The impact of electrosurgical devices on electromyography-based neuromuscular monitoring during abdominal laparotomy: a case series.

The present study aimed to evaluate the effect of electrosurgical devices on neuromuscular monitoring using an electromyography (EMG)-based neuromuscular monitor during abdominal laparotomy. Seventeen women (aged 32-64 years) undergoing gynecological laparotomy under total intravenous general anesthesia were enrolled in the study. A TetraGraph™ was placed to stimulate the ulnar nerve and to monitor the abductor digiti minimi muscle. After device calibration, train-of-four (TOF) measurements were repeated at intervals of 20 s. Rocuronium 0.6 to 0.9 mg/kg was administered for induction, and additional doses of 0.1 to 0.2 mg/kg were administered to maintain TOF counts ≤ 2 during the surgery. The primary outcome of the study was the ratio of measurement failure. The secondary outcomes of the study were the total number of measurements, the number of measurement failures, and the most extended consecutive number of measurement failures. The data are expressed as median (range). Of the 3091 (1480-8134) measurements, the number of measurement failures was 94 (60-200), resulting in a failure ratio of 3.5% (1.4-6.5%). The most extended consecutive number of measurement failures was 8 (4-13). All attending anesthesiologists were able to maintain and reverse neuromuscular blocks under EMG guidance. This prospective observational study demonstrated that the use of EMG-based neuromuscular monitoring does not seem to be heavily affected by electrical interference during lower abdominal laparotomic surgery. Trial registration This trial was registered in the University Hospital Medical Information Network under registration number UMIN000048138 (registration date; June 23, 2022).

Use of intraoperative neuromuscular monitor reduces the reversal dose of sugammadex: a single-center retrospective study.

PURPOSE: We compared the reversal doses of sugammadex in surgical cases in which intraoperative neuromuscular monitor were used, to cases in which intraoperative neuromuscular monitoring was not used, retrospectively. METHODS: Data were collected by reviewing the electronic medical records of patients who received rocuronium and sugammadex during general anesthesia at Asahikawa Medical University Hospital between May 1, 2017 and April 30, 2018. The primary outcome was the reversal dose of sugammadex per patient actual body weight (mg/kg) between the group in which intraoperative neuromuscular monitoring was used (NM+ group) and the group in which intraoperative neuromuscular monitoring was not used (NM- group). RESULTS: A total of 3496 patients were evaluated, with 2544 patients (73%) included in NM+ group and 952 patients (27%) in NM- group. The reversal doses of sugammadex per actual body weight were significantly higher in NM- group compared to NM+ group. In the NM+ group, 521 patients (20%) received < 2 mg/kg sugammadex, 1377 patients (54%) received 2 ~ 2.5 mg/kg sugammadex, and 646 patients (25%) received > 2.5 mg/kg sugammadex. In contrast, 128 patients (13%) received < 2 mg/kg sugammadex, 362 patients (38%) received 2 ~ 2.5 mg/kg sugammadex and 462 patients (49%) received > 2.5 mg/kg sugammadex in NM- group. CONCLUSION: This single-center retrospective study demonstrated that the use of intraoperative neuromuscular monitor reduced the reversal dose of sugammadex.

Impact of high spinal anesthesia technique on fast-track strategy in cardiac surgery: retrospective study.

BACKGROUND AND OBJECTIVES: Although high spinal anesthesia (HSA) has been used in cardiac surgery, the technique has not yet been widely accepted. This retrospective study was designed to investigate the impact of HSA technique on fast-track strategy in cardiac surgery. METHODS: Elective cardiac surgery cases (n=1025) were divided into two groups: cases with HSA combined with general anesthesia (GA) (HSA group, n=188) and cases with GA only (GA group, n=837). In the HSA group, bupivacaine and morphine were intrathecally administered immediately before GA was induced. Outcomes included fast-track extubation (less than 6 hours), extubation in the operating room, fast-track discharge from the intensive care unit (ICU) (less than 48 hours) and hospital (less than 7 days). RESULTS: In the HSA group, 60.1% were extubated in less than 6 hours after ICU admission, as compared with 39.9% in the GA group (p<0.001). In the HSA group, 33.0% were extubated in the operating room, as compared with 4.4% in the GA group (p<0.001). LOS in the ICU was less than 48 hours in 67.6% in the HSA group, as compared with 57.2% of those in the GA group (p=0.033). LOS in the hospital was less than 7 days in 63.3% in the HSA group, as compared with 53.5% in the GA group (p=0.084). CONCLUSIONS: HSA technique combined with GA in cardiac surgery increased the rate of fast-track extubation (less than 6 hours) when compared with GA only.

