Clinical Benefit of Cancer Philosophy Clinic for Cancer Patients Using EQ-5D-5L Scores.

Objective: This study aims to understand the role of Cancer Philosophy Clinic activities among participants and whether participation is correlated to increase in QOL. Materials and Methods: Among the 150 Cancer Philosophy Clinics, questionnaire surveys were distributed at 28 locations that consented to participating in the study. The data was analyzed based on the respondent's situation and health related Quality of Life (QOL) prior to and after participating in Cancer Philosophy Clinic using the EQ-5D-5L questionnaire (Japanese version) regarding health related QOL prior to and after participating in Cancer Philosophy Clinic. Results: There were more female participants than male participants; 224 and 76 respectively. 46.5%, or approximately half of all participants in the Cancer Philosophy Clinic were "cancer patients," followed by 17.2% who were "family members of cancer patients," 16.6% who were "not suffering from any diseases," 11.4% who were "suffering from diseases other than cancer" and 3.2% who were classified as "other," who were bereaved family members. 51.7% were "currently receiving treatment, "32.1% were "receiving follow-up medical care, "and 15.3% were "survivors." There was 1 participant who commented, "refusing treatment." Based on an evaluation of QOL using EQ-5D-5L of 184 participants who were participating in the Cancer Philosophy Clinic, an increase in overall average index value from 0.827 to 0.867 was observed after participation compared to prior participation. In particular, there was a significant improvement in "pain/discomfort," "anxiety/depression. Conclusions: Cancer Philosophy clinic has been found important role in encouraging existing shift.

Introduction of a Multidisciplinary Preoperative Clinic at Juntendo University Hospital - A Retrospective Observational Study Focusing on Effects of Preoperative Interventions on Clinical Outcomes.

Objectives: To investigate the effects of interventions provided by a multidisciplinary team consisting of anesthesiologists, dentists, pharmacists, and nurses at a Preoperative Clinic (POC) on postoperative outcomes. Methods: We retrospectively investigated patients who underwent preoperative evaluation at the POC at Juntendo University Hospital between May and July, 2019. Patients were divided into intervention and non-intervention groups according to whether they received intervention(s) at the POC or not. Postoperative outcomes were compared between the groups, before and after propensity score (PS) matching. Results: We investigated 909 patients who completed POC evaluation and underwent surgery. Patients in the intervention group (n = 455 [50.1%]) received at least one intervention delivered, in the order of higher delivery frequencies, by dentists, pharmacists, nurses, and anesthesiologists. Before PS matching, the intervention group was associated with older age, more frequent cardiovascular comorbidities, and higher ASA-PS grades than the non-intervention group, while neither frequencies nor severities of postoperative complications differed between the groups. These outcomes did not differ between 382 PS-matched pairs with comparable risk factors either. Conclusions: Before PS matching, postoperative outcomes did not differ between the groups, although the intervention group was associated with higher risks. These suggested that POC interventions could have improved postoperative outcomes in the higher-risk intervention group to the same level as in the non-intervention group. However, such potential beneficial effects of interventions could not be proven after PS matching. Further studies are required to elucidate effects of POC interventions on postoperative outcomes.

Possible mechanism for improving the endogenous immune system through the blockade of peripheral µ-opioid receptors by treatment with naldemedine.

BACKGROUND: It has been considered that activation of peripheral µ-opioid receptors (MORs) induces side effects of opioids. In this study, we investigated the possible improvement of the immune system in tumour-bearing mice by systemic administration of the peripheral MOR antagonist naldemedine. METHODS: The inhibitory effect of naldemedine on MOR-mediated signalling was tested by cAMP inhibition and ß-arrestin recruitment assays using cultured cells. We assessed possible changes in tumour progression and the number of splenic lymphocytes in tumour-bearing mice under the repeated oral administration of naldemedine. RESULTS: Treatment with naldemedine produced a dose-dependent inhibition of both the decrease in the cAMP level and the increase in ß-arrestin recruitment induced by the MOR agonists. Repeated treatment with naldemedine at a dose that reversed the morphine-induced inhibition of gastrointestinal transport, but not antinociception, significantly decreased tumour volume and prolonged survival in tumour-transplanted mice. Naldemedine administration significantly decreased the increased expression of immune checkpoint-related genes and recovered the decreased level of toll-like receptor 4 in splenic lymphocytes in tumour-bearing mice. CONCLUSIONS: The blockade of peripheral MOR may induce an anti-tumour effect through the recovery of T-cell exhaustion and promotion of the tumour-killing system.

