micrometer) and exposed to 3-morpholinosydnonimine (SIN-1, 1mM). Agarose gel electrophoresis of DNA was done with the extracts from SH-SY5Y cells. The cells were treated with selective ligands for opioid receptor subtypes and with PI3-kinase inhibitors. Cell damage was assessed by using an MTT assay. Spectrophotometric absorption spectra were measured from the mixture of morphine (100 micrometer) plus peroxynitrite (1 mM) at room temperature. RESULTS: SIN-1 treated cells showed the occurrence of a specific form of chromosomal DNA fragmentation which pretreatment with morphine inhibited. The selective ligands for opioid receptor subtypes, [D-Ala2, N-Me-Phe4, Gly-ol5]enkephalin (DAMGO, micro-opioid receptor agonist), [D-Pen2,5] enkephalin (DPDPE, delta-opioid receptor agonist) and U-69593 (K-opioid receptor agonist) at a concentration of 10 micrometer did not prevent the cell death induced by SIN-1. Naloxone (20 micrometer) hardly antagonized the effect of morphine in SIN-1-induced cell death. The PI3-kinase inhibitors Wortmannin and LY294002 did not inhibit the action of morphine on apoptotic cell death. In the measurements of spectrophotometric absorption spectra, the peak of the absorbance of the mixture of morphine plus peroxynitrite at 295 300 nm disappeared three minutes after mixing. CONCLUSIONS: The present study showed that morphine protected the human neuroblastoma cell line,SH-SY5Y, from peroxynitrite-induced apoptotic cell death. However, it is suggested that the protective action of morphine is not via the activation of opioid receptors and/or the PI3-kinase pathway but possibly via direct chemical reaction.
Absorption ; Cell Death ; Cell Line ; Cells, Cultured ; DNA ; DNA Fragmentation ; Electrophoresis, Agar Gel ; Enkephalins ; Humans* ; Ligands ; Morphine* ; Naloxone ; Neuroblastoma* ; Peroxynitrous Acid ; Phosphatidylinositol 3-Kinases ; Receptors, Opioid

Injury to a peripheral nerve due to a drug injection is of particular concern, because of both its clinical and medicolegal implications. Among numerous agents, local anesthetic solutions are most frequently injected near the main nerve trunks. In spite of the low incidence of nerve fiber injury associated with these local anesthetic agents, there are several clinical reports of injury. The author experimentally induced injection injury into the rat sciatic nerve with 2% lidocaine HCL and 0.5% bupivacaine. The neurotoxicity of these agents to the peripheral nerve was observed by light and electron microscope. The results are as follows: 1) Some inflammatory round cells and vasodilation were observed in the surrounding loose areolar tissues immediately after injection. No fibroblast or fibrosis was observed on light and electron microscopic examinations. 2) Immediately after injection, the axons were seperated by the splitting of the collagen fibers between the axons. But within one week, the collagen fibers were reunited and compacted. 3) Most cytoplasmic organelles of the axon, including the microtubules and micro filaments, were quite normal and were not altered by injection injury. But the shape of the axon was changed and shrinked to create a large space from the myelin sheath. The above change returned to normal within one week. 4) The Schwann cells, maintained the normal structure of their cytoplasm and nucleus, but some Schwann cells were seperated from the axons, and floated in the collagen tissue. They were reunited with the axons within one week. 5) There were no significant histologic differences between lidocaine and bupivacaine. 6) The above changes were easily reversible and not severe enough to interfere with nerve function permanently. In conclusion, local injection of these agents is very safe to the peripheral nerve.
Anesthetics ; Animals ; Axons ; Bupivacaine ; Collagen ; Cytoplasm ; Fibroblasts ; Fibrosis ; Incidence ; Lidocaine ; Microtubules ; Myelin Sheath ; Nerve Fibers ; Organelles ; Peripheral Nerves* ; Rats ; Schwann Cells ; Sciatic Nerve ; Vasodilation

