Effect of dietary fish and exercise training on urinary F2-isoprostane excretion in non-insulin-dependent diabetic patients.

Despite the potential benefits of dietary treatment with marine omega3 fatty acids in cardiovascular disease, there remains concern with respect to their potential for increased lipid peroxidation. Thus far, data from in vivo studies are inconclusive. Increased lipid peroxidation has also been associated with acute exercise in some studies, but the methods have been nonspecific. The quantitation of F2-isoprostanes provides a more reliable and useful assessment of in vivo lipid peroxidation. We therefore aimed to assess the independent and combined effects of dietary omega3 fatty acids and aerobic exercise training on urinary F2-isoprostane levels in dyslipidemic non-insulin-dependent diabetic (NIDDM) patients. In a randomized controlled trial, 55 untrained, sedentary, dyslipidemic NIDDM patients were randomly assigned to a low-fat diet (30% of daily energy) with or without one daily fish meal (3.6 g omega3 fatty acids per day) and further randomized to either a moderate (55% to 65% maximal oxygen consumption [VO2max]) or light (heart rate <100 bpm) exercise training program for 8 weeks. Twenty-four-hour urine samples from 49 subjects were collected for measurement of urinary F2-isoprostanes by gas chromatography-mass spectrometry before and after intervention. The fish diets reduced urinary F2-isoprostanes by 830+/-321 pmol/24 h (20%, P = .013) relative to the low-fat diet alone. This effect was independent of age, gender, and body weight change. Moderate exercise training did not alter F2-isoprostanes. These findings show that, at least in the short-term, exercise had no effect, whereas the inclusion of regular fish meals as part of a low-fat diet reduced in vivo lipid peroxidation in dyslipidemic NIDDM patients. This response could further complement the known benefits of omega3 fatty acids and exercise favoring a reduced cardiovascular risk in diabetic patients.

Repair of left ventricular diverticulum with ventricular bigeminy in an infant.

Surgical repair of left ventricular diverticulum usually is not required in infancy even though it combines with other anomalies. In addition to prevention of rupture of the diverticulum and thrombus formation, treatment of combined ventricular tachycardia is thought to be an indication for resection of the diverticulum. We describe a successful repair performed by excising the isolated left ventricular diverticulum under cardiopulmonary bypass in a 9-day-old infant. The combined ventricular bigeminy has disappeared 9 months after the operation.

Prevention of severe bleeding by tranexamic acid in a patient with disseminated intravascular coagulation.

Severe bleeding took place in a patient when abdominal aneurysm was removed by operation. Bleeding continued after infusion of heparin, antithrombin III (ATIII), fresh platelets and fresh blood. Infusion of tranexamic acid resulted in an immediate cessation of bleeding and improvement of his general condition. Sometime after the cessation by the administration of tranexamic acid, severe bleeding started again, resulting in intraperitoneal hematoma formation. Second time bleeding also stopped after the administration of tranexamic acid. Major finding of plasma parameters of fibrinolysis is that alpha 2AP which had been unable to inhibit plasmin, became able to inhibit it after the administration of tranexamic acid.

Successful cerebral artery stent placement for total occlusion of the vertebrobasilar artery in a patient suffering from acute stroke. Case report.

A 64-year-old man suffering from crescendo brainstem symptoms due to acute total occlusion of the vertebrobasilar artery was successfully treated by cerebral artery stent placement. The total occlusion of a long segment of the vertebrobasilar artery was completely recanalized by implanting two flexible, balloon-expandable coronary stents. The patient's clinical outcome 30 days later was favorable. No complications occurred during or after the procedure. This therapeutic option may prove to be a useful means to revascularize an acute total occlusion of the vertebrobasilar artery.

Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy.

BACKGROUND: Pancreatoenterostomic leakage after pancreatoduodenectomy may be caused partly by pancreatic juice leakage from transected branch pancreatic ducts on the pancreatic cut surface that do not drain into the main pancreatic duct after pancreatectomy. METHODS: We devised a new technique of pancreatic transection using an ultrasonic dissector followed by duct-to-mucosa pancreatojejunostomy, in order to prevent pancreatoenterostomic leakage after pancreatoduodenectomy in patients with a soft pancreas and a small main pancreatic duct. During pancreatic transection, branch pancreatic ducts and blood vessels are adequately skeletonized and securely ligated. The pancreatic duct is anastomosed to the full thickness of the jejunum with four to six interrupted sutures. RESULTS: Ten patients with a nondilated pancreatic duct (2 to 3 mm) underwent pancreatoduodenectomy by the present method. During pancreatic transection, 24 to 35 ducts including the pancreatic ducts and blood vessels were skeletonized and ligated. Postoperatively, no patients developed pancreatojejunostomic leakage. The present method may prevent pancreatoenterostomic leakage after pancreatoduodenectomy.

Preoperative endoscopic pancreatic stenting for safe local pancreatic resection.