Significant neonatal intraoperative cerebral and renal oxygen desaturation identified with near-infrared spectroscopy.

INTRODUCTION: Near-infrared spectroscopy (NIRS) was used to monitor intraoperative regional oxygen saturation (rSO2) during open (Op) and minimally invasive (MI) surgery performed in neonates (N) and children. MATERIALS AND METHODS: NIRS sensors were applied to the forehead and flanks for cerebral rSO2 (C-rSO2) and renal rSO2 (R-rSO2), respectively. MI included laparoscopy (La), retroperitoneoscopy (Re) and thoracoscopy (Th). In children, Op and MI were major operations taking at least 3 h (MOp; MMI). Pathological desaturation (PD) was defined as > 20% deterioration in rSO2. RESULTS: Mean ages at surgery were N: 5.2 ± 8.2 days, MOp: 2.4 ± 2.9 years, and MMI: 3.8 ± 4.3 years. Despite significantly shorter operative times in N (169 ± 94 min; p < 0.0001), PD was significantly worse; PD(C-rSO2): N = 14/35 (40.0%) versus MOp = 3/36 (8.3%) and MMI = 7/58 (12.1%); p = 0.0006, and PD(R-rSO2): N = 27/35 (77.1%) versus MOp = 6/36 (16.7%) and MMI = 7/58 (12.1%); p < 0.0001, respectively. PD(R-rSO2) occurred immediately with visceral reduction in NOp (Fig. 1) and PD was frequent during NMI(Th) (Fig. 2). rSO2 was stable throughout MOp and MMI (Fig. 3). Fig. 1 Pathological desaturation in renal rSO2 after visceral reduction for gastroschisis. Renal rSO2 deteriorated immediately after viscera were returned to the abdominal cavity rSO2 regional oxygen saturation Fig. 2 Fragility of tissue perfusion during thoracoscopic lung lobectomy in a neonate. Pathological desaturation occurred frequently during neonatal thoracoscopic surgery rSO2 regional oxygen saturation Fig. 3 Changes in cerebral and renal rSO2 according to operative time. Cerebral and renal rSO2 did not appear to change according to operative time during major open and major minimally invasive surgery in children. rSO2 regional oxygen saturation CONCLUSIONS: NIRS is a non-invasive technique for monitoring rSO2 as an indicator of intraoperative stress and vascular perfusion. PD was so significant in neonates that intraoperative NIRS is highly recommended during thoracoscopy and procedures requiring visceral manipulation.

A Comparison Between Effects of Amenamevir and Famciclovir on Intensities of Acute Pain and the Incidence of Postherpetic Neuralgia in Adult Patients with Herpes Zoster.

Objective: Herpes zoster (HZ) is a common disease, whose most common complication is postherpetic neuralgia (PHN). We conducted this study to compare effects of amenamevir (AMNV) and famciclovir (FCV) on intensities of acute HZ pain and the incidence of PHN, which have not been compared yet. Methods: After approval by the Ethics Committee, we retrospectively investigated adult patients with HZ treated with AMNV or FCV at Juntendo University Hospital between October, 2018 and February, 2020. We compared, between 143 AMNV-treated and 131 FCV-treated patients, pain scores of acute HZ pain evaluated on an 11-point numerical rating scale (NRS) and the incidence of PHN with the Mann-Whitney U test and Pearson's chi-square test, respectively. The univariate logistic regression analysis was used to identify predictors of PHN. Results: Pain scores during the acute HZ period remained significantly lower in AMNV-treated patients than FCV-treated patients (p = 0.049, 0.011, and 0.016 for Day 3-4, Day 7, and Week 2-3, respectively), although the pain score at Day 0 before treatment didn't differ between them (p > 0.05). The incidence of PHN didn't differ between them (9.8% vs. 11.5%, p > 0.05). In the total cohort, the pain score at Week 2-3 was significantly associated with the development of PHN (r 2 = 0.180, p < 0.00001). Conclusions: Compared with FCV, AMNV was more effective in reducing acute HZ pain, possibly reflecting its unique mechanism of action. However, AMNV didn't reduce the incidence of PHN possibly due to the multifactorial etiology of PHN.

