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Due to the increasing demand for higher performance, greater flexibility, smaller size, and lighter weight in mobile and wearable electronic products, there have been growing needs of various electronic packaging products and fine-pitch interconnection technologies. To realize various state-of-art mobile and wearable electronic products, fine pitch and flexible packaging & interconnection technologies are needed. As one of the promising fine pitch and flexible packaging and interconnection technologies, conductive adhesive films materials such as ACFs(Anisotropic Conductive Films) and NCFs(Non Conductive Films) are widely used now.In general, ACFs have two technical limitations such as (1) ultra-fine pitch shortage free interconnection and (2) higher current handling capability. For (1) ultra-fine pitch applications without electrical shortage, new concept of Nano-fiber ACFs and APL(Anchoring Polymer Layer) ACFs have been successfully invented by KAIST both for less than 20 micron pitch COG(Chip On Glass), COP(Chip On Polymer). and COF(Chip On Flex). And they can be also used for less than 50 micron pitch FOF(Flex On Flex) and FOB(Flex On Board) applications. In addition, for (2) higher current handling capability applications, new solder ACFs have been also introduced by KAIST to replace the conventional metal particles based ACFs interconnection. By solder ACFs, 30% low contact resistance, 4 X higher current handling capability, and excellent reliability were successfully achieved compared with conventional ACFs. Furthermore, ACFs materials-based packaging and interconnection method can provide the flexible interconnect solution for OLED(Organic LED) COP and COF/CIF(Chip In Flex) packages to realize wearable electronic products.Recently the 3-D die chip stacking using the Through silicon via (TSV) technology has been widely used for stacking memory and ASIC chips. In the 3D-TSV vertical interconnection, Cu pillar/Sn-Ag eutectic solder bump is one of the promising bonding method. After the 3D-TSV chips are interconnected with the bumps, the gap between stacked chips should be filled with underfill materials. However, capillary flow underfill between 3D-TSV stacked chips become difficult because of increased chip/wafer area, decreased gap height, and multiple chip/wafer stacking. Therefore, new bonding method using NCFs materials, which performs both Cu-pillar/Sn-Ag flip chip bump to metal pads interconnection and underfils at the same time has been extensively used.In this presentation, the ACFs materials for ultra-fine pitch and higher current carrying interconnection and the NCFs for 3D-TSV chip stacking applications will be introduced.

Due to the increasing demand for higher performance, greater flexibility, smaller size, and lighter weight in mobile electronic products, there have been growing needs of wearable electronic products in near future. Wearable watches, glasses, wrist bands, shoes, and clothes have been recently introduced in the market. To realize wearable electronic products, there should be four core electronic hardware technologies — (1) flexible semiconductor, (2) flexible display, (3) flexible battery and (4) flexible packaging & interconnection technologies. In the flexible semiconductor devices, ICs are thinned down to several hundred nanometer thickness, and then transferred to a polymer film. However, much more development is still needed for the real applications of flexible semiconductors in the future. In contrast, flexible displays are already available by introducing OLED (organic LED) realized on polymer films. And flexible batteries are also demonstrated by several companies by adapting solid electrolytes and so on. However, there has been little development on flexible packaging & interconnection areas. As a one of the promising flexible packaging and interconnection technologies, flexible IC packaging such as COF(Chip On Flex)/CIF(Chip In Flex) technologies using FPCs substrates and ACFs bonding materials become very important for realizing wearable electronic products, because ACFs interconnection provides excellent electrical flexibility compared with conventional solder- or socket-based interconnection methods which have a limitation of bending and flexing. [1]-[3] By attaching the cover adhesive film with a polyimide film to COF packages, CIF packages were successfully fabricated. During both convex and concave dynamic bending test[4], the minimum bending radius of CIF was obtained at no chip-crack condition. After fabrication of CIF packages, the effect of ACFs resin properties on the dynamic bending performance of CIF packages up to 160 k cycles was also investigated. It was found that the lowest modulus resin resulted early delamination between the conductive ball and the electrode interface. For the higher resin modulus of 1.04 GPa, the conductive balls and electrodes interface delamination was significantly suppressed due to lower deformation of ACFs. And among the various conductive ball types, metal coated polymer balls showed no electrical and mechanical failure even after 160K dynamic bending cycles, because the metal coated polymer balls had better compliance compared to the solder ball and Ni ball, which eventually prevented chip crack and ACF contact loss to occur.

Fluids are administered in the intraoperative period to (a) replace blood loss during surgery, (b) replace fasting and evaporative losses, (c) preoperative bowel preparation in bowel cases, and (d) for maintenance. Loss of vascular tone after anesthetic administration leads to a decrease in circulat

Hyperechogenic pancreas (HP) suggestive of fatty replacement is a common finding during endoscopic ultrasound (EUS). Recent data have implicated pancreatic steatosis as a risk factor for pancreatitis and pancreatic malignancy. Hepatic steatosis has been linked to obesity, increased age, hypertriglyceridemia, hyperglycemia, and hyperinsulinemia. The objective of this study was to evaluate the effect of body mass index (BMI), hepatic steatosis, and other metabolic risk factors on HP seen on EUS.Patients with HP were identified by a review of a structured EUS database. The degree of echogenicity was judged relative to the liver (or spleen if the liver is hyperechogenic) at a similar depth. Various demographic and metabolic risk factors were assessed. Chronic pancreatitis was excluded based on normal findings on prior imaging studies. Each case was age matched and sex matched to 1 control with a normal pancreas on EUS.By multivariate logistic regression analysis, BMI, hepatic steatosis, and alcohol use in excess of 14 g/wk were highly associated with the presence of HP compared with controls (all P0.002). Hepatic steatosis was the strongest predictor with an odds ratio of nearly 14-fold.Hepatic steatosis, alcohol use, and increased BMI are predictors of HP, which can be a marker for steatosis.