Local pancreatic resection and enucleation have the advantage of preserving pancreatic parenchyma but pancreatic fistula often occurs postoperatively. We describe a case in which preoperative endoscopic pancreatic stenting prevented pancreatic fistula formation following local pancreatic resection. A pancreatic stent seems to prevent leakage from small pancreatic branch ducts not identified or ligated intraoperatively, via the pancreatic decompression effect. The present case demonstrates a novel indication for endoscopic pancreatic stenting.

Swallowing function following hypopharyngeal reconstruction with the pectoralis major musculocutaneous flap.

Swallowing function was studied in three patients following the pectoralis major musculocutaneous reconstruction of the hypopharynx and cervical esophagus after extensive resection for hypopharyngeal cancer. Fluoroscopy and endoscopy revealed the formation of a sphincter-like ring at the proximal end of the remaining intact esophagus. This ring may act to prevent reflux from the lower esophagus, although its sphincteric power is weak. Manometric testing showed that no swallowing pressure was produced in the reconstructed gullet; therefore, bolus propulsion at the pharyngeal stage occurs mainly by gravity. Follow-up studies on swallowing indicate a minimum length of the suture line of 11 cm in order to prevent esophageal stenosis due to anastomotic stricture at the distal mucocutaneous junction.

[A tuberculosis outbreak in a mental hospital].

PURPOSE AND METHODS: We experienced a tuberculosis outbreak in a mental hospital and discussed preventive measures for nosocomial tuberculosis infection. RESULTS: There are 18 mental hospitals within the administrative area of Hachioji public health center (PHC). A Total of 18 pulmonary tuberculosis cases were diagnosed in one of these hospitals between December 1995 and November 1998. They were all inpatients and two of them had history of tuberculosis. Fifty-two persons became candidates for isoniazid (INH) chemoprophylaxis as a consequence of the first extraordinary health examination. Chest radiographs of the inpatients had not been taken regularly in this hospital. Our recognition of the tuberculosis outbreak was delayed by omission of not only the case notification from the doctor who had diagnosed tuberculosis but the information from the PHC that had received the application of public subsidy for medical treatment. All cultured bacilli from 8 patients were susceptible to INH, rifampicin, streptomycin and ethambutol. Restriction fragment length polymorphism (RFLP) analysis of 4 strains, which we could have obtained, demonstrated an identical pattern. CONCLUSIONS: To prevent tuberculosis outbreaks in mental hospitals, we should consider these problems as follows; 1) Physical conditions of inpatients should be observed carefully and suitable physical checkups on inpatients with tuberculosis symptoms should be carried out by mental hospitals. 2) The doctor who had diagnosed a patient as having tuberculosis must send the case notification to the nearest PHC. 3) The PHC that received the information should investigate the case carefully and notify all related PHC's. 4) Extraordinary health examinations should be done appropriately by leadership of the PHC. 5) RFLP analysis of the tubercle bacilli is very useful to probe the source and route of infection. 6) Criteria for chemoprophylaxis for more than middle-aged persons should be established.

[Chest wall reconstruction for lung cancer patient].

To prevent flail chest after chest wall resection, chest wall reconstruction was performed to 74 primary lung cancer patients during the period between 1975 and 1994, out of 1,435 resected lung cancer patients, while in 29 cases, chest wall resection were performed without reconstruction. Numbers of ribs resected were from 1 to 5, mean 2.7, median 3. Chest wall reconstructions were performed in 66.7% of the patients for 2 ribs resected cases, 83.8% for 3 ribs cases, and 90.9% for more than 4 ribs cases. For chest wall reconstruction double layered Marlex mesh was used since 1982, while Dacron or Teflon felt was used until 1984. There was no flail chest, wound infection or operative death in the patients with chest wall resection and reconstruction. Survival curve of the p-T 3 N 0, 1 M 0 received chest wall reconstruction was compatible to the stage II cases out of 1,435 resected lung cancer patients (47.1% and 43.0% at 5 years). There is no need to perform chest wall reconstruction in cases like 1st to 3rd rib resection, or whose chest wall defect is covered with scapula. If the chest wall defect is lower than that and also lateral or anterior, chest wall reconstruction is indicated, even if resected ribs are less than 3. We should not hesitate to remove chest wall in order to get complete resection of the tumor, if tumor invasion is suspected surgically. Because we can reconstruct the chest wall with satisfactorily low risk of complications.

[A case of ruptured distal aortic arch aneurysm with bronchiolitis obliterans organizing pneumonia].

We report a case of histologically proved bronchiolitis obliterans organizing pneumonia (BOOP) associated with ruptured distal aortic arch aneurysm (DAAA) into the lung. A 63-years-old male with preoperative episode of hemosputum and hemoptysis was diagnosed DAAA. Preoperative computed tomographic scanning demonstrated that the aneurysm was surrounded with the structure of 2 layers of the enhanced high density external layer and the not enhanced low density internal layer. Combined resection of the left upper lobe and the aneurysm was performed safely because of marked adhesion between the lung and the aneurysm. Postoperative histological examination revealed that the perianeurysmal structure was due to BOOP.

[Hepatic arterial infusion after hepatectomy for liver metastases of colorectal carcinoma to prevent residual hepatic recurrence].

The hepatic recurrent rate after hepatic resection of colorectal liver metastases was 60-70%. Prevention of residual hepatic recurrence will result in a markedly better prognostic outcome. Thus, 51 patients with liver metastases of colorectal carcinoma were administered 5-FU from gastroduodenal artery after hepatectomy. The results were as follows: the cumulative 5-year survival rate; hepatic arterial infusion (+): 43.4%; (-): 18.5% (p < 0.05); the residual hepatic recurrent rate, hepatic arterial infusion (+): 33.3%; (-): 58.6% (p < 0.05); The total dose of 5-FU > or = 15 g administration group got less residual hepatic recurrent rate; and proved rather effective for prevention of residual hepatic recurrence. But the 5-year survival rate in extra-hepatic recurrence (+) was 14.1% and that of (-) was 70.9% (p < 0.001). In future, it will be necessary to prevent extra-hepatic recurrence after hepatectomy.

[Interferon therapy after ablation of Kent bundle for a patient with chronic hepatitis type B complicated with WPW syndrome].

Cardiotoxicity of interferon-alpha or gamma, such as fatal arrhythmia and myocardial infarction, has been reported. Therefore cardiotoxicity of interferon should be seriously considered before administration for patients with a pre-existing heart disease. We treated a patient with chronic active hepatitis type B, coexisted with Wolff-Parkinson-White syndrome, who has had frequent attacks of paroxysmal atrial fibrillation. To prevent the occurrence of fatal arrhythmia with an interferon therapy in this patient, we performed radiofrequency catheter ablation of the Kent bundle. After the successful ablation, we could safely administered recombinant interferon alpha-2b for chronic hepatitis type B.

[Epidemiological review of tuberculosis].

Current situation of tuberculosis (TB) problem of the world and of Japan is reviewed in terms of epidemiology and control strategy. Globally, TB has been increasing in the human history as ever. Even in the industrialized countries it is now in upsurge as one of the "re-emerging diseases". However, it is expected that with the wider and quick coverage of the new policy of treatment of cases using "DOTS strategy", we could attain the historical breakthrough of TB within couple of years. Japan is also faced with threats of TB with its new features to which the Japanese national control programme has not experienced enough. If we succeed in reorienting its programme well responding to the new TB problem, we will be able to achieve the goal of TB elimination by 2060, but maybe never earlier than that.

Evidence-based clinical practice guidelines for cholelithiasis 2016

BACKGROUND: This clinical practice guideline addresses six questions related to liberation from mechanical ventilation in critically ill adults. It is the result of a collaborative effort between the American Thoracic Society (ATS) and the American College of Chest Physicians (CHEST). METHODS: A multidisciplinary panel posed six clinical questions in a population, intervention, comparator, outcomes (PICO) format. A comprehensive literature search and evidence synthesis was performed for each question, which included appraising the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The Evidence-to-Decision framework was applied to each question, requiring the panel to evaluate and weigh the importance of the problem, confidence in the evidence, certainty about how much the public values the main outcomes, magnitude and balance of desirable and undesirable outcomes, resources and costs associated with the intervention, impact on health disparities, and acceptability and feasibility of the intervention. RESULTS: Evidence-based recommendations were formulated and graded initially by subcommittees and then modified following full panel discussions. The recommendations were confirmed by confidential electronic voting; approval required that at least 80% of the panel members agree with the recommendation. CONCLUSIONS: The panel provides recommendations regarding liberation from mechanical ventilation. The details regarding the evidence and rationale for each recommendation are presented in the American Journal of Respiratory and Critical Care Medicine and CHEST

Maintenance of weight loss after lifestyle interventions for overweight and obesity, a systematic review.

Lifestyle interventions can reduce body weight, but weight regain is common and may particularly occur with higher initial weight loss. If so, one may argue whether the 10% weight loss in clinical guidelines is preferable above a lower weight loss. This systematic review explores the relation between weight loss during an intervention and weight maintenance after at least 1 year of unsupervised follow-up. Twenty-two interventions (during at least 1 month) in healthy overweight Caucasians were selected and the mean percentages of weight loss and maintenance were calculated in a standardized way. In addition, within four intervention groups (n > 80) maintenance was calculated stratified by initial weight loss (0-5%, 5-10%, >10%). Overall, mean percentage maintenance was 54%. Weight loss during the intervention was not significantly associated with percentage maintenance (r = -0.26; P = 0.13). Percentage maintenance also not differed significantly between interventions with a weight loss of 5-10% vs. >10%. Consequently, net weight loss after follow-up differed between these categories (3.7 vs. 7.0%, respectively; P < 0.01). The analyses within the four interventions confirmed these findings. In conclusion, percentage maintenance does not clearly depend on initial weight loss. From this perspective, 10% or more weight loss can indeed be encouraged and favoured above lower weight loss goals.