Effectiveness and Safety of Ultrasound Guided Lower Extremity Nerve Blockade in Infragenicular Bypass Grafting for High Risk Patients With Chronic Limb Threatening Ischaemia.

OBJECTIVES: Surgical revascularisation to accomplish limb salvage remains preferable in some patients with chronic limb threatening ischaemia (CLTI). The aim of this study was to evaluate the effectiveness and safety of ultrasound guided lower extremity nerve blockade (UGNB) in infragenicular bypass surgery (IGBS). METHODS: This was a single centre, retrospective clinical study. Fifty-nine patients with CLTI (67 limbs) who underwent IGBS under UGNB (femoral and sciatic nerve blockade) at Asahikawa Medical University between January 2012 and December 2017 were compared with patients with CLTI (137 limbs) who underwent IGBS under general anaesthesia (GA) over the same period. Propensity score matching based on pre-operative comorbidities was used to minimise background differences of the two groups. RESULTS: Fifty-six pairs of CLTIs were matched and analysed (55% dialysis dependent). Procedure duration was similar between the two groups, but intraoperative catecholamine index and intravenous fluid volume were lower with UGNB compared with GA (2.9 ± 4.6 vs. 5.9 ± 6.5; p < .01 and 1831 ± 990 vs. 2335 ± 931 mL; p < .01, respectively). The mean arterial blood pressure during induction of anaesthesia was significantly decreased with GA. Post-operatively, the time period to resume a clear liquid and solid food diet was significantly shorter with UGNB (P<0.01 for both outcome measures). Intravenous fluid volume was significanlty lower, while cardiac complications and delirium, based on the NEECHAM confusion scale, occurred significantly less often with UGNB than GA. These significant differences show advantages of UGNB compared to GA. No mortality or major amputations were observed in either group. Early graft thrombosis was observed in five limbs (8.9%) with UGNB and in four limbs with GA (7.1%) (p = .73). CONCLUSIONS: UGNB has advantages for intra- and post-operative management and could be a useful method to prevent peri-operative complications for high risk patients with CLTI. To ensure the effectiveness of UGNB for IGBS for future indications, a randomised study is required.

Assessment of mitigation strategies as tools for risk management under future uncertainties: a multi-model approach.