Purpose To study the anatomy and kinematics of the thumb sagittal band (SB) and the influence of simulated injury on the stability of the extensor pollicis longus (EPL) tendon. Methods Twenty-four below-elbow, cadaveric amputation specimens were used. The study had 3 components: SB anatomy, SB kinematics, and assessment of SB influence on extensor stability through simulated injury by serial sectioning. Results The radial and ulnar components of the SB originated on their respective sides of the thumb metacarpophalangeal joint from a soft tissue confluence and inserted into the margins of the EPL tendon. The radial component was much more transparent and thinner, but slightly wider (2.4 mm) and longer (0.5 mm) than the ulnar component. The SB fibers were oriented perpendicular to the long axis of the thumb and EPL tendon. Interphalangeal joint motion had the greatest influence on SB fiber angulation and excursion. Partial and complete sectioning of the ulnar SB had minimal influence on EPL tendon stability. Partial sectioning of the radial SB resulted in ulnar EPL tendon subluxation. Complete sectioning of the radial SB resulted in ulnar dislocation of the EPL tendon. Conclusions The radial component of the thumb SB seems to be more important to EPL stabilization at the level of the metacarpophalangeal joint than its ulnar counterpart. EPL tendon instability was observed to be proportional to the degree of radial SB injury. Knowledge of the anatomy of the thumb SB and its functional relationship to the extensor apparatus provides an understanding of the repair and reconstructive considerations for conditions of EPL tendon instability associated with trauma and inflammatory and nonrheumatoid thumb deformities.

Pancreatic juice (PJ) [IL-8] has been proposed as a marker for pancreatic diseases. We compared the accuracy of PJ [IL-8] and endoscopic ultrasound (EUS) to diagnose chronic pancreatitis (CP).79 patients with symptoms suspicious for CP were enrolled. PJ emptied into the duodenum was collected during an upper endoscopy with IV secretin and [IL-8] was measured. CP was diagnosed when PJ [IL-8] was20 pg/ml. CP was diagnosed at EUS whenor=4 of the 9 established criteria were present. CP was diagnosed by using composite gold standard: ERCP, histology, CT or MRI, and clinical follow-up (mean 20 months).38 patients had CP, whereas 41 patients had no pancreatic disease. To diagnose CP, PJ [IL-8] was significantly less sensitive compared to EUS (47 vs. 71%), but equally accurate (71 vs. 80%) and specific (93 vs. 88%). By combining PJ [IL-8] and EUS, sensitivity and specificity significantly increased to 82% (either IL-8 or EUS positive) and 100% (both IL-8 and EUS positive).Both PJ [IL-8] and EUS are accurate diagnostic modalities for CP. PJ collection can be performed at the time of EUS. PJ [IL-8] and EUS are complementary with higher sensitivity and specificity when used together.

Pancreatic cancer is one of the leading causes of cancer-related death in the USA. Recently, several centers have introduced portal and superior mesenteric vein resection and reconstruction during extended pancreatectomy, rendering the previously inoperable cases resectable. The aim of this study is to confirm whether patients with locally advanced pancreatic cancer and mesenteric vascular invasion can be cured with extended pancreatectomy with vascular reconstruction (VR) and to compare their survival to patients treated with pancreatectomy without VR and those treated without resection (palliation). Survival of 22 patients who underwent pancreatectomy with VR was compared with two control groups: 54 patients who underwent pancreatectomy without the need for VR and 28 patients whose pre-operative imaging suggested resectability but whose laparotomy indicated inoperability. A slight survival benefit was noted in patients who did not require VR (33.5%) compared to those who did require VR [20%, p = 0.18], although not reaching statistical significance. Despite a low 15% three-year survival in patients treated palliatively, this was not statistically different compared to survival after resection with VR (P = 0.23). The presence of nodal metastasis was associated with worse survival (p = 0.006), and the use of adjuvant therapy was associated with better survival (p = 0.001). Pancreatic cancers that require VR to completely resect the tumor have a similar survival to those not requiring VR. Long-term survival was achievable in approximately 1 out 5 patients requiring VR, although we were not able to demonstrate statistically improved survival compared to palliative care.

A predictive method for estimating the minimum dynamic critical system pressure required to disperse the blowing agents in molten polystyrene has been introduced based on the relationship between dynamic and equilibrium solubility determined using the Theory of Corresponding States. This method can be used to estimate the minimum dynamic system pressure required to disperse new blowing agent systems as a function of temperature and blowing agent concentration in the foam extrusion line. A brief discussion on the effect of dynamic system pressure on the cellular structure, skin, quality, and the pressure drop calculations through the foam extrusion line will be given.