Histone modification of pain-related gene expression in spinal cord neurons under a persistent postsurgical pain-like state by electrocautery.

Chronic postsurgical pain (CPSP) is a serious problem. We developed a mouse model of CPSP induced by electrocautery and examined the mechanism of CPSP. In this mouse model, while both incision and electrocautery each produced acute allodynia, persistent allodynia was only observed after electrocautery. Under these conditions, we found that the mRNA levels of Small proline rich protein 1A (Sprr1a) and Annexin A10 (Anxa10), which are the key modulators of neuropathic pain, in the spinal cord were more potently and persistently increased by electrocautery than by incision. Furthermore, these genes were overexpressed almost exclusively in chronic postsurgical pain-activated neurons. This event was associated with decreased levels of tri-methylated histone H3 at Lys27 and increased levels of acetylated histone H3 at Lys27 at their promoter regions. On the other hand, persistent allodynia and overexpression of Sprr1a and Anxa10 after electrocautery were dramatically suppressed by systemic administration of GSK-J4, which is a selective H3K27 demethylase inhibitor. These results suggest that the effects of electrocautery contribute to CPSP along with synaptic plasticity and epigenetic modification.

Direct evidence that the brain reward system is involved in the control of scratching behaviors induced by acute and chronic itch.

In the present study, we demonstrated that there is a direct relationship between scratching behaviors induced by itch and functional changes in the brain reward system. Using a conditional place preference test, the rewarding effect was clearly evoked by scratching under both acute and chronic itch stimuli. The induction of ΔFosB, a member of the Fos family of transcription factors, was observed in dopamine transporter (DAT)-positive dopamine neurons in the ventral tegmental area (VTA) of mice suffering from a chronic itch sensation. Based on a cellular analysis of scratching-activated neurons, these neurons highly expressed tyrosine hydroxylase (TH) and DAT genes in the VTA. Furthermore, in an in vivo microdialysis study, the levels of extracellular dopamine in the nucleus accumbens (NAcc) were significantly increased by transient scratching behaviors. To specifically suppress the mesolimbic dopaminergic pathway using pharmacogenetics, we used the TH-cre/hM4Di mice. Pharmacogenetic suppression of mesolimbic dopaminergic neurons significantly decreased scratching behaviors. Under the itch condition with scratching behaviors restricted by an Elizabethan collar, the induction of ΔFosB was found mostly in corticotropin-releasing hormone (CRH)-containing neurons of the hypothalamic paraventricular nucleus (PVN). These findings suggest that repetitive abnormal scratching behaviors under acute and chronic itch stimuli may activate mesolimbic dopamine neurons along with pleasant emotions, while the restriction of such scratching behaviors may initially induce the activation of PVN-CRH neurons associated with stress.

The dynamic collapse of the trachea during anesthesia for a pediatric patient with a large anterior mediastinal mass: A case report.

Anesthesia for patient with large anterior mediastinal mass might induce life-threatening complication. Maintaining the spontaneous breathing throughout the procedure and finding rescue position are the cornerstones of anesthetic management.

Insomnia and caregiver burden in chronic pain patients: A cross-sectional clinical study.

Insomnia is a major comorbid symptom of chronic pain and is likely to affect caregiver burden. This cross-sectional study investigated the association between insomnia in chronic pain patients and family caregiver burden. Participants were 60 patients with chronic pain of ≥3 months duration. Demographic and clinical information were collected using the Athens Insomnia Scale (AIS), the Pain Disability Assessment Scale (PDAS), the Hospital Anxiety and Depression Scale (HADS), and a pain intensity numerical rating scale (NRS). Family members who accompanied chronic pain patients to hospital completed the Zarit Burden Interview (ZBI). Univariate regression analysis and multiple regression analysis were conducted to clarify the associations between ZBI scores and total/subscale AIS scores. Covariates were age; sex; pain duration; and scores on the PDAS, HADS anxiety subscale, HADS depression subscale, and NRS. Insomnia was independently associated with ZBI scores [ß: 0.27, 95% confidence interval (CI): 0.07-0.52, p = 0.001]. Scores on the AIS subscale of physical and mental functioning during the day were significantly associated with ZBI scores (ß: 0.32, 95% CI: 0.05-0.59, p = 0.007). In conclusion, the findings suggest that in chronic pain patients, comorbid insomnia and physical and mental daytime functioning is associated with family caregiver burden independently of pain duration, pain-related disability, and pain intensity.