Although the world understands the possible threat of the future of climate changes, there remain serious barriers to be resolved in terms of policy decisions. The scientific and the societal uncertainties in the climate change policies must be the large part of this barrier. Following the Paris Agreement, the world comes to the next stage to decide the next actions. Without a view of risk management, any decision will be "based on neglecting alternatives" behavior. The Ministry of the Environment, Japan has established an inter-disciplinary research project, called Integrated Climate Assessment-Risks, Uncertainties, and Society (ICA-RUS) conducted by Dr. Seita Emori, National Institute for Environmental Studies. ICA-RUS consists of five research themes, i.e., (1) synthesis of global climate risks, (2) optimization of land, water, and ecosystem for climate risks, (3) analysis of critical climate risks, (4) evaluation of climate risk management options, and (5) interactions between scientific and social rationalities. We participated in the fourth theme to provide the quantitative assessment of technology options and policy measures by integrating assessment model simulations. We employ the multi-model approach to deal with the complex relationships among various fields such as technology, economics, and land use changes. Four different types of integrated assessment models, i.e., MARIA-14 (Mori), EMEDA (Washida), GRAPE (Kurosawa), and AIM (Masui), participate in the fourth research theme. These models contribute to the ICA-RUS by providing two information categories. First, these models provide common simulation results based on shared socioeconomic pathway scenarios and the shared climate policy cases given by the first theme of ICA-RUS to see the ranges of the evaluation. Second, each model also provides model-specific outcomes to answer special topics, e.g., geoengineering, sectoral trade, adaptation, and decision making under uncertainties. The purpose of this paper is to describe the outline and the main outcomes of the multi-model inter-comparison among the four models with a focus upon the first and to present the main outcomes. Furthermore, in this study, we introduce a statistical meta-analysis of the multi-model simulation results to see whether the differently structured models provide the inter-consistent findings. The major findings of our activities are as follows: First, in the stringent climate target, the regional economic losses among models tend to diverge, whereas global total economic loss does not. Second, both carbon capture and storage (CCS) as well as BECCS are essential for providing the feasibility of stringent climate targets even if the deployment potential varies among models. Third, the models show small changes in the crop production in world total, whereas large differences appear between regions. Fourth, the statistical meta-analysis of the multi-model simulation results suggests that the models would have an implicit but common relationship between gross domestic product losses and mitigation options even if their structures and simulation results are different. Since this study is no more than a preliminary exercise of the statistical meta-analysis, it is expected that more sophisticated methods such as data mining or machine learning could be applicable to the simulation database to extract the implicit information behind the models.

A case of iatrogenic pneumothorax in which chest tube placement could be avoided by intraoperative evaluation with transthoracic ultrasonography.

We report a case of iatrogenic pneumothorax in which chest tube placement was avoided by continuous intraoperative evaluation with transthoracic ultrasonography. A 53-year-old man had undergone a subsegmentectomy. While attempting to place a central venous catheter in the right internal jugular vein after the induction of anesthesia, we identified gas absorption during the puncture and suspected a pneumothorax. Chest X-ray revealed an ~5-mm collapse of the right lung apex. Tension pneumothorax was a concern during surgery because of the long-term positive pressure ventilation, but we decided to start the operation without preventative chest tube placement. During the operation, we regularly observed the midclavicular line of the second intercostal space using ultrasound. The operation was completed uneventfully. In this case, we effectively utilized ultrasound and avoided preventive chest tube placement and the associated complications. Transthoracic ultrasonography could be performed easily and continuously during surgery and was effective for evaluating the progression of an intraoperative pneumothorax.

Detection of dexmedetomidine in human breast milk using liquid chromatography-tandem mass spectrometry: Application to a study of drug safety in breastfeeding after Cesarean section.

Several analytical methods for dexmedetomidine (DEX) in human plasma have been published, but quantification of DEX in human breast milk has not been described. In this article, we describe a high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method suitable for quantification of DEX in human breast milk. DEX and an internal standard were extracted in a single liquid-liquid extraction step with diethyl ether from 200µL of human breast milk. HPLC was performed on a TSK-gel ODS-100V column with isocratic elution at a flow rate of 0.3mL/min using a mobile phase of 5mM ammonium formate:0.1% formic acid in acetonitrile (60:40, v/v). Detection was performed using an API4000 mass spectrometer with positive electrospray ionization. The method was validated in the concentration range of 10pg/mL (lower limit of quantification) to 2000pg/mL. The intra- and inter-day accuracy were within ±5.8% and precision was <6.31% based on the coefficient of variation. The recoveries of DEX in human breast milk were 82.4-87.9%. Recovery and matrix effects were consistent and reproducible for human breast milk. The method is robust and was successfully used in a study of drug safety in breastfeeding in patients after administration of DEX.

Pulse oximetry-derived pleth variability index can predict dexmedetomidine-induced changes in blood pressure in spontaneously breathing patients.