Background On-site determination of cytologic adequacy increases the accuracy of EUS-guided FNA (EUS-FNA); however, on-site cytotechnologists are not available to all endosonographers. We hypothesize that experienced endosonographers can accurately assess whether an on-site FNA specimen is adequate. Objective To determine the accuracy of on-site cytopathology interpretation of EUS-FNA specimens by comparing endosonographers with a cytotechnologist. Design Prospective double-blind controlled trial. Setting Academic medical center with a high-volume EUS practice. Patients Consecutive patients undergoing EUS-FNA of lymph nodes or pancreas tumors. Main Outcome Measurements Accuracy, sensitivity, and specificity of 3 endosonographers and 1 cytotechnologist for interpretation of cytologic specimen adequacy and diagnosis compared with a criterion standard of a board-certified cytopathologist. Results There were 59 lymph node, 49 pancreas, and 9 liver specimens (117 total). For determination of adequacy, none of the endosonographers were statistically equivalent to the cytotechnologist ( P = .004). For determination of suspicious/malignant versus benign specimens, all 3 endosonographers were inferior ( P Limitations This study represents a small group of trained endosonographers in a high-volume practice and may not be applicable to other settings. The sample size does not allow an accurate evaluation of different biopsy sites (eg, pancreas vs lymph node). Conclusions Even trained endosonographers have variable and, in some cases, inferior abilities to interpret on-site cytologic adequacy compared with cytotechnologists.

The diagnosis of chronic pancreatitis (CP) remains challenging. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) have been proposed as highly accurate diagnostic modalities. Although endoscopic retrograde cholangiopancreatography (ERCP) has been previously used as a gold standard, it is associated with a small but significant risk. We aim to compare the accuracy of EUS and MRCP with the composite gold standard using ERCP, surgical pathology, and/or long-term clinical follow-up.Ninety-nine patients with clinical signs and/or symptoms suggestive of CP were prospectively enrolled. The diagnosis of CP by MRCP was established when one or more of these features were present: main duct dilation without obstruction, dilated side branches, intraductal stones, ductal irregularity, reduced T1-signal intensity, parenchymal atrophy, and reduced secretory response to secretin administration. The diagnosis of CP by EUS was made when 4 or more of the established criteria were present. Accuracy of all criteria used ("EUS only," "MRCP only," "either EUS or MRCP," and "both EUS and MRCP") was compared with the composite gold standard.Forty patients were diagnosed with CP by the composite gold standard whereas the remaining 59 patients were controls. EUS only seemed more sensitive but equally specific compared with MRCP only to diagnose CP. The combination of EUS and MRCP had a sensitivity of 98% for either EUS or MRCP and a specificity of 100% for both EUS and MRCP.EUS and MRCP are highly accurate modalities for the diagnosis of CP and are complementary when used together. If confirmed in larger series, the diagnosis of CP by both EUS and MRCP is highly predictive and ERCP is unlikely to add any useful information.

Introduction: The purpose of this research was to evaluate the anterior face height (AFH) of a native African ethnic group. Methods: Cephalograms of 101 adult ethnic Shona subjects (51 men, 50 women; age range, 18 to 38 years) were evaluated and compared with norms of African Americans and North American whites. A number of measurements, some conventionally used and others specifically derived for this study, were assessed, including ANS to Me, Me to PP, and Me to FH, TAFH, NOrb, NANS, NPP, OrbANS, and OrbPP. Three age groups were considered: less than 22 years, 22 to 25, and more than 25 years. Results: ANOVA detected significant differences among the 3 age groups and between the sexes. AFH was higher in men than in women. The post hoc Bonferroni test showed that NPP, NANS, and OrbPP were significantly different at ages less than 22 and more than 25. The older age group had shorter heights than the younger group. The AFH of the Shona was significantly lower than that of the African Americans. All AFHs for the men and only TAFH for the women were significantly shorter for the Shona than for the whites. Conclusions: The anterior vertical dimension of the Shona subjects was anatomically shorter than that of whites and African Americans, and conventional measurements did not provide the true status of the Shona, who had shorter lower AFHs.

Lymphangiomas are benign neoplasms usually occurring in childhood and located in the head and neck. Intraabdominal lymphangiomas account for less than 5% of cases. The involvement of the gallbladder is rare. We report a case of a 29-year-old woman who presented with right upper quadrant pain that had persisted for 6 months. Imaging with ultrasound and magnetic resonance imaging (MRI) revealed a multiseptated lesion surrounding the gallbladder. The patient underwent an exploratory laporatomy, and the mass was resected en bloc with the gallbladder. Histological evaluation of the cystic mass revealed findings consistent with lymphangioma. The prognosis is generally good after complete surgical excision, as was the case for our patient.

To examine the perioperative cardiac morbidity and mortality in patients undergoing major vascular surgery with beta-blockade after a positive stress test or cardiac catheterization.Retrospective review of a quality assurance database.A university teaching hospital.A consecutive series of 31 patients undergoing peripheral vascular or aortic surgery after a positive stress test or catheterization between November 2001 and September 2003.None.All 31 patients had a preoperative positive stress test and/or cardiac catheterization, with 12 having multiple areas at risk for myocardial ischemia. None had an intervening coronary revascularization. Twenty-seven had at least one of the intermediate clinical predictors as defined by the American College of Cardiology and 7 had a left ventricular ejection fraction40%. Twenty-three patients had been on a beta-blocker and continued on it, while the remainder started on it de novo perioperatively. None of the patients suffered from myocardial infarction, congestive heart failure, or cardiac death perioperatively.This case series reports on the authors' experience with patients undergoing high-risk vascular surgery after a positive stress test or catheterization, but without an intervening coronary intervention. All patients received perioperative beta-blockade and had a very low adverse cardiac event rate. With reduction of adverse events by beta-blockade, the likelihood of a positive event may be reduced and the utility of the test in risk stratification may be questioned.