BACKGROUND: Poly(L-lactic acid) (PLLA) is a biodegradable polymer (BP) that replaces conventional petroleumbased polymers. The hydrophobicity of biodegradable PLLA periodontal barrier membrane in wet state can be solved by alloying it with natural polymers. Alloying PLLA with gelatin imparts wet mechanical properties, hydrophilicity, shrinkage, degradability and biocompatibility to the polymeric matrix. METHODS: To investigate membrane performance in the wet state, PLLA/gelatin membranes were synthesized by varying the gelatin concentration from 0 to 80 wt%. The membrane was prepared by electrospinning. RESULTS: At the macroscopic scale, PLLA containing gelatin can tune the wet mechanical properties, hydrophilicity, water uptake capacity (WUC), degradability and biocompatibility of PLLA/gelatin membranes. As the gelatin content increased from 0 to 80 wt%, the dry tensile strength of the membranes increased from 6.4 to 38.9 MPa and the dry strain at break decreased from 1.7 to 0.19. PLLA/gelatin membranes with a gelatin content exceeding 40% showed excellent biocompatibility and hydrophilicity. However, dimensional change (37.5% after 7 days of soaking), poor tensile stress in wet state (3.48 MPa) and rapid degradation rate (73.7%) were observed. The highest WUC, hydrophilicity, porosity, suitable mechanical properties and biocompatibility were observed for the PLLA/40% gelatin membrane. CONCLUSION PLLA/gelatin membranes with gelatin content less than 40% are suitable as barrier membranes for absorbable periodontal tissue regeneration due to their tunable wet mechanical properties, degradability, biocompatibility and lack of dimensional changes.

PURPOSE: To evaluate the prognostic value of multimodal evoked potentials in predicting both awakening and failure to awake from coma due to cardiac arrest. METHODS: Multimodal evoked potentials composed of somatosensory evoked potentials (SEPs), visual evoked potentials (VEPs) and brainstem auditory evoked potentials (BAEPs) were recorded for 46 patients with anoxicischemic encephalopathy who had coma duration>24 h. Patients with trauma, stroke, malignancy, or age<14 y were excluded. Outcomes were categorized as awakening (GOS 3-5) vs. vegetative state or death (GOS 1-2). RESULTS: Forty-one percent of patients regained consciousness, and 59% died or remained vegetative. Bilaterally absent SEP N20 peaks predicted non-awakening with a sensitivity of 52% and a specificity of 100%. Unilaterally or bilaterally absent BAEP III-V predicted non-awakening with a sensitivity of 12% and a specificity of 100%. Using bilaterally absent SEP N20 peaks, unilaterally or bilaterally absent BAEP III-V, or both of the above predicted non-awakening with a sensitivity of 56% and a specificity of 100%. Bilaterally present SEP N20 peaks predicted awakening with a sensitivity of 100% and a specificity of 63%. However, the combination of bilateral presence of SEP N20 and VEP P100 in predicting awakening increased the specificity to 74%, reaching a sensitivity of 89%, a PPV of 71% and a NPV of 91%. CONCLUSION: Non-awakening in postanoxic coma can be reliably predicted with SEPs and BAEPs. Bilaterally preserved SEPs and VEPs predicted awakening with an accuracy of 80% at 1~4 days after cardiopulmonary resuscitation.
Coma ; Consciousness ; Evoked Potentials ; Evoked Potentials, Auditory, Brain Stem ; Evoked Potentials, Somatosensory ; Evoked Potentials, Visual ; Heart Arrest ; Humans ; Persistent Vegetative State ; Prognosis ; Sensitivity and Specificity ; Stroke ; Survivors

BACKGROUND: The effect of opioids on nitric oxide (NO)- and peroxynitrite-induced neuronal cell death is largely unknown. In the present study, we examined the effect of morphine on NO- and peroxynitrite-induced cell death using a human neuroblastoma SH-SY5Y cell line, which abundantly expresses micro, delta, kappa-opioid receptors. METHODS: The cultured cells were pretreated with morphine and exposed to 3-morpholinosydnonimine (SIN-1) that simultaneously generates NO and superoxide, thus possibly forming peroxynitrite. The cell damage was assessed by using MTT assay and crystal violet staining. Morphological nuclear changes and enzymatic evidences of apoptosis of the cells after exposure to SIN-1 for 24 hours were evaluated by using 4', 6-diamidino-2-phenylindole (DAPI) staining and the measurement of pro-apoptotic protease (caspase-3) activity, respectively. Levels of reduced glutathion (GSH) were measured by monochloronimane (MCB) assay. RESULTS: Pretreatment of SH-SY5Y with morphine significantly inhibited the apoptotic cell death. Morphine also inhibited SIN-1-induced caspase-3 (pro-apoptotic protease) activity in a dose-dependent manner. However, naloxone (20 microM) could not antagonize completely the effect of morphine in SIN- 1-induced cell death. Pre-administered GSH and N-acetylcysteine (NAC) have been found to protect SIN-induced apoptosis, and the neuroblastoma cells treated with morphine had significantly elevated the levels of GSH. CONCLUSIONS: The present study shows that morphine protects the human neuroblastoma cell line SH- SY5Y from peroxynitrite-induced apoptotic cell death through elevated GSH levels. The protective actionof morphine seems to be associated with inhibition of the apoptotic pathway. However, it is suggested that morphine protects the cells possibly via other unknown mechanisms in addition to the activation of opioid receptors.
Acetylcysteine ; Analgesics, Opioid ; Apoptosis* ; Caspase 3 ; Cell Death ; Cell Line ; Cells, Cultured ; Gentian Violet ; Humans* ; Morphine* ; Naloxone ; Neuroblastoma* ; Neurons ; Nitric Oxide ; Peroxynitrous Acid ; Receptors, Opioid ; Superoxides