STUDY OBJECTIVE: Hypertension or hypotension in patients receiving continuous infusions of dexmedetomidine (DEX) is often due to changes in vascular resistance caused by α2 receptor stimulation. We investigated whether baseline perfusion index (PI) and pleth variability index (PVI), derived from pulse oximetry readings, could predict DEX-induced changes in the hemodynamic status in spontaneously breathing patients. DESIGN: Observational study. SETTING: Operating room. PATIENTS: Patients (American Society of Anesthesiologists performance status 1 or 2) scheduled to undergo lower extremity or abdominal procedures under regional anesthesia were approached. INTERVENTIONS: The PI and PVI were set as baseline upon arrival in theater and were then measured at 2.5-minute intervals. Upon attaining stable hemodynamic status under spontaneous breathing, intravenous administration of DEX was initiated at 6 µg kg(-1) h(-1) for 10minutes, followed by continuous infusion at 0.6 µg kg(-1) h(-1). MEASUREMENTS: Blood pressure, heart rate, PI, and PVI were measured. Hypertension was defined as an increase in systolic blood pressure (SBP) >15% and hypotension as a decrease in SBP <15% from baseline. MAIN RESULTS: Baseline PI and PVI correlated with the degree of change in SBP. The maximum percentage increase as well as the maximum percentage of decrease in SBP from baseline correlated with baseline PI (r=0.418 [P=.005] and r=0.507 [P<.001], respectively) and PVI (r=-0.658 [P<.001] and r=-0.438 [P=.003], respectively). PVI <15 identified DEX-induced hypertension (sensitivity 94%, specificity 85%) and PVI >16 identified DEX-induced hypotension (sensitivity 83%, specificity 64%). CONCLUSIONS: PVI may predict DEX-induced changes in blood pressure in spontaneously breathing patients.

[Evaluation of the Effects of Remifentanil Doses on Hemodynamics and Perfusion Index at the Onset of Pneumoperitoneum during Laparoscopic Surgery].

BACKGROUND: The aim of this study was to investigate whether changes in perfusion index (PI) correlate with non-invasive haemodynamic parameters (HR, BP) following the onset of pneumoperitoneum under two doses (moderate-dose (MD) and high-dose (HD)) of remifentanil and to compare its reliability. METHODS: We divided 33 patients who were scheduled for laparoscopic surgery under general anesthesia into two groups according to the dose of continuously infused remifentanil: moderate dose 0.5 µg x kg(-1) x min(1) (MD group, n = 16) and high dose 1.0 µg x kg(-1) x min(-1) (HD group, n = 17). Non-invasive blood pressure (NIBP), HR, and PI were measured before the start of surgery (time 1), after the start of surgery (time 2), before the start of pneumoperitoneum (time 3), and 1 min after the stable state of pneumoperitoneum (time 4). RESULTS: PI decreased from the baseline after pneumoperitoneum in MD group, on the other hand PI did not change in HD group. Between the two groups, the magnitude of the PI changes was statistically different although MBP and HR were not statistically different CONCLUSIONS: PI may be a reliable and easier alternative to conventional haemodynamic parameters for detection of stress response to pneumoperitoneum during remifentanil anaesthesia in adult patients.

[The Efficacy of Ultrasound-guided Radial Artery Catheterization.]

BACKGROUND: The goal of this study was to evaluate in patients with peripheral arterial disease (PAD) whether ultrasound-guided radial artery catheterization decreased procedural time and number of attempts compared with the traditional palpation technique. METHODS: Ultrasonography was evaluated for arte- rial catheterization after the traditional palpation tech- nique was unsuccessful in 480 seconds in 10 patients with PAD. The vascular access was performed by a single anesthesiologist. The successful catheterization time and the number of attempts were recorded. We also measured the diameter of the radial artery, the skin-to-artery distance, and the distance between the linear probe and puncture site. RESULTS: The mean overall time per patient for catheter insertion was 220.0?112.6 sec in the ultra- sound group vs. 480 sec in the palpation group (P= 0.0029). The mean number of attempts was 1.30?0.48 in the ultrasound group vs. 4.50?0.53 in the palpation group (P = 0.0024). All catheterizations were success- ful, and no failure was encountered in the ultrasound group. CONCLUSIONS: Ultrasound-guided radial artery cath- eterization took less time to establish the arterial line, and it reduced the number of attempts when com- pared with the palpation technique.

Target-controlled infusion and population pharmacokinetics of landiolol hydrochloride in patients with peripheral arterial disease.

