Peri-operative neurological monitoring with electroencephalography and cerebral oximetry: a narrative review.

Surgery and anaesthesia subject the brain to considerable stress in the peri-operative period. This may be caused by potentially neurotoxic anaesthetic drugs, impaired cerebral perfusion and reperfusion injury related to surgery or thromboembolic events. Patient monitoring using electroencephalogram and cerebral oximetry can assist in optimising depth of anaesthesia and assessment of cerebral metabolic activity. However, research findings have been contradictory as to whether these monitors can help ameliorate peri-operative neurocognitive complications. In this narrative review, we will discuss recent evidence in the use of electroencephalography and cerebral oximetry and the underlying scientific principles. It is important to appreciate the raw electroencephalographic changes under anaesthesia and those associated with ageing, in order to interpret depth of anaesthesia indices correctly. Cerebral oximetry is useful not only for the detection of cerebral desaturation but also to identify those patients who are particularly vulnerable to injury, for better risk stratification. An algorithm-based approach may be most effective in managing the episodes of cerebral desaturation.

Influence of propofol-based total intravenous anaesthesia on peri-operative outcome measures: a narrative review.

Propofol-based total intravenous anaesthesia is well known for its smooth, clear-headed recovery and anti-emetic properties, but there are also many lesser known beneficial properties that can potentially influence surgical outcome. We will discuss the anti-oxidant, anti-inflammatory and immunomodulatory effects of propofol and their roles in pain, organ protection and immunity. We will also discuss the use of propofol in cancer surgery, neurosurgery and older patients.

Bifidobacterium Infantis Ameliorates Chemotherapy-Induced Intestinal Mucositis Via Regulating T Cell Immunity in Colorectal Cancer Rats.

BACKGROUND/AIMS: Intestinal mucositis (IM) is a commonly encountered side effect in cancer patients receiving chemotherapy. This study aimed to investigate the effect of Bifidobacterium infantis (B. infantis) in attenuating the severity of chemotherapy-induced intestinal mucositis by regulating the T cell subsets in rats with colorectal cancer (CRC). METHODS: Thirty male Sprague-Dawley (SD) rats were injected dimethyl hydrazine (DMH) subcutaneously for 10 weeks, and then injected SW480 cells in rectal mucosa to create a CRC model, and the rats were randomly divided into three groups: Control group (saline + saline), Chemotherapy group (saline + 5-FU+Oxaliplatin), B. infantis group (B. infantis + 5-FU+Oxaliplatin). IM was evaluated based on diarrhea severity, intestinal villus height, crypt depth, pro-inflammatory cytokines (IL-6, IL-1ß, TNF-α), T cell subsets (CD4+ IL17A+ cells and CD4+ CD25+ Foxp3+ Tregs) and related cytokine profiles. RESULTS: The results showed that the B. infantis group demonstrated a higher body weight (BW) and intestinal villus height and a deeper crypt depth compared to the Chemotherapy group. The level of IL-6, IL-1ß and TNF-α which increased by chemotherapy, was lowered by B. infantis administration. Real time reverse transcription- polymerase chain reaction (RT-PCR) showed B. infantis reduced relative expression of Th17 and Th1 cells related cytokines, and increased relative expression of CD4+ CD25+ Foxp3+ Tregs related cytokines. Furthermore, Flow cytometry analysis showed B. infantis reduced CD4+ IL17A+ cells and increased CD4+ CD25+ Foxp3+ Tregs in mesenteric lymph nodes (MLNs) compared to the Chemotherapy group. CONCLUSION: B. infantis effectively attenuates chemotherapy-induced intestinal mucositis by decreasing Th1 and Th17 response and increasing CD4+ CD25+ Foxp3+ Tregs response.

Surgery for metastatic spine tumors in the elderly. Advanced age is not a contraindication to surgery!