Yokukansan, a Japanese Herbal Medicine, Suppresses Substance PInduced Production of Interleukin-6 and Interleukin-8 by Human U373 MG Glioblastoma Astrocytoma Cells.

BACKGROUND: Yokukansan is a traditional Japanese herbal medicine that has an antiallodynic effect in patients with chronic pain. However, the mechanisms by which yokukansan inhibits neuropathic pain are unclear. OBJECTIVE: This study aimed to investigate the molecular effects of yokukansan on neuroinflammation in U373 MG glioblastoma astrocytoma cells, which express a functional high-affinity neurokinin 1 receptor (substance P receptor), and produce interleukin (IL)-6 and IL-8 in response to stimulation by substance P (SP). METHODS: We assessed the effect of yokukansan on the expression of ERK1/2, P38 MAPK, nuclear factor (NF)-κB, and cyclooxygenase-2 (COX-2) in U373 cells by western blot assay. Levels of IL-6 and IL-8 in conditioned medium obtained after stimulation of cells with SP for 24 h were measured by enzyme-linked immunosorbent assay. All experiments were conducted in triplicate. Results were analyzed by one-way ANOVA, and significance was accepted at p < 0.05. RESULTS: Yokukansan suppressed SP-induced production of IL-6 and IL-8 by U373 MG cells, and downregulated SP-induced COX-2 expression. Yokukansan also inhibited phosphorylation of ERK1/2 and p38 MAPK, as well as nuclear translocation of NF-κB, induced by SP stimulation of U373 MG cells. CONCLUSION: Yokukansan exhibits anti-inflammatory activity by suppressing SP-induced production of IL-6 and IL-8 and downregulating COX-2 expression in U373 MG cells, possibly via inhibition of the activation of signaling molecules, such as ERK1/2, p38 MAPK, and NF-κB.

Correlation between urinary biomarker and organ failure in patients with sepsis and patients after esophagectomy: a prospective observational study.

BACKGROUND: Neutrophil gelatinase-associated lipocalin (NGAL) is a diagnostic marker for acute kidney injury (AKI). NGAL expression is highly induced not only in kidney injury but also in bacterial infection, inflammation, and cancer. The factors regulating NGAL expression are proinflammatory cytokines, and plasma NGAL levels have been increased in septic shock. However, there are no reports of urine neutrophil gelatinase-associated lipocalin (uNGAL) levels after open esophagectomy. METHODS: We prospectively enrolled critically ill patients, including patients with sepsis (n = 45) and patients who underwent open esophagectomy (n = 40). We compared vital signs, PaO2/FIO2, serum C-reactive protein (CRP) levels, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, and uNGAL levels between the sepsis group and the esophagectomy group. Then, we investigated whether uNGAL is associated with the severity of illness and organ failure, and whether uNGAL is a reliable screening test for AKI. RESULTS: The median uNGAL levels, APACHE II score, SOFA score, and serum CRP levels were significantly (p < 0.001) higher in the sepsis group than in the esophagectomy group on ICU day 1. In the sepsis group, uNGAL levels were significantly (p < 0.05) correlated with APACHE II score and SOFA score on intensive care unit (ICU) day 1, 2, and 3. In the esophagectomy group, uNGAL levels were significantly (p < 0.05) correlated with SOFA score on ICU day 3 and 4. In the sepsis group, 1 patient developed AKI stage 2 and 6 patients developed AKI stage 3. No patients developed AKI in the esophagectomy group. In a total of 85 patients of this study, 80 patients had an abnormal value of uNGAL and only 7 patients (8.7%) of those 80 patients developed AKI. CONCLUSIONS: uNGAL levels were correlated with the severity of illness and organ failure in critically ill patients. The value of uNGAL increases under the surgical and inflammatory responses, thereby losing a significance of a screening test of AKI in critically ill patients.

NF-kB signaling in cardiomyocytes is inhibited by sevoflurane and promoted by propofol.