PURPOSE: We previously determined the pharmacokinetic (PK) parameters of landiolol in healthy male volunteers and gynecological patients. In this study, we determined the PK parameters of landiolol in patients with peripheral arterial disease. METHODS: Eight patients scheduled to undergo peripheral arterial surgery were enrolled in the study. After inducing anesthesia, landiolol hydrochloride was administered at target plasma concentrations of 500 and 1,000 ng/mL for 30 minutes each. A total of 112 data points of plasma concentration were collected from the patients and used for the population PK analysis. A population PK model was developed using a nonlinear mixed-effect modeling software program (NONMEM). RESULTS: The patients had markedly decreased heart rates at 2 minutes after initiation of landiolol hydrochloride administration; however, systolic blood pressures were lower than the baseline values at only five time points. The concentration time course of landiolol was best described by a two-compartment model with lag time. The estimates of PK parameters were as follows: total body clearance, 30.7 mL/min/kg; distribution volume of the central compartment, 65.0 mL/kg; intercompartmental clearance, 48.3 mL/min/kg; distribution volume of the peripheral compartment, 54.4 mL/kg; and lag time, 0.633 minutes. The predictive performance of this model was better than that of the previous model. CONCLUSION: The PK parameters of landiolol were best described by a two-compartment model with lag time. Distribution volume of the central compartment and total body clearance of landiolol in patients with peripheral arterial disease were approximately 64% and 84% of those in healthy volunteers, respectively.

Target-controlled infusion and population pharmacokinetics of landiolol hydrochloride in gynecologic patients.

PURPOSE: We previously determined the pharmacokinetic (PK) parameters of landiolol in healthy male volunteers. In this study, we evaluated the usefulness of target-controlled infusion (TCI) of landiolol hydrochloride and determined PK parameters of landiolol in gynecologic patients. METHODS: Nine patients who were scheduled to undergo gynecologic surgery were enrolled. After inducing anesthesia, landiolol hydrochloride was administered at the target plasma concentrations of 500 and 1,000 ng/mL for each 30 min. A total of 126 data points of plasma concentration were collected from the patients and used for the population PK analysis. Furthermore, a population PK model was developed using the nonlinear mixed-effect modeling software. RESULTS: The patients had markedly decreased heart rates (HRs) at 2 min after the initiation of landiolol hydrochloride administration; however, their blood pressures did not markedly change from the baseline value. The concentration time course of landiolol was best described by a 2-compartment model with lag time. The estimate of PK parameters were total body clearance (CL) 34.0 mL/min/kg, distribution volume of the central compartment (V 1) 74.9 mL/kg, inter-compartmental clearance (Q) 70.9 mL/min/kg, distribution volume of the peripheral compartment (V 2) 38.9 mL/kg, and lag time (ALAG) 0.634 min. The predictive performance of this model was better than that of the previous model. CONCLUSION: TCI of landiolol hydrochloride is useful for controlling HR, and the PK parameters of landiolol in gynecologic patients were similar to those in healthy male volunteers and best described by a 2-compartment model with lag time.

The dexmedetomidine concentration required after remifentanil anesthesia is three-fold higher than that after fentanyl anesthesia or that for general sedation in the ICU.

PURPOSE: The general dexmedetomidine (DEX) concentration required for sedation of intensive care unit patients is considered to be approximately 0.7 ng/mL. However, higher DEX concentrations are considered to be required for sedation and/or pain management after major surgery using remifentanil. We determined the DEX concentration required after major surgery by using a target-controlled infusion (TCI) system for DEX. METHODS: Fourteen patients undergoing surgery for abdominal aortic aneurysms (AAA) were randomly, double-blindly assigned to two groups and underwent fentanyl- or remifentanil-based anesthetic management. DEX TCI was started at the time of closing the peritoneum and continued for 12 hours after stopping propofol administration (M0); DEX TCI was adjusted according to the sedation score and complaints of pain. The doses and concentrations of all anesthetics and postoperative conditions were investigated. RESULTS: Throughout the observation period, the predicted plasma concentration of DEX in the fentanyl group was stable at approximately 0.7 ng/mL. In contrast, the predicted plasma concentration of DEX in the remifentanil group rapidly increased and stabilized at approximately 2 ng/mL. The actual DEX concentration at 540 minutes after M0 showed a similar trend (0.54±0.14 [fentanyl] versus 1.57±0.39 ng/mL [remifentanil]). In the remifentanil group, the dopamine dose required and the duration of intubation decreased, and urine output increased; however, no other outcomes improved. CONCLUSION: The DEX concentration required after AAA surgery with remifentanil was three-fold higher than that required after AAA surgery with fentanyl or the conventional DEX concentration for sedation. High DEX concentration after remifentanil affords some benefits in anesthetic management.