Since its development and introduction to clinical practice, endoscopic ultrasonography (EUS) has progressed rapidly from being a purely imaging modality with limited use in the detection of small pancreatic cancers to one that can provide a tissue diagnosis by fine-needle aspiration (FNA) and deliver therapy. EUS has now firmly established a place as the investigation of choice in the diagnosis, locoregional staging and management of a wide range of gastrointestinal cancers. With the increasing use of FNA, the accuracy of EUS has substantially improved and may become a stand-alone investigation in some situations. However, it is recommended that a combination of information obtained from other imaging modalities and EUS is needed to maximize the accuracy, in particular to complete staging beyond locoregional stage. In addition to well-established indications, newer applications of EUS are emerging and are no longer limited to the gastrointestinal system. In lung cancer, EUS combined with endobronchial ultrasonography is emerging as an accurate, minimally invasive, nonsurgical alternative to staging of the mediastinum. Furthermore, the ability of EUS to acquire tissue safely and conveniently results in a potential role of the molecular diagnostics to enhance the performance of EUS-guided FNA. Besides a diagnostic role of EUS, there continues to be technological advances in the field of interventional EUS, with many potential applications under investigation. This review focuses on the current and future roles of EUS in the diagnosis and management of cancers.

New techniques have expanded the role of endoscopy in the diagnosis, staging, therapy, and palliation of malignancies. Three major areas of emerging technologies--endoscopic ultrasound (EUS), luminal stent technology, and photodynamic therapy (PDT)--are discussed in this article. Although EUS and PDT have been used for more than two decades, they have only recently emerged as established integral methods in the armamentarium of the gastrointestinal endoscopist.

Objectives There is a genetic predisposition to hepatitis B vaccine nonresponse. The link between human leukocyte antigen (HLA) genotype and ineffective development of immunity to the hepatitis B vaccine has been characterized in multiple studies. Celiac disease has a strong association with a particular HLA genotype of DQ2; interestingly, this HLA genotype is seen in association with nonresponders to the hepatitis B vaccine. We report a disproportionate number of patients with celiac disease who are nonresponders to the hepatitis B vaccine series. Methods We reviewed the hepatitis B vaccine records, serological tests for anti–hepatitis B surface antigen antibody (anti-HBs), and HLA genotypes of celiac disease patients identified as nonresponders to hepatitis B vaccine. Subjects were identified from a database of patients diagnosed with celiac disease at our institution or referred to our center for evaluation and management of celiac disease between November, 2000, and October, 2002. Results A total of 23 subjects were reviewed. All had a clinical and pathological diagnosis of celiac disease. All subjects reported receiving the full series of hepatitis B vaccinations. Of the subjects, 19 had testing for hepatitis B vaccine response. Of these 19 subjects, 13 did not achieve long-term immunity as seen by the negative qualitative or quantitative anti-HBs antibody titer. All tested subjects were either homozygous or heterozygous for DQ2. Conclusions We postulate that celiac disease patients may have a significant predisposition to hepatitis B vaccine nonresponse. Both celiac disease and hepatitis B vaccine nonresponse is genetically mediated. Celiac disease patients may have a failure of induction of humoral immune response needed for development of long term immunity; the mechanism for this is unclear.