BACKGROUND: With recent advances in oncologic treatments, there has been an increase in patient survival rates and concurrently an increase in the number of incidence of symptomatic spinal metastases. Because elderly patients are a substantial part of the oncology population, their types of treatment as well as the possible impact their treatment will have on healthcare resources need to be further examined. PURPOSE: We studied whether age has a significant influence on quality of life and survival in surgical interventions for spinal metastases. STUDY DESIGN: We used data from a multicenter prospective study by the Global Spine Tumor Study Group (GSTSG). This GSTSG study involved 1,266 patients who were admitted for surgical treatments of symptomatic spinal metastases at 22 spinal centers from different countries and followed up for 2 years after surgery. PATIENT SAMPLE: There were 1,266 patients recruited between March 2001 and October 2014. OUTCOME MEASURES: Patient demographics were collected along with outcome measures, including European Quality of Life-5 Dimensions (EQ-5D), neurologic functions, complications, and survival rates. METHODS: We realized a multicenter prospective study of 1,266 patients admitted for surgical treatment of symptomatic spinal metastases. They were divided and studied into three different age groups: <70, 70-80, and >80 years. RESULTS: Despite a lack of statistical difference in American Society of Anesthesiologists (ASA) score, Frankel neurologic score, or Karnofsky functional score at presentation, patients >80 years were more likely to undergo emergency surgery and palliative procedures compared with younger patients. Postoperative complications were more common in the oldest age group (33.3% in the >80, 23.9% in the 70-80, and 17.9% for patients <70 years, p=.004). EQ-5D improved in all groups, but survival expectancy was significantly longer in patients <70 years old (p=.02). Furthermore, neurologic recovery after surgery was lower in patients >80 years old. CONCLUSIONS: Surgeons should not be biased against operating elderly patients. Although survival rates and neurologic improvements in the elderly patients are lower than for younger patients, operating the elderly is compounded by the fact that they undergo more emergency and palliative procedures, despite good ASA scores and functional status. Age in itself should not be a determinant of whether to operate or not, and operations should not be avoided in the elderly when indicated.

Habituation deficit of auditory N100m in patients with fibromyalgia.

BACKGROUND: Habituation refers to the brain's inhibitory mechanism against sensory overload and its brain correlate has been investigated in the form of a well-defined event-related potential, N100 (N1). Fibromyalgia is an extensively described chronic pain syndrome with concurrent manifestations of reduced tolerance and enhanced sensation of painful and non-painful stimulation, suggesting an association with central amplification of all sensory domains. Among diverse sensory modalities, we utilized repetitive auditory stimulation to explore the anomalous sensory information processing in fibromyalgia as evidenced by N1 habituation. METHODS: Auditory N1 was assessed in 19 fibromyalgia patients and age-, education- and gender-matched 21 healthy control subjects under the duration-deviant passive oddball paradigm and magnetoencephalography recording. The brain signal of the first standard stimulus (following each deviant) and last standard stimulus (preceding each deviant) were analysed to identify N1 responses. N1 amplitude difference and adjusted amplitude ratio were computed as habituation indices. RESULTS: Fibromyalgia patients showed lower N1 amplitude difference (left hemisphere: p = 0.004; right hemisphere: p = 0.034) and adjusted N1 amplitude ratio (left hemisphere: p = 0.001; right hemisphere: p = 0.052) than healthy control subjects, indicating deficient auditory habituation. Further, augmented N1 amplitude pattern (p = 0.029) during the stimulus repetition was observed in fibromyalgia patients. CONCLUSIONS: Fibromyalgia patients failed to demonstrate auditory N1 habituation to repetitively presenting stimuli, which indicates their compromised early auditory information processing. Our findings provide neurophysiological evidence of inhibitory failure and cortical augmentation in fibromyalgia. WHAT'S ALREADY KNOWN ABOUT THIS TOPIC?: Fibromyalgia has been associated with altered filtering of irrelevant somatosensory input. However, whether this abnormality can extend to the auditory sensory system remains controversial. N!00, an event-related potential, has been widely utilized to assess the brain's habituation capacity against sensory overload. WHAT DOES THIS STUDY ADD?: Fibromyalgia patients showed defect in N100 habituation to repetitive auditory stimuli, indicating compromised early auditory functioning. This study identified deficient inhibitory control over irrelevant auditory stimuli in fibromyalgia.