Population pharmacokinetics of olprinone in healthy male volunteers.

BACKGROUND: Olprinone decreases the cardiac preload and/or afterload because of its vasodilatory effect and increases myocardial contractility by inhibiting phosphodiesterase III. PURPOSE: The objective of this study was to characterize the population pharmacokinetics of olprinone after a single continuous infusion in healthy male volunteers. METHODS: We used 500 plasma concentration data points collected from nine healthy male volunteers for the study. The population pharmacokinetic analysis was performed using the nonlinear mixed effect model (NONMEM®) software. RESULTS: The time course of plasma concentration of olprinone was best described using a two-compartment model. The final pharmacokinetic parameters were total clearance (7.37 mL/minute/kg), distribution volume of the central compartment (134 mL/kg), intercompartmental clearance (7.75 mL/minute/kg), and distribution volume of the peripheral compartment (275 mL/kg). The interindividual variability in the total clearance was 12.4%, and the residual error variability (exponential and additive) were 22.2% and 0.129 (standard deviation). The final pharmacokinetic model was assessed using a bootstrap method and visual predictive check. CONCLUSION: We developed a population pharmacokinetic model of olprinone in healthy male adults. The bootstrap method and visual predictive check showed that this model was appropriate. Our results might be used to develop the population pharmacokinetic model in patients.

[Case report of cardiac arrest during carotid body tumor resection].

We report a case of 30-second cardiac arrest that occurred during carotid body tumor resection due to the carotid sinus reflex. The patient was a 20-year-old man diagnosed with a carotid body tumor and scheduled for tumor resection. General anesthesia was induced and maintained with target controlled infusion of propofol. Analgesia was achieved with continuous administration of remifentanil. When the surgery was initiated, 1% lidocaine 3 ml was locally injected into the carotid bifurcation. When surgery was initiated in the neck region, the patient developed sudden cardiac arrest. Chest compression was immediately initiated, and atropine 0.5 mg was administered; subsequently circulation was restored. Surgery was resumed after placing a temporary pacemaker through the left subclavian vein. The surgery was successfully performed without any other bradycardia complications, and the patient recovered from general anesthesia without sequelae. Thus, the findings indicate the importance of considering the pacemaker placement before carotid body tumor resection.

Preoperative morphological analysis by transesophageal echocardiography and predictive value of plasma landiolol concentration during systolic anterior motion mitral valve repair : a report of three cases.

We report three cases with systolic anterior motion (SAM) after mitral valve plasty. Preoperative mitral valve morphology is a risk factor for SAM. The morphological characteristics of SAM have been revealed in several studies. We found a small distance between coaptation and the interventricular septum in all cases, and cases 2, and 3 had a low AL/PL ratio, whereas case 3 had a large PML, which was revealed by transesophageal echocardiography. With the use of 3D transesophageal echocardiography, when mitral valve prolapse was investigated, in all three cases, it was easy to specify lesions. The issue for the future is 3D analysis when SAM is occurring.

[Intraoperative evaluation of visceral arteries by transesophageal echocardiography during aortic fenestration].