In a 1998 survey of New York metropolitan area anesthesiologists, surgeons, and cardiologists, the three specialties were in general agreement that important purposes of a cardiology consultation are to treat an inadequately treated cardiac condition before surgery (e.g., unstable angina or congestive heart failure [CHF]), to provide data to use in anesthesia management (e.g., ischemic threshold of tachycardia on stress test or left ventricular ejection fraction), and possibly to diagnose a medical condition before surgery (e.g., the cause of a new-onset atrial fibrillation). The yield of a cardiology consultation, in terms of new therapy or significant effect on patient management strategy prior to surgery, has, however, been reported to vary widely from 10% to more than 70%. The reasons why the consultation process often falls short of ideal are probably multifold, but may often originate from vague understanding of the consultation process. The physician initiating the consultation, whether an anesthesiologist or a surgeon, may not make it clear to the cardiologist why the consultation is being sought. In a retrospective review of 202 cardiology consultations at a university hospital, it was found that 108 just asked for an “evaluation,” 79 asked for a “clearance,” and 9 did not specifically request anything. Only six posed a specific question. As a result, the consultant often makes broadly inclusive, general remarks about perioperative management of the patient and may recommend preoperative diagnostic work-up that does not influence the patient’s outcome but prolongs the hospital stay. In this review are presented (1) the indications for cardiology consultations as implied in the American College of Cardiology–American Heart Association (ACC–AHA) guidelines on preoperative cardiac evaluation, and (2) suggestions on how the ACC–AHA guidelines may be critically applied to, and improve, the consultation process. Preoperative Cardiac Consultation Based on the ACC–AHA Guidelines The ACC–AHA guidelines on preoperative cardiac evaluation were published initially in 1996 and were also endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Vascular Surgery. An updated version of the guidelines was published in 2002. The guidelines were based on the then-available literature as well as expert opinions from the disciplines of anesthesiology, cardiology, electrophysiology, vascular medicine, vascular surgery, and noninvasive cardiac testing. The guidelines provided an 8-step algorithm for stratifying the patient’s risks and triaging to either surgery or cardiac evaluation. The first three steps of the guidelines consider the urgency of the operation and the recency of cardiac evaluation and intervention. If the operation is not emergent and if there has not been recent cardiac evaluation and/or intervention with no significant interim changes, then the remainder of the guidelines are applied. Steps 4 through 7 deal with an assessment of the patient’s clinical predictors of cardiac risk, functional status, and the risk of the surgery proposed. Step 8, or noninvasive cardiac testing to further define the patient’s risk, is indicated (1) if the patient has a major clinical predictor, (2) if the patient has an intermediate clinical predictor and either has poor functional status or is undergoing a high-risk surgery, or (3) if the patient has poor functional status and is undergoing a high-risk surgery. As defined by the ACC–AHA, major clinical predictors are unstable coronary syndrome, decompensated congestive heart failure (CHF), significant arrhythmias, and severe valvular disease. Intermediate clinical predictors are mild angina pectoris, history of myocardial infarction (MI) or CHF, diabetes mellitus, and chronic renal failure with serum creatinine greater than 2 mg/dl. A high-risk surgery carries a greater than 5% perioperative risk of cardiac events such as MI, CHF, or death and is exemplified by emergent major operations, especially in the elderly, aortic, and other major vascular procedures, peripheral vascular bypass procedures, and anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss. An intermediate-risk surgery carries 1–5% perioperative risk of cardiac events and is exemplified by carotid endarterectomy, intraperitoneal and Director of Vascular Anesthesia, Department of Anesthesia & Critical Care, Beth Israel Deaconess Medical Center, and Associate Professor of Anaesthesia, Harvard Medical School.

Food packaging is a dynamic system of the food product, packaging material, visual and structural designs, transportation and distribution. A number of packaging materials are introduced to provide desirable functions within the packaging system for numerous types of food products. In most commercial food products, paper and paperboard and plastics are primary packaging materials. Metal and glass are also widely used for various liquid and semi-solid food products. Sustainability concern in the food industry, which is a global hot topic in general, drives the more use of sustainable packaging materials such as bioplastics and bio-based materials which are either synthetized or naturally originated. The appropriate selection of packaging material is a most important factor for assurance of the safety and quality of food. Typically, the process primarily relies on the characteristics of major packaging materials (paper and paperboard, plastics, glass and metal) and their compatibility with food products. Typical properties for the food packaging system fall into the gas barrier property, mechanical, thermal, rheological, morphological, optical and physical properties. Gas barrier property is often considered as the most important factor to ensure the shelf-life of food products. Therefore, the general characteristics of major food packaging materials and their industrial uses will be discussed in this chapter.

The adenosine triphosphate (ATP)-sensitive potassium channels (K(+)-ATP channels) are activated by decreases in intracellular ATP and help to match blood flow to tissue needs. Such metabolism-flow coupling occurs predominantly in the smallest arterioles measuring 50 microm or less in diameter. Previous studies demonstrated that isoflurane may activate the K(+)-ATP channels in larger arteries. We examined whether isoflurane also activates the channels in the smallest arterioles of approximately 50 microm. Microvessels of approximately 50 microm were dissected from right atrial appendages from patients undergoing coronary artery bypass surgery and were monitored in vitro for diameter changes by videomicroscopy. With or without preconstriction with the thromboxane analog U46619 1 microM, vessels were exposed to isoflurane 0%-3% either in the presence or absence of the K(+)-ATP channel blocker glibenclamide 1 microM. Without preconstriction, isoflurane neither dilated nor constricted the vessels significantly. After preconstriction, isoflurane had a concentration-dependent dilation of the small arterioles (39 +/- 13% [mean +/- SD] dilation at 3% isoflurane) (P0.001), and this effect was significantly attenuated by glibenclamide (18 +/- 5% dilation at 3% isoflurane) (P0.01). In comparison, nitroprusside 10(-4) M produced 79 +/- 6% dilation, and adenosine diphosphate 10(-4) M produced 29 +/- 7% dilation. We conclude that isoflurane-mediated dilation of the smallest resistance arterioles may be in part based on activation of the K(+)-ATP channels when the arterioles are relatively constricted.Vasodilation of very small coronary arterioles by isoflurane depends on preexisting tone and may in part be mediated by the K(+)-ATP channels.

The thermomechanical behavior of multilayer structures is a subject of perennial interest. Among various multilayer structures, we provided a thorough investigation on the lamination-based thick-film multilayer substrates, or the multichip module substrates. Firstly, we offered an in-depth look at the composite bean analysis (CBA) recently suggested for thick-film multilayer structures. The calculated substrate bow values using the CBA model were compared with the measured values and calculated values from numerical analysis. The magnitude and distribution of biaxial, shear, and peel stresses in thick-film multilayer substrates during sequential build-up of thick-film polymer dielectrics were calculated and discussed. Secondly, for users’ convenience, the most widely-used analytical methods for microelectronics applications were summarized along with the CBA model, and their possible applications were suggested.

An interfacial edge crack of a length a in two bonded dissimilar anisotropic quarter planes having an anti-plane singularity such as a screw dislocation or anti-plane line force is analyzed. The energy release rate and stress intensity factor are explicitly expressed in terms of complex potentials. The interaction problems in two bonded orthotropic quarter planes are exemplified. It is confirmed that the present solution reduces to the known solutions dealing with particular cases of the present problem.

The thermomechanical behavior of multilayer structures is a subject of perennial interest. Stoney’s formula has long been one of the most important tools for understanding thermomechanical stress for single-layered structures like spin-coated polyimides or deposited metal thin film on substrates. In today’s microelectronics, however, as multilayer substrates have become widely available, the “modified version” of Stoney’s formula for multilayer applications is not only useful but necessary. While the majority of reports in the literature have focused on single-layer analysis, in this study, we examined an extended usage of Stoney’s formula for multilayer analysis. A simple model, the multilayer-modified Stoney’s formula, which predicts the stress contribution of each individual layer is proposed and verified through experiments and numerical analysis. Using various kinds of materials employed in a typical lamination-based multichip module technology, the thermomechanical behavior of the lamination-based multilayer substrates was measured by a laser profilometry during thermal cycling. The measured values were compared with calculated values using the multilayer-modified Stoney’s formula.

We examined whether pulmonary endothelial dysfunction associated with cardiopulmonary bypass (CPB) may be mediated by complement C5a in pigs. Pigs were placed on normothermic CPB for 1 h with or without a previous administration of 1.6 mg/kg anti-C5a monoclonal antibody (MAb), then reperfused for 2 h. Pulmonary tissue myeloperoxidase activity was measured. Expression of nitric oxide synthase (NOS) was measured by reverse transcriptase polymerase chain reaction and Western blotting. Pulmonary arterioles approximately 100 m mi n diameter were preconstricted with the thromboxane analog U46619 1 mM, and relaxation responses to adenosine diphosphate 10 29 ‐10 24 M, substance P 10 212 ‐10 26 M, and sodium nitroprusside 10 29 ‐10 24 M were examined in vitro by videomicroscopy. Relaxation to the endothelium-dependent dilators adenosine diphosphate and substance P was attenuated after CPB; this attenuation was prevented by the previous administration of MAb. Relaxation to sodium nitroprusside was not affected by CPB. Neutrophil sequestration, as measured by MPO activity, increased after CPB, either with or without MAb. Transcription of NOS was unchanged by CPB, but translation of constitutive NOS was decreased after CPB, and this decrease was prevented by a previous administration of MAb. We conclude that pig pulmonary endothelial dysfunction associated with CPB may be mediated by C5a. The mechanism may involve changes in NOS translation. Implications: In pigs, pulmonary endothelial dysfunction may occur after cardiopulmonary bypass due to product(s) of complement activation.

Peritoneal insufflation with carbon dioxide during laproscopic Nissen fundoplication is an essential part of the procedure. Elevations in intraperitoneal pressures during laparoscopy can result in decreased mesenteric venous flow and result in thrombosis in predisposed individuals. We describe the case of a patient who developed an insidious onset of postprandial abdominal pain following laparoscopic Nissen fundoplication related to mesenteric venous thrombosis.

We report a case in which flow-directed placement of the pulmonary artery catheter led to its inadvertent placement in the coronary sinus, in the absence of congenital anomalies. Incorrect placement was diagnosed by use of the transesophageal echocardiography. If unrecognized, the catheter might have provided misleading information and led to mismanagement of the patient.

The anatomy of the sagittal bands was studied in 56 cadaver digits. The sagittal band is part of an extensor retinacular system which is integrated with the extrinsic and intrinsic musculotendinous structures. The extensor retinacular system is a single unit with radial and ulnar components and has transverse, sagittal and oblique fibres. The transverse-sagittal fibres, along with the palmar plate, form a closed cylindrical tube which surrounds the metacarpal head. The oblique fibres form the triangular lamina distal to the sagittal band. The radial component of the sagittal band is often thinner and longer than the ulnar component. The sagittal band envelops the extensor digitorum tendon and the superficial fibres are thinner than deep fibres, especially in the central digits. The central digits have palmar soft tissue confluence on each side consisting of the sagittal band, palmar plate, annular pulley and deep transverse metacarpal ligament. The sagittal band also appears to envelop the superficial interosseous tendons on both sides. Our findings explain the propensity for radial sagittal band injuries and suggest that the sagittal band is the primary stabilizer of the extensor digitorum at the metacarpophalangeal joint.

Volatile anesthetics attenuate endothelium-dependent vasodilation but the mechanism of attenuation remains controversial. The present study examines the mechanism of isoflurane- and halothane-mediated attenuation of endothelium-dependent vasodilation in Wistar rat coronary microvessels of about 100 microns internal diameter. The vessels were studied in vitro in a pressurized (40 mm Hg), no-flow state using video microscopy. After preconstriction of the vessels with the thromboxane analog U46619 1 microM, concentration response curves to acetylcholine (ACh), the calcium ionophore A23187, sodium nitroprusside (SNP), or the stable cyclic guanosine monophosphate (cGMP) analog 8-bromo-cGMP (Br-cGMP) were obtained in the presence of 0% (control), 1% or 2% isoflurane, or 1% or 2% halothane. Isoflurane 1% and 2% significantly attenuated vasodilation to ACh and A23187. Isoflurane 2%, but not 1%, attenuated vasodilation to SNP. Vasodilation to Br-cGMP was not affected by isoflurane. Halothane attenuated vasodilation to ACh, but had no effect on vasodilation to A23187, SNP, or Br-cGMP. We conclude that isoflurane attenuates endothelium-dependent vasodilation by impairing at least two distinct steps in the nitric oxide (NO)-cGMP pathway, the first being between endothelial increase of calcium and smooth muscle guanylate cyclase and the second being inhibition of soluble guanylate cyclase activity. These two steps appear to have different sensitivities to the effect of isoflurane. Halothane has an effect at the endothelial receptor level, but not any distal steps in the NO-cGMP pathway.