Word use in first-person accounts of schizophrenia.

BACKGROUND: Language use is often disrupted in patients with schizophrenia; novel computational approaches may provide new insights. AIMS: To test word use patterns as markers of the perceptual, cognitive and social experiences characteristic of schizophrenia. METHOD: Word counting software was applied to first-person accounts of schizophrenia and mood disorder. RESULTS: More third-person plural pronouns ('they') and fewer first-person singular pronouns ('I') were used in schizophrenia than mood disorder accounts. Schizophrenia accounts included fewer words related to the body and ingestion, and more related to religion. Perceptual and causal language were negatively correlated in schizophrenia accounts but positively correlated in mood disorder accounts. CONCLUSIONS: Differences in pronouns suggest decreased self-focus or perhaps even an understanding of self as other in schizophrenia. Differences in how perceptual and causal words are correlated suggest that long-held delusions represent a decreased coupling of explanations with sensory experience over time.

Intestinal bacteria induce TSLP to promote mutualistic T-cell responses.

Thymic stromal lymphopoietin (TSLP) is constitutively expressed in the intestine and is known to regulate inflammation in models of colitis. We show that steady-state TSLP expression requires intestinal bacteria and has an important role in limiting the expansion of colonic T helper type 17 (Th17) cells. Inappropriate expansion of the colonic Th17 cells occurred in response to an entirely benign intestinal microbiota, as determined following the colonization of germ-free C57BL/6 or TSLPR(-/-) mice with the altered Schaedler flora (ASF). TSLP-TSLPR (TSLP receptor) interactions also promoted the expansion of colonic Helios(-)Foxp3(+) regulatory T cells, necessary for the control of inappropriate Th17 responses following ASF bacterial colonization. In summary, these data reveal an important role for TSLP-TSLPR signaling in promoting steady-state mutualistic T-cell responses following intestinal bacterial colonization.

Experiment and simulation of resistance of nanoporous dentin biomaterial to CO2 laser irradiation.

The resistance of nanoporous dentin biomaterial to CO2 laser irradiation was investigated by experiment and simulation for potential tooth hypersensitivity treatment. The controlled parameters including laser power of 0.03-0.150 W, scanning speeds of 11.4-34.2 mm/s and focus/defocus modes were used for studying interaction between laser energy and dentin of human tooth. Most of the dentin specimens were etched after CO2 laser irradiation with the power larger than 0.12 W at a scanning speed of 11.4 mm/s. Compared with the simulation results of temperature distribution, the maximum temperature at laser powers from 0.12 to 0.15 W is increased from 1961 to 2245°C, which exceeded the melting point (1570°C) of dentin's main content hydroxyapatite (HA). Increasing scanning speed can reduce the linear density of laser output energy for just locally melting porous microstructure of dentin surface without etching. Varying focus mode can also improve the damage of nanoporous dentin microstructure. At parameters of 0.150 W power and 34.2 mm/s scanning speed under defocus operation, laser treatment was successfully performed on the nano-HA coated dentin with well-molten sealing on tubules of porous microstructure at a simulate surface temperature of about 574°C, which was the potential for dentin hypersensitivity cure application.

Effect of substrate temperature on the in-situ formation of crystalline SiC nanostructured film using ultra-high-vacuum ion beam sputtering.

In this paper, we have investigated the effect of substrate temperature on the in-situ formation of crystalline SiC (c-SiC) nanostructured film using ultra-high-vacuum ion beam sputtering (UHV IBS). The phase transformation, bonding behavior, morphology, composition and interdiffusion of the SiC nanostructured film were examined by X-ray diffraction, Raman spectra, high resolution scanning electron microscopy (SEM) with the attached energy dispersive X-ray detector and Auger electron spectroscopy (AES) depth profile, respectively. The in-situ formation of c-SiC was through interdiffusion and reaction between the sputtered carbon (C) and the crystalline Si (c-Si) substrate at high temperature. The amorphous-like C microstructure is stable up to 500 degrees C and transformed into a new phase of c-SiC together with the remained C at 600 degrees C. Complete C and Si reaction was found at 700 degrees C from Raman spectra without any C peaks. The main diving force for the c-SiC formation is the thermal energy to activate the large interdiffusion between C and c-Si which was detected from AES depth profile. Also, a nanoweb-like morphology of the c-SiC was observed on the surface of film from the SEM image. Therefore, the c-SiC nanostructured film can be obtained at 700 degrees C using in-situ UHV IBS process, which is much lower than conventional CVD c-SiC.

Water-assisted CO(2) laser ablated glass and modified thermal bonding for capillary-driven bio-fluidic application.

The glass-based microfluidic chip has widely been applied to the lab-on-a-chip for clotting tests. Here, we have demonstrated a capillary driven flow chip using the water-assisted CO(2) laser ablation for crackless fluidic channels and holes as well as the modified low-temperature glass bonding with assistance of adhesive polymer film at 300 degrees Celsius. Effect of water depth on the laser ablation of glass quality was investigated. The surface hydrophilic property of glass and polymer film was measured by static contact angle method for hydrophilicity examination in comparison with the conventional polydimethylsiloxane (PDMS) material. Both low-viscosity deionized water and high-viscosity whole blood were used for testing the capillary-driving flow behavior. The preliminary coagulation testing in the Y-channel chip was also performed using whole blood and CaCl(2) solution. The water-assisted CO(2) laser processing can cool down glass during ablation for less temperature gradient to eliminate the crack. The modified glass bonding can simplify the conventional complex fabrication procedure of glass chips, such as high-temperature bonding, long consuming time and high cost. Moreover, the developed fluidic glass chip has the merit of hydrophilic behavior conquering the problem of traditional hydrophobic recovery of polymer fluidic chips and shows the ability to drive high-viscosity bio-fluids.

Hybrid pulse anodization for the fabrication of porous anodic alumina films from commercial purity (99%) aluminum at room temperature.

Most porous anodic alumina (PAA) or anodic aluminum oxide (AAO) films are fabricated using the potentiostatic method from high-purity (99.999%) aluminum films at a low temperature of approximately 0-10 degrees C to avoid dissolution effects at room temperature (RT). In this study, we have demonstrated the fabrication of PAA film from commercial purity (99%) aluminum at RT using a hybrid pulse technique which combines pulse reverse and pulse voltages for the two-step anodization. The reaction mechanism is investigated by the real-time monitoring of current. A possible mechanism of hybrid pulse anodization is proposed for the formation of pronounced nanoporous film at RT. The structure and morphology of the anodic films were greatly influenced by the duration of anodization and the type of voltage. The best result was obtained by first applying pulse reverse voltage and then pulse voltage. The first pulse reverse anodization step was used to form new small cells and pre-texture concave aluminum as a self-assembled mask while the second pulse anodization step was for the resulting PAA film. The diameter of the nanopores in the arrays could reach 30-60 nm.

Predictors of surgical outcome and pathologic considerations in focal cortical dysplasia.

BACKGROUND: Although surgical resection has been an important alternative treatment for patients with intractable epilepsy related to focal cortical dysplasia (FCD), the prognostic relevance of the degree of pathologic severity is controversial and there has been only limited information regarding the prognostic factors involved in the surgical treatment of refractory epilepsy in patients with FCD. METHODS: We undertook the present study to assess whether the pathologic subtypes of FCD affect surgical outcomes in patients with drug-resistant epilepsy. We also studied the prognostic roles of clinical factors and various diagnostic modalities in the surgical treatment. RESULTS: A total of 166 consecutive patients were included. By univariate analysis, incomplete resection of epileptogenic area (p < 0.001), mild pathologic features (p = 0.01), and the presence of secondary tonic clonic seizures (2GTCS) (p = 0.05) were associated with poor surgical outcomes. There was a strong tendency for patients with severe pathologic features to have MRI abnormalities (p < 0.001). Incomplete resection of epileptogenic area (p < 0.001) and mild pathologic features (p = 0.02) were poor independent outcome predictors on multivariate analysis. The results of MRI, scalp EEG, fluorodeoxyglucose-PET, and ictal SPECT were not associated with surgical outcomes. CONCLUSIONS: Our study shows that there is a strong tendency for patients with severe pathologic features to have MRI abnormalities, and patients with incomplete resection, mild pathologic features, or the presence of secondary tonic clonic seizures have a high chance of a poorer surgical outcome.