76-year-old man was diagnosed with DeBakey type IIIb acute aortic dissection, for which he underwent axillo-femoral bypass surgery. Two days postoperatively, hematochezia developed suddenly. Laboratory data revealed AST 5,088 IU x l(-1), ALT 3,822 IU x l(-1), and CK 27,746 IU x l(-1) suggesting intestinal malperfusion due to stenosis of the celiac artery (CEA) and superior mesenteric artery (SMA). The abdominal aorta and visceral arteries were evaluated by transesophageal echocardiography (TEE). Color Doppler imaging revealed increased blood flow velocity (4.0 m x sec(-1)) in CEA due to the stenosis, while that in SMA was decreased. Open abdominal aortic fenestration was performed. The aorta was clamped at the level of the infra-renal and inferior mesenteric arteries, and the septum between the false and true lumens was resected. On postoperative TEE assessment, CEA stenosis was resolved, and flow velocity was improved (3.0 m x sec(-1)). Color Doppler imaging demonstrated that fenestration resulted in recovery of SMA perfusion. Aortic fenestration is useful in the treatment of ischemic complications of aortic dissection. Its advantages include minimal invasiveness and short operative time. Bypass surgery and reoperation were avoided by evaluating visceral arteries by TEE in the case reported here.

[Diagnosing pneumothorax by using transthoracic lung ultrasonography during one lung ventilation].

BACKGROUND: Ultrasound guided neuraxial block or central venous puncture is now becoming popular in our anesthesia practice to reduce the risk of complications. Pneumothorax is a rare, but possible complication related to these interventions even if the ultrasound is used. However, the pneumothorax itself can also be diagnosed by the ultrasound. We therefore examined the efficacy of ultrasound for diagnosing pneumothorax during lung surgery requiring one lung ventilation. METHODS: In 20 elective surgery patients, transthoracic lung ultrasonography was performed. The lung sliding, comet-tail artifact, M-mode, lung pulse, and power sliding were used to eliminate pneumothorax, and the reverberation artifact was used as a sign of the pneumothorax. Ultrasound procedure was videotaped for postprocedure analysis. Both sensitivity and specificity were calculated in each case. RESULTS: Lung sliding and M-mode procedure showed high sensitivity and specificity in diagnosing pneumothorax. Reverberation artifact also showed high sensitivity, but its specificity was too low to determine pneumothorax. CONCLUSIONS: Among six ultrasonic lung findings, lung sliding and M-mode procedure are most useful as screening methods of differentiating a pneumothorax.

Molecular typing of Salmonella enterica serotype Typhimurium and serotype 4,5,12:i:- isolates from cattle by multiple-locus variable-number tandem-repeats analysis.

To evaluate the usefulness of multiple-locus variable-number tandem-repeats analysis (MLVA) as a tool for the epidemiological analysis of bovine Salmonellosis, Salmonella enterica serotype Typhimurium and serotype 4,5,12:i:- isolates (544 and 18, respectively) obtained from cattle in Hokkaido, Japan, between 1977 and 2009, were characterised by MLVA. MLVA identified 184 profiles versus 121 profiles identified by pulsed-field gel electrophoresis (PFGE). Cluster analysis of the MLVA profiles demonstrated 3 major clusters (A, B, and C) and 3 minor clusters (D, E, and F). Cluster A was associated with PFGE cluster I, which included isolates of definitive phage type 104 (DT104), while cluster C was associated with PFGE cluster VII, which has been disseminating among cattle since 2002. An isolate of serotype Typhimurium belonging to MLVA cluster F, in which 10 serotype 4,5,12:i:- isolates were included, was found to have an MLVA profile closely related to those of serotype 4,5,12:i:- isolates, suggesting that such a strain may be an ancestral candidate for serotype 4,5,12:i:-. Overall, the discriminatory power of MLVA was higher than that of PFGE, and MLVA differentiated between the isolates of the DT104 family, which appeared to be clonal by PFGE. However, this depended on PFGE clusters because PFGE allowed greater discrimination between isolates within PFGE cluster IV and VI than MLVA. The combination of PFGE and MLVA data allowed for improved subtype discrimination and enabled the identification of recently disseminated clones. Hence, MLVA can be used in combination with PFGE to effectively accelerate the molecular epidemiologic investigation of Salmonella.