PURPOSE: Primary hepatic neuroendocrine tumor (PHNET) is a very rare neoplasm, requiring strict exclusion of metastasis from possible extrahepatic primary sites for its diagnosis. METHODS: We reviewed our clinical experience of 13 patients with primary hepatic NET who underwent liver resection from January 1997 to December 2015. RESULTS: The mean age of the 13 patients (8 males and 5 females) was 51.1 ± 12.8 years; the most common clinical manifestation was vague, nonspecific abdominal pain (n = 9). Of them, 11 patients underwent preoperative liver biopsy, 7 of which correctly diagnosed as neuroendocrine tumor (NET). Ten patients underwent R0 resection, and 3 underwent R1 resection. Diagnosis of PHNET was confirmed both immunohistochemically and by absence of extrahepatic primary sites. All tumors were single lesions, with a mean size of 9.6 ± 7.6 cm and a median size of 4.3 cm; all showed positive staining for synaptophysin and chromogranin. During a mean follow-up period of 95.1 ± 86.6 months, 7 patients died from tumor recurrence, whereas the other 6 remain alive to date, making the 5-year tumor recurrence rate 56.0% and the 5-year patient survival rate 61.5%. When confined to R0 resection, 5-year recurrence and survival rates were 42.9% and 70.0%, respectively. Univariate analysis showed that Ki-67 proliferative index was the only risk factor for tumor recurrence. CONCLUSION: PHNET is a very rare tumor with no specific clinical features, and its final diagnosis depends primarily on pathology, immunohistochemistry, and exclusion of metastasis from other sites. Aggressive surgical treatment is highly recommended for PHNET because of acceptably favorable postresection outcomes.
Abdominal Pain ; Biopsy ; Carcinoid Tumor ; Diagnosis ; Follow-Up Studies ; Hepatectomy ; Humans ; Immunohistochemistry ; Liver ; Male ; Neoplasm Metastasis ; Neuroendocrine Tumors ; Pathology ; Prognosis ; Recurrence ; Risk Factors ; Survival Rate ; Synaptophysin

Background: Whether anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody levels post-third coronavirus disease (COVID-19) vaccination correlate with worse outcomes due to breakthrough infection is unclear. We evaluated the association between anti-SARS-CoV-2 antibody levels and symptomatic breakthrough infection or hospitalization during the Omicron surge in kidney transplant recipients. Methods: In total, 287 kidney transplant recipients expected to receive a third vaccination were enrolled between November 2021 and February 2022. The Abbott SARS-CoV-2 IgG II Quant test (Abbott, Chicago, IL, USA) was performed within three weeks before and four weeks after the third vaccination. The incidence of symptomatic breakthrough infection and hospitalization from two weeks to four months post-third vaccination was recorded. Results: After the third vaccination, the seropositive rate and median antibody titer of the 287 patients increased from 57.1% to 82.2% and from 71.7 (interquartile range [IQR] 7.2– 402.8) to 1,612.1 (IQR 153.9–5,489.1) AU/mL, respectively. Sixty-four (22.3%) patients had symptomatic breakthrough infections, of whom 12 required hospitalization. Lower anti-receptor-binding domain (RBD) IgG levels ( < 400 AU/mL) post-third vaccination were a risk factor for symptomatic breakthrough infection (hazard ratio [HR] = 3.46, P < 0.001).Anti-RBD IgG levels < 200 AU/mL were a critical risk factor for hospitalization (HR = 36.4, P = 0.007). Conclusions Low anti-spike IgG levels after third vaccination in kidney transplant recipients were associated with symptomatic breakthrough infection and, particularly, with hospitalization during the Omicron surge. These data can be used to identify patients requiring additional protective measures, such as passive immunization using monoclonal antibodies.