Both inhalational and intravenous anesthetics affect myocardial remodeling, but the precise effect of each anesthetic on molecular signaling in myocardial remodeling is unknown. Here, we performed in silico analysis to investigate signaling alterations in cardiomyocytes induced by inhalational [sevoflurane (Sevo)] and intravenous [propofol (Prop)] anesthetics. Bioinformatics analysis revealed that nuclear factor-kappa B (NF-kB) signaling was inhibited by Sevo and promoted by Prop. Moreover, nuclear accumulation of p65 and transcription of NF-kB-regulated genes were suppressed in Sevo-administered mice, suggesting that Sevo inhibits the NF-kB signaling pathway. Our data demonstrate that NF-kB signaling is inhibited by Sevo and promoted by Prop. As NF-kB signaling plays an important role in myocardial remodeling, our results suggest that anesthetics may affect myocardial remodeling through NF-kB.

The effects of a recruitment manoeuvre with positive end-expiratory pressure on lung compliance in patients undergoing robot-assisted laparoscopic radical prostatectomy.

The effects of a recruitment manoeuvre (RM) with positive end-expiratory pressure (PEEP) on lung compliance (CLUNG) are not well characterised in robot-assisted laparoscopic radical prostatectomy (RARP). Patients were allocated to group R (n = 10; with an RM) or C (n = 9; without an RM). An RM involved sustained inflation of 30 cmH2O for 30 s. The lungs were ventilated with volume-controlled ventilation with tidal volume of 7 mL kg-1 of predicted body weight and fraction of inspired oxygen of 0.5. End-tidal carbon dioxide pressure was maintained at normocapnia. Patients were in the horizontal lithotomy position (pre-op). After pneumoperitoneum, patients underwent RARP in a steep Trendelenburg lithotomy position at a PEEP level of 0 cmH2O (RARP0). An RM was used in the R group but not in the C group. Patients were then ventilated with 5 cmH2O PEEP for 1 h after RARP0 (RARP5.1) and 2 h after RARP0 (RARP5.2). Oesophageal pressure and airway pressure were measured for calculating CLUNG and chest wall compliance. CLUNG significantly decreased from pre-op to RARP0 and did not significantly increase from RARP0 to RARP5.1 and RARP5.2 in either group. CLUNG differed significantly between groups at RARP5.1 and RARP5.2 (103 ± 30 vs. 68 ± 11 mL cm-1 H2O and 106 ± 35 vs. 72 ± 9 mL cm-1 H2O; P < 0.05). In patients undergoing RARP, with the addition of RM, the CLUNG was effectively increased from the horizontal lithotomy position to the steep Trendelenburg lithotomy position under pneumoperitoneum.

Shortened cataract surgery by standardisation of the perioperative protocol according to the Joint Commission International accreditation: a retrospective observational study.

OBJECTIVES: To investigate the impact of standardisation of the perioperative protocol based on the Joint Commission International (JCI) accreditation guidelines for operating time in cataract surgery. DESIGN: Retrospective observational study. SETTING: Single centre in Japan. PARTICIPANTS: Between March 2014 and June 2016, 3127 patients underwent cataract surgery under topical anaesthesia including 2581 and 546 patients before and after JCI accreditation, respectively. PRIMARY AND SECONDARY OUTCOMES: We compared three time periods, comprising the preprocedure/surgery time (pre-PT), PT and post-PT, and total PT (TPT) of cataract surgery between patients before and after JCI accreditation, by regression analysis adjusted for age, sex and cataract surgery-associated confounders. RESULTS: The main outcomes were pre-PT, PT, post-PT and TPT. Pre-PT (19.8±10.5 vs 13.9±8.5 min, p<0.001) and post-PT (3.5±4.6 vs 2.6±2.1 min, p<0.001) significantly decreased after JCI accreditation, while PT did not significantly change (16.8±6.7 vs 16.2±6.3 min, p=0.065). Consequently, TPT decreased on average by 7.3 min per person after JCI accreditation (40.1±13.4 vs 32.8±10.9 min, p<0.001). After adjusting for confounders, pre-PT (ß=-5.82 min, 95% CI -6.75 to -4.88), PT (ß=-0.76 min, 95% CI -1.34 to -1.71), post-PT (ß=-0.85 min, 95% CI -1.24 to -0.45) and TPT (ß=-7.43 min, 95% CI -8.61 to -6.24) were significantly shortened after JCI accreditation. CONCLUSION: Perioperative protocol standardisation, based on JCI accreditation, shortened TPT in cataract surgery under local anaesthesia.