Protein kinase C (PKC), important in signal transduction, may help generate and maintain vascular smooth muscle tone. We sought to examine the effect of the volatile anesthetics isoflurane and halothane on PKC agonist-induced vasoconstriction and PKC inhibitor-induced vasorelaxation. Subepicardial resistance arteries were dissected from rat hearts. Changes in vessel diameters were monitored in response to the membrane-bound PKC agonist 12-deoxyphorbol-13-isobutyric-20-acetate (PBE) 10(-8)-10(-7) M or the cytosolic PKC agonist oleic acid 10(-7)-10(-5.5) M either in the presence of isoflurane 1.15%, isoflurane 2.3%, halothane 0.77%, halothane 1.54%, or no volatile anesthetics (control). In addition, after preconstriction with the thromboxane analog U46619 1 microM, relaxation responses to the PKC inhibitor staurosporine 10(-8)-10(-7) M were examined in the presence or absence of the anesthetics as above. PBE-induced constriction was attenuated by either concentration of halothane (P0.05) but was unaltered by isoflurane (P0.5). Oleic acid-induced constriction was abolished by halothane (P0.001) but enhanced by isoflurane (P0.01). Staurosporine-induced relaxation of U46619-preconstricted vessels was attenuated by isoflurane (P0.05) but unaltered by halothane (P0.3). We conclude that isoflurane may enhance cytosolic PKC-mediated vasoconstriction, whereas halothane may attenuate both cytosolic and membrane-bound PKC-mediated vasoconstriction.

Previous in vitro studies on the effect of propofol on coronary arteries have shown variable results, ranging from constriction to no effect to dilation. Although most of these studies reported that the observed effect is endothelium-independent, propofol also releases nitric oxide from cultured porcine endothelial cells. The present study examines the direct effect of propofol in rat distal coronary arteries in vitro, especially in regard to endothelial dependence and involvement of the adenosine triphosphate (ATP)-sensitive potassium channels (KATP channels). Forty-three subepicardial arteries (size 91.1 +/- 15.8 microns) from Wistar rats were studied in vitro in a no-flow, pressurized (40 mm Hg) state, using an optical density video detection system. After preconstriction with the thromboxane analog U46619 1 microM, relaxation responses to increasing concentrations of propofol (10(-6)-10(-4) M) were measured after 1) endothelial denudation, 2) pretreatment with the nitric oxide synthase inhibitor NG-nitro-L-arginine (L-NNA), 3) pretreatment with the cyclooxygenase inhibitor indomethacin, 4) pretreatment with the KATP channel blocker glibenclamide, or 5) no intervention (control). Propofol produced a significant concentration-dependent vasodilation of the U46619-preconstricted coronary arteries. This effect was significantly attenuated by endothelial denudation, pretreatment with L-NNA, or indomethacin, but was not affected by glibenclamide. We conclude that propofol has a direct vasodilatory effect on distal coronary arteries in rats. This effect is primarily endothelium-dependent and is mediated by multiple substances, including nitric oxide (NO) and a vasodilatory prostanoid. The effect is not mediated by opening of the K(ATP) channels.

BACKGROUND The authors previously reported that in rabbits, isoflurane exhibited a heterogeneous vasomotor effect, constricting small resistance coronary arteries and dilating larger conductance arteries. The novelty of isoflurane-induced constriction of small coronary arteries raised the question of whether the finding depended on the unique experimental setup or species used. The purpose of this study was to address these questions. Therefore, a second species was studied, namely rats, as well as a second volatile anesthetic, halothane. In addition, the dependence of the vasomotor effect on the preexisting tone of the vessels was examined. METHODS Thirty-six large coronary arteries (262 +/- 23 microns) and 42 small coronary arteries (99 +/- 15 microns) from 31 Wistar rats were isolated. Each vessel was placed in a microvessel chamber and was (1) submaximally preconstricted with the thromboxane analog U46619; (2) submaximally predilated with sodium nitroprusside; or (3) neither preconstricted nor predilated. The vessel was then subjected to increasing concentrations of either isoflurane or halothane, 0-3%. Changes in inner diameter were monitored and recorded with optical density video detection system. RESULTS Isoflurane constricted predilated or untreated small coronary arteries, but had no effect on preconstricted small arteries. Isoflurane dilated large coronary arteries, with the preconstricted vessels dilating the most. In contrast, halothane dilated both the small and large coronary arteries to a similar extent. Preconstricted vessels dilated more to halothane than vessels with no added tone. CONCLUSIONS Whereas isoflurane has a heterogeneous vasomotor effect in rat coronary arteries, constricting the small vessels and dilating the large ones, halothane dilates both the small and large arteries. The vasoconstriction effect was most evident in vessels with no added tone, whereas the vasodilatory effect was most significant in preconstricted vessels.

Isoflurane induces endothelium-dependent constriction of rabbit coronary resistance arteries in vitro. This effect is inhibited by the cyclooxygenase inhibitor indomethacin. To determine whether thromboxane or oxygen-derived free radicals, a byproduct in the cyclooxygenase pathway, mediate this effect, subepicardial coronary arterioles (103 +/- 21 mu) from New Zealand White rabbits were studied in vitro in a pressurized (40 mm Hg), no-flow state using videomicroscopy. The vessels were subjected to increasing concentrations of isoflurane, 0%-3%, in the presence of Dazmegrel (a specific inhibitor of thromboxane synthesis; Pfizer Ltd., Sandwich, UK) or SOD-Mn (manganese superoxide dismutase, a scavenger of superoxide radicals) or mannitol (hydroxyl radical scavenger) 20 or 100 mM or in their absence (control). The control vessels showed a concentration-dependent constriction to isoflurane (P < 0.0001), with reduction in internal diameter of 11.4% +/- 3.5% at isoflurane 3%. This response was unaffected by Dazmegrel (P = 0.78), but was abolished by SOD-Mn (P < 0.01) or mannitol (P < 0.01). We conclude that isoflurane causes concentration-dependent constriction of rabbit coronary resistance arteries and that this effect is mediated by oxygen-derived free radicals. (Anesth Analg 1995;80:1163-7)

Previous in vitro studies on the mechanism of isoflurane-elicited vasodilation have examined conductance arteries and reported conflicting data on whether the vasomotor response is mediated through the release of endothelium-derived nitric oxide. The current study was undertaken to define the effect of isoflurane on both resistance and conductance coronary arteries in rabbits and to elucidate the mechanism of the effect.Rabbit coronary arteries of varying sizes were dissected and each placed in a microvessel chamber. The arteries were studied in a pressurized (40 mmHg), no-flow state and were exposed to increasing concentrations of isoflurane, 0-3%, by an in-line bubble-through vaporizer. The vessel lumen diameter was monitored using an optical density video detection system. Selected experiments were performed on microvessels after preincubation with indomethacin, NG-monomethyl-L-arginine, or methylene blue or after endothelial denudation.Isoflurane caused a dose-dependent constriction of small rabbit coronary arteries (internal diameter of 139 +/- 34 mu, mean +/- SD), whereas it caused dilation of large coronary arteries (371 +/- 54 mu). The vasoconstriction of the small coronary arteries by isoflurane was abolished by endothelial denudation or after preincubation with indomethacin. The vasodilation of the large vessels by isoflurane was inhibited by endothelial denudation or after preincubation with NG-mono-methyl-L-arginine, methylene blue, or indomethacin.Our data suggest that vessel size is a determinant of the vasomotor response to isoflurane. Exposure to isoflurane produces vasodilation of conductance coronary arteries, whereas it is associated with vasoconstriction of resistance coronary microvessels. The latter appears to be endothelium-dependent and mediated by cyclooxygenase product(s), whereas the former, also endothelium-dependent, is mediated by both product(s) of cyclooxygenase and endothelium-derived nitric oxide.

Anesthesia and perioperative care for aortic surgery / , Anesthesia and perioperative care for aortic surgery / , کتابخانه دیجیتال جندی شاپور اهواز

Each year in the USA, nearly 30 million patients are estimated to undergo noncardiac surgery, and about one third of these patients have coronary artery disease (CAD) or risk factors for CAD.1 About one million of those patients have perioperative cardiac complications that result in more than $20 billion in health-care expenditures.1 The current standards for preoperative cardiac evaluation of these patients are the guidelines published by the American College of Cardiology (ACC) and the American Heart Association (AHA), initially in 19962 and updated in 2002 3 and again in 2007.4 These guidelines were developed based on a review of the then-available literature and the opinions of experts from the disciplines of anesthesiology, cardiology, electrophysiology, vascular medicine, vascular surgery, and noninvasive cardiac testing.

Introduction Doppler transabdominal ultrasound is a validated screening test for chronic mesenteric ischaemia, but gas and obesity are limitations. Endoscopic ultrasound has been proposed as a comprehensive test to evaluate chronic upper abdominal pain and is capable of Doppler measurement. We aim to evaluate the accuracy of Doppler endoscopic ultrasound (D-EUS) as a single screening test to rule out chronic mesenteric ischaemia in patients with abdominal pain and compare it with Doppler transabdominal ultrasound (D-TUS). Methods We enrolled all patients ≥50 years with chronic upper abdominal pain and vascular risk referred for endoscopic ultrasound. All were scheduled for D-EUS and D-TUS plus a confirmatory test if one of the previous resulted positive. We estimated the accuracy of both techniques comparing them using McNemar test. Results 68 patients completed the study. Fifty-three (78%) underwent D-EUS, D-TUS, and a confirmatory test. Fifteen (38%) underwent follow-up after negative results. Three (4%) in the D-EUS group and 14 in the D-TUS (21%) were excluded due to artefacts. D-EUS presented a sensitivity of 63%, specificity of 84%, whilst D-TUS presented a sensitivity of 80% and a specificity of 78%. Specificity of D-EUS was not significantly different to D-TUS. Conclusions These results support the role of Doppler endoscopic ultrasound to exclude chronic mesenteric ischaemia as cause of chronic abdominal pain.