The clinical outcomes after complete surgical resection of intramedullary cavernous angiomas: changes in motor and sensory symptoms.

STUDY DESIGN: Evaluation of the surgical effects of patients with intramedullary spinal cord cavernous angiomas (CAs). OBJECTIVES: To assess the sensory and motor deficits in the clinical symptoms of patients with intramedullary CAs after complete surgical resection. SETTING: Seoul National University Hospital, Korea. METHODS: The authors reviewed 14 patients with intramedullary spinal cord CAs who underwent surgical resection between 1995 and 2006. The average follow-up duration was 55.0+/-45.1 months. To analyze the changes in the patients' symptoms after surgery, the ASIA (American Spinal Injury Association) and JOA (Japanese Orthopedic Association) scoring systems were used at different time points: preoperative, postoperative and during the final follow-up period. RESULTS: The patients' mean ASIA score at follow-up was increased in comparison to the preoperative score (97.2+/-5.3 vs 95.2+/-7.6, P=0.201), but this difference was not significant. The mean JOA motor score at follow-up was slightly increased in comparison to the preoperative score (7.2+/-1.3 vs 6.8+/-1.3, P=0.107). There was a significant difference between the patients' preoperative and follow-up JOA sensory score (4.3+/-1.0 vs 4.9+/-0.9, P=0.007). The rates of complete resolution of motor and sensory deficits were 45.5% (5/11 patients) and 7.1% (1/14 patients), respectively. CONCLUSION: Although complete surgical resection could improve the clinical symptoms of intramedullary CAs, the sensory deficits usually remain in the long-term period after complete resection.

Foreskin length in uncircumcised men is associated with subpreputial wetness.

This study was performed to identify possible factors associated with penile wetness, defined as the observation of a diffuse homogenous film of moisture on the surface of the glans and coronal sulcus, in men attending a sexually transmitted infection clinic. Genital examination was undertaken in 422 uncircumcised men and any degree of subpreputial wetness observed was recorded. The degree of visibility of the urinary meatus on direct inspection was also assessed. Subjects were asked whether they retracted the foreskin while urinating and how long since they had last passed urine. Penile wetness was observed in 13.0% of the men and was more common in those whose foreskin covered the urinary meatus on direct inspection (17.4% vs. 4.9%) and those with balanitis (33.3%). On multivariate analysis, penile wetness was independently associated with balanitis, non-specific urethritis/chlamydia, reporting sex with another man and having a visible urinary meatus on direct inspection. Penile wetness was not associated with retracting the foreskin while passing urine or duration since last passed urine. Men with a foreskin covering the urinary meatus on direct observation should be advised about the benefits of good genital hygiene if penile wetness was observed.

Mixing behavior of the rhombic micromixers over a wide Reynolds number range using Taguchi method and 3D numerical simulations.

A planar micromixer with rhombic microchannels and a converging-diverging element has been systematically investigated by the Taguchi method, CFD-ACE simulations and experiments. To reduce the footprint and extend the operation range of Reynolds number, Taguchi method was used to numerically study the performance of the micromixer in a L(9) orthogonal array. Mixing efficiency is prominently influenced by geometrical parameters and Reynolds number (Re). The four factors in a L(9) orthogonal array are number of rhombi, turning angle, width of the rhombic channel and width of the throat. The degree of sensitivity by Taguchi method can be ranked as: Number of rhombi > Width of the rhombic channel > Width of the throat > Turning angle of the rhombic channel. Increasing the number of rhombi, reducing the width of the rhombic channel and throat and lowering the turning angle resulted in better fluid mixing efficiency. The optimal design of the micromixer in simulations indicates over 90% mixing efficiency at both Re > or = 80 and Re < or = 0.1. Experimental results in the optimal simulations are consistent with the simulated one. This planar rhombic micromixer has simplified the complex fabrication process of the multi-layer or three-dimensional micromixers and improved the performance of a previous rhombic micromixer at a reduced footprint and lower Re.

Surgical treatment of delayed epilepsy in hemiconvulsion-hemiplegia-epilepsy syndrome.

OBJECTIVE: Hemiconvulsion-hemiplegia-epilepsy (HHE) syndrome is an uncommon consequence of prolonged febrile convulsive seizures in infancy and early childhood. Delayed epilepsy in HHE syndrome is frequently intractable to medical treatment. The present study evaluated the role and prognosis of surgical treatment in patients with delayed epilepsy of HHE syndrome. METHODS: We included 26 consecutive patients who were diagnosed with HHE syndrome and underwent surgical treatment for delayed epilepsy at Seoul National University Hospital. The multidisciplinary presurgical evaluations included brain MRI, video-EEG monitoring, FDG-PET, and ictal SPECT. Anterior temporal lobectomy (ATL), cortical resection, functional hemispherectomy, and callosotomy were performed according to the results of presurgical evaluations. RESULTS: Patients were grouped into either the temporal lobe epilepsy (TLE) group (n = 12) or the neocortical/multifocal epilepsy group (n = 14) according to the results of presurgical evaluations. Patients were included in the TLE group if there was strong evidence that the mesial temporal lobe was the only ictal-onset area. The other patients were included in the neocortical/multifocal group. There were no significant differences in demographic characteristics between the two groups. All patients in the TLE group became seizure-free after ATL, but only four patients became seizure-free, and additional two patients showed improvement after various surgical procedures in the neocortical/multifocal group (p = 0.002). CONCLUSION: Surgical intervention may be helpful in patients with delayed epilepsy in hemiconvulsion-hemiplegia-epilepsy (HHE) syndrome, especially if the mesial temporal lobe appears to be the only epileptogenic area, regardless of the presence of additional abnormalities seen with neuroimaging. Therefore, surgical treatment should be considered for selected patients with delayed epilepsy in HHE syndrome.

A hybrid CO(2) laser processing for silicon etching.

A novel approach to silicon (Si) etching has been demonstrated using glass assisted CO(2) laser processing. Conventional Si etching can be performed by wet etching, dry etching, Nd:YAG or UV lasers. No CO(2) laser was used to etch Si due to the absorption problem. We have etched Si with the assistance of glass beneath the Si. This approach changes light absorption behavior of Si and makes Si be etched from the top surface toward the interface. The new mechanism was discussed in viewpoint of the variation of electronic band structure, surface oxidation and light absorption of Si at high temperature.

Baculovirus transduction of human mesenchymal stem cell-derived progenitor cells: variation of transgene expression with cellular differentiation states.

We have previously demonstrated that baculovirus can efficiently transduce human mesenchymal stem cells (MSCs). In this study, we further demonstrated, for the first time, that baculovirus can transduce adipogenic, chondrogenic and osteogenic progenitors originating from MSCs. The transduction efficiency (21-90%), transgene expression level and duration (7-41 days) varied widely with the differentiation lineages and stages of the progenitors, as determined by flow cytometry. The variation stemmed from differential transgene transcription (as revealed by real-time reverse transcription-polymerase chain reaction), rather than from variability in virus entry or cell cycle (as determined by quantitative real-time PCR and flow cytometry). Nonetheless, the baculovirus-transduced cells remained capable of differentiating into adipogenic, osteogenic and chondrogenic pathways. The susceptibility to baculovirus transduction was higher for adipogenic and osteogenic progenitors, but was lower for chondrogenic progenitors. In particular, the duration of transgene expression was prolonged in the transduced adipogenic and osteogenic progenitors (as opposed to the MSCs), implicating the possibility of extending transgene expression via a proper transduction strategy design. Taken together, baculovirus may be an attractive alternative to genetically modify adipogenic and osteogenic progenitors in the ex vivo setting for cell therapy or tissue engineering.