Effect of Propofol on the Production of Inflammatory Cytokines by Human Polarized Macrophages.

Macrophages are key immune system cells involved in inflammatory processes. Classically activated (M1) macrophages are characterized by strong antimicrobicidal properties, whereas alternatively activated (M2) macrophages are involved in wound healing. Severe inflammation can induce postoperative complications during the perioperative period. Invasive surgical procedures induce polarization to M1 macrophages and associated complications. As perioperative management, it is an important strategy to regulate polarization and functions of macrophages during inflammatory processes. Although propofol has been found to exhibit anti-inflammatory activities in monocytes and macrophages, it is unclear whether propofol regulates the functions of M1 and M2 macrophages during inflammatory processes. This study therefore investigated the effects of propofol on human macrophage polarization. During M1 polarization, propofol suppressed the production of IL-6 and IL-1ß but did not affect TNF-α production. In contrast, propofol did not affect the gene expression of M2 markers, such as IL-10, TGF-ß, and CD206, during M2 polarization. Propofol was similar to the GABAA agonist muscimol in inducing nuclear translocation of nuclear factor-E2-related factor 2 (Nrf2) and inhibiting IL-6 and IL-1ß, but not TNF-α, production. Knockdown of Nrf2 using siRNA significantly reduced the effect of propofol on IL-6 and IL-1ß production. These results suggest that propofol prevents inflammatory responses during polarization of human M1 macrophages by suppressing the expression of IL-6 and IL-1ß through the GABAA receptor and the Nrf2-mediated signal transduction pathway.

Association between change in self-efficacy and reduction in disability among patients with chronic pain.

PURPOSE: This study aimed to investigate whether changes in psychosocial factors and pain severity were associated with reduction in disability due to pain among patients with chronic pain. We hypothesized that increased self-efficacy would reduce disability. PATIENTS AND METHODS: This longitudinal observational study included 72 patients. Patients' psychological and physical variables were assessed before and after 3 months of treatment. Demographic and clinical information were collected, including the Pain Disability Assessment Scale (PDAS), the Pain Self-Efficacy Questionnaire (PSEQ), the Hospital Depression and Anxiety Scale, and the Numeric Rating Scale (NRS) to assess pain intensity. First, univariate regression analyses were conducted to clarify associations between change in PDAS and sex, age, pain duration, changes in psychosocial factors (self-efficacy, anxiety, and depression) and change in pain intensity. Second, multivariate regression was conducted using the variables identified in the univariate analyses (PSEQ and NRS) to detect the most relevant factor for reducing disability. RESULTS: Univariate regression analyses clarified that changes in PSEQ (ß = -0.31; 95% CI: -0.54--0.08, p = 0.008) and NRS (ß = 0.24; 95% confidence interval [CI]: 0.01-0.47, p = 0.04) were associated with reduction in PDAS. Multivariate regression analysis demonstrated that change in PSEQ (ß = 0.26; 95% CI: -0.50--0.02; p = 0.01) was associated with a reduction in disability, independent of change in NRS. CONCLUSION: These findings suggest improved self-efficacy is associated with reduced disability in patients with chronic pain, independent of reduction in pain intensity. Focusing on improvement in self-efficacy may be an effective strategy in chronic pain treatment in addition to pain relief.

Thoracoscopic Pulmonary Lobectomy for Densely Fused Pulmonary Lobes in Children with Congenital Pulmonary Airway Malformation: Technical Tips.

AIM: Thoracoscopic pulmonary lobectomy (TPL) is extremely challenging in cases where severe incomplete fissure causes densely fused pulmonary lobes (DFPL) since pulmonary arteries (PAs) are buried and completely concealed by DFPL. We describe TPL for DFPL including a technical tip to prevent pitfalls. MATERIALS AND METHODS: Four congenital pulmonary airway malformation (CPAM) and DFPL (left-upper: 2, left-lower: 1, right-middle: 1) were treated. During TPL, DFPL prevent interlobar PAs from being identified and searching for them only promotes bleeding and air leakage, serious pitfalls that affect the safety and success of TPL. Our tip is to ligate and divide the pulmonary veins (PVs) at the pulmonary hilum and the hilar PA supplying the CPAM lobe to expose the bronchus of the lobe, which is then ligated and divided. The main PA supplying the lobe running underneath the DFPL is exposed and visible from the pulmonary hilum allowing the PA supplying the lobe to be ligated and divided safely. A line demarcating the fused fissure becomes apparent, and an endoscopic stapler or EnSeal® device can be used to divide the DFPL along the line taking great care not to injure the main PA or interlobar PAs. RESULTS: There were no intra-/postoperative complications in any case. All patients performed well without respiratory tract-related symptoms after a mean follow-up of 4.6 years. CONCLUSIONS: TPL for DFPL in children with CPAM can be performed safely and successfully as a virtually bloodless procedure and without incidence of air leakage by ligating and dividing the PA after dividing the PVs and bronchus to the lobe.

Intercostal misplacement of a thoracic epidural catheter discovered during lung cancer surgery: a case report.

BACKGROUND: Blind epidural catheter placement can lead to inadvertent misplacement. We present a case of intercostal misplacement of a thoracic epidural catheter. CASE PRESENTATION: A 67-year-old male underwent left lung cancer surgery via thoracotomy with epidural analgesia via the Th 5-6 intervertebral space, although with some difficulty. We detected dermatomal cold sensory loss around Th five min after initial administration of local anesthetics through the catheter before general anesthesia induction. However, the epidural catheter was intraoperatively found below the fifth rib, running along the course of the intercostal nerve. The catheter was successfully withdrawn via his back, and we postoperatively performed paravertebral block under ultrasound guidance. He did not complain of complications at discharge. CONCLUSIONS: Detailed bilateral assessment of sensory loss after initial local anesthetic administration might have facilitated preoperative detection of the misplacement. In cases requiring multiple catheter insertion attempts, switching to another analgesic method should be considered.

High-flow oxygen via tracheostomy facilitates weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction: two case reports.

BACKGROUND: Weaning from prolonged mechanical ventilation is extremely difficult in tracheostomized patients with restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy supplies heated and humidified oxygen gas at > 10 L/minute. However, little has been reported on the use of high-flow oxygen via tracheostomy during weaning from ventilators in patients with restrictive pulmonary dysfunction. We report successful weaning from ventilators in patients with restrictive pulmonary dysfunction using high-flow oxygen via tracheostomy. CASE PRESENTATION: The first patient is a 78-year-old Japanese man with severe pneumococcal pneumonia who was mechanically ventilated for more than 1 month after esophagectomy for esophageal cancer. After he underwent tracheostomy because of prolonged mechanical ventilation, restrictive pulmonary dysfunction appeared: tidal volume 230-240 mL and static compliance 14-15 mL/cmH2O with 10 cmH2O pressure support ventilation. He was weaned from the ventilator under inspiratory support with high-flow oxygen via tracheostomy over a period of 16 days (flow at 40 L/minute and fraction of inspired oxygen of 0.25). The second patient is a 69-year-old Japanese man who developed aspiration pneumonia after esophagectomy and received prolonged mechanical ventilation via tracheostomy. He developed restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy (flow at 40 L/minute with fraction of inspired oxygen of 0.25) was administered with measurement of the airway pressure and at the entrance of the tracheostomy tube. The measured values were as follows: 0.21-0.3 cmH2O, 0.21-0.56 cmH2O, 0.54-0.91 cmH2O, 0.76-2.01 cmH2O, 1.17-2.01 cmH2O, and 1.76-2.01 cmH2O at 10 L/minute, 20 L/minute, 30 L/minute, 40 L/minute, 50 L/minute, and 60 L/minute, respectively. The airway pressures were continuously positive and did not become negative even during inspiration, suggesting that high-flow oxygen via tracheostomy reduces inspiratory effort. He was weaned from the ventilator under inspiratory support with high-flow oxygen via tracheostomy over a period of 12 days. CONCLUSIONS: High-flow oxygen via tracheostomy may reduce the inspiratory effort and enhance tidal volume by delivering high-flow oxygen and facilitate weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction.