Study of factors related to the reflection abilities of dental trainees.

INTRODUCTION: This study analysed the internal and external factors related to the reflection abilities of dental trainees. PARTICIPANTS AND METHODS: We created transcripts from oral presentations by the dental trainees of Hiroshima University Hospital (n = 35, 2012-2013) at a significant event analysis conference. The reflection depths were compared between the trainees of the university hospital and external clinical combination groups. We determined and statistically analysed the reflection depths. RESULTS: At the end of training, a Mann-Whitney U-test revealed a significant difference in the median reflection depths of the groups (U = 66, W = 342 and P = 0.007). The results of multiple regression analysis indicated a significant relation between the reflection depth and external training completion (P = 0.024). There were no relations with other factors, including gender and academic background. CONCLUSION: Experiences in external clinics create a close connection between the staff and trainees because communities of practice can cause deeper reflections. We need to create small groups in large-scale organisations such as university hospitals. This construct can be adapted not only for Japanese dental trainees but also for global dental and other medical trainees.

Therapeutic Effect of Sirolimus for Lymphangioleiomyomatosis Remaining in the Abdominopelvic Region After Lung Transplantation: A Case Report.

PURPOSE: Sirolimus (SRL) is used to treat pulmonary lymphangioleiomyomatosis (P-LAM). There is limited evidence that SRL has systemic efficacy for the patients with extrapulmonary lymphangioleiomyomatosis (E-LAM) remaining after lung transplantation (LT) for P-LAM. This report examines the efficacy of SRL treatment for the patient with E-LAM remaining after an LT for P-LAM. CASE SUMMARY: The course of the patient's recovery from an LT for P-LAM was complicated by lymphedema in the left femoral region that was caused by two E-LAM lesions remaining in the left pelvic cavity and in the retroperitoneal area. After the LT was performed, the patient started SRL treatment to reduce the E-LAM lesions. The daily SRL dose, selected based on the standard SRL dose for P-LAM, was initiated at 1 mg/d and was maintained at 2 mg/d. The remaining E-LAM lesions and lymphedema in the left femoral region improved in approximately 9 months after the LT with the administration of both SRL and the standard immunosuppressive therapy used by Okayama University Hospital, including tacrolimus, mycophenolate mofetil, and prednisolone. The SRL and tacrolimus trough concentrations in whole blood were maintained within the therapeutic window for the next 1.5 years after initiation of SRL treatment. The patient experienced no severe adverse events that required discontinuation of the SRL treatment during this time. CONCLUSION: The patients with remaining E-LAM lesions may receive SRL treatment to improve the quality of life after LT for P-LAM as effective therapy in cases where the patient's recovery is complicated by E-LAM lesions.

Pulmonary function in patients with chronic rhinosinusitis and allergic rhinitis.

BACKGROUND: A close relationship between upper and lower respiratory tract diseases has been reported. However, little is known about pulmonary function in patients with upper respiratory tract diseases. METHODS: Pulmonary function was measured in: 68 patients with chronic rhinosinusitis without nasal polyps, 135 patients with chronic rhinosinusitis with nasal polyps, 89 patients with allergic rhinitis and 100 normal control subjects. The relationships between pulmonary function and clinical parameters were assessed. These parameters included radiographic severity of chronic rhinosinusitis, serum total immunoglobulin E levels, concentrations of cytokines in nasal secretions and exhaled nitric oxide levels. RESULTS: The pulmonary function of patients with chronic rhinosinusitis was significantly affected. The level of interleukin-5 in nasal secretions was significantly correlated with pulmonary function in patients with chronic rhinosinusitis. CONCLUSION: The findings indicated latent obstructive lung function changes in chronic rhinosinusitis patients. The cytokines in nasal secretions might be related to obstructive lung function changes in chronic rhinosinusitis.

Successful lung transplantation in a case with diffuse pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia.

Diffuse pulmonary arteriovenous malformations (AVMs) are associated with a poor prognosis and the therapeutic strategy remains controversial. We describe a pediatric patient with diffuse pulmonary AVMs associated with hereditary hemorrhagic telangiectasia (HHT), who presented with two cerebral AVMs in the parietal and occipital lobes as well. Of note, successful bilateral lung transplantation not only improved the hypoxemia but also resulted in size reduction of the cerebral AVMs. Although it is essential to consider involvements other than pulmonary AVMs, especially brain AVMs, to decide the indication, lung transplantation can be a viable therapeutic option for patients with diffuse pulmonary AVMs and HHT.

Activations of mitogen-activated protein kinases and regulation of their downstream molecules after rat lung transplantation from donors after cardiac death.

OBJECTIVES: Accepting organs donated after cardiac death (DCD) is an effective approach to the donor shortage. However, lung transplantations from DCD donors show severe rapid pulmonary graft dysfunction (PGD) followed by warm ischemia-reperfusion injury (IRI). This study sought to clarify the molecular mediators in warm IRI, including activation of mitogen-activated protein kinase (MAPK) and the downstream cascades. METHODS: We performed single left lung transplantation using organs from male Sprague-Dawley rats after 0 (CIT group), 30 (30WIT group), or 180 (180WIT group) minutes of warm ischemia time. Pulmonary graft functions were estimated by blood gas analysis. At 1 hour after reperfusion, the phosphorylation status of MAPKs (ERK, p38, and JNK) and the gene expression levels of transcription factors (Egr-1 and ATF-3) and immune mediators (MCP-1, MIP-2, PAI-1, ICAM-1, TNF-α, IL-1ß, IL-6, and COX-2) in the grafts were examined using Western blotting and real-time polymerase chain reaction assays. RESULTS: Severe PGD was observed in the 180WIT group compared with transplanted lungs in the other groups, which exhibited good pulmonary graft function. ERK and JNK activations, as well as mRNA levels of transcription factors (Egr-1 and ATF3) significantly increased with greater warm ischemic times. The pattern of JNK activation correlated with the severity of PGD. MCP-1, ICAM-1, IL-1ß, IL-6, and COX-2 were also up-regulated among the 180WIT group, although MIP-2 and PAI-1 showed no significant differences among the groups. CONCLUSIONS: We suggest that the ERK and JNK pathways may play important roles to induce the injury caused by prolonged warm ischemia followed by reperfusion in the setting of lung transplantation from DCD donors.

Less maintenance immunosuppression in lung transplantation following hematopoietic stem cell transplantation from the same living donor.

Living-donor lobar lung transplantation (LDLLT) is one of the final options for saving patients with pulmonary complications after hematopoietic stem cell transplantation (HSCT). We retrospectively investigated 19 patients who had undergone LDLLT after HSCT in Japan. Eight patients underwent LDLLT after HSCT in which one of the donors was the same living donor as in HSCT (SD group), while 11 received LDLLT from relatives who were not the HSCT donors (non-SD group). In the SD group, three patients underwent single LDLLT. The 5-year survival rate was 100% and 58% in the SD and non-SD groups, respectively. In the SD group, postoperative immunosuppression was significantly lower than in the non-SD group. Two patients died of infection and one died of post-transplant lymphoproliferative disease (PTLD) in the non-SD group, while only one patient died of PTLD 7 years after LDLLT in the SD group. Hematologic malignancy relapsed in two patients in the non-SD group. For the three single LDLLTs in the SD group, immunosuppression was carefully tapered. In our study, LDLLT involving the same donor as for HSCT appeared to have advantages related to lower immunosuppression compared to LDLLT from relatives who were not the HSCT donors.

[Treatment strategy and outcomes of invading apical lung cancer].

Invading apical lung cancers are generally the non-small-cell lung cancers (NSCLCs) which involve the apex of the chest wall. These tumors should be classified into 2 types based on the main location of tumor because of the difference of involved surrounding structures ; (1) the superior sulcus tumor origi nally termed Pancoast tumor which involves posterior region of the apex and (2) the anterior apical tumor which involves anterior region of the apex. Previously, these NSCLCs were considered to be inoperable showing a dismal prognosis. With the development of combined modality therapies for locally advanced NSCLCs, the prognosis of invading apical NSCLCs has been improved, especially since intro duction of the neoadjuvant chemoradiotherapy. Surgical resection for invading apical NSCLCs is 1 of challenging procedures for thoracic surgeons. The point is the anatomical complication of the small apex surrounding vital structures. Several approaches have been developed such as the posterior Paul-son's approach or anterior Masaoka's approach. In particular, the approach from anterior chest has been modified or devised to achieve safe and complete resection of tumors invading anterior structures like subclavian vessels. In this article, we reviewed our 13 cases of invading apical NSCLCs, especially from the view point of surgical approach. Thoracic surgeons should understand the properties of each approach and master them for complete resection avoiding serious complications.

Predicting the chance of weaning dysphagic stroke patients from enteral nutrition: a multivariate logistic modelling study.

AIM: The aim of this article was to develop a simple predictive model of dysphagia outcome for stroke patients. The study enrolled patients recovering from first-ever stroke (supratentorial lesions) staying in a long-term rehabilitation hospital. On admission, all patients were being fed via nasogastric or percutaneous endoscopic gastrostomy (PEG) tube. METHODS: Functional Independence Measure (FIMTM) scores were assessed on admission. FIM-motor and cognition score, age, days after onset on admission were set as explanatory variables. Target criteria were defined as dichotomous categories; completely oral feeding or any need for nutrition via tube feeding. Multivariate logistic analysis was performed on these data. RESULTS: Thirty patients were enrolled: age range was 50-94 (median 75) years; FIM-motor scores spanned 13 to 17 (median 13), FIM-cognition scores spanned 5 to 19 (median 9); and days from stroke onset to transfer to long-term rehabilitation care ranged from 15 to 64 (median 43.5) days. Of these patients, 12 were weaned back to oral feeding and 18 were not. Multivariate logistic regression modelling was successful on these data (P=0.0003, R2=0.518; Logit=0.770xFIM-motor+0.089xFIM-cognition 0.070xdays after onset 0.255xage+10.222). Estimated probability for return to oral feeding is nearly 10% when logit equals -2, 50% when logit equals 0, nearly 90% when logit equals 2. CONCLUSIONS: A logit formula factoring in age, FIM scores, and days after stroke onset can readily predict oral feeding outcome. Further studies are needed to assess external validation to establish wide clinical applicability of this prediction model.

Association between primary graft dysfunction among lung, kidney and heart recipients from the same multiorgan donor.

Even organs from an ideal donor will occasionally develop primary graft dysfunction (PGD) causing a significant morbidity and mortality after transplantation. It is likely that this situation represents subtle undetectable levels of ongoing donor organ dysfunction. The aim of this study is to investigate the association of PGD between lung, kidney and heart recipients from the one donor. From 202 multiorgan donors, contributed 231 consecutive lung transplants at the Alfred Hospital, 378 kidney and 114 heart transplants were subsequently performed at multiple centers across Australia and New Zealand. Eight hundred seventy-five organs were used for 723 transplants. The incidence of PGD after lung, kidney and heart transplants was 20% (47/231), 24% (92/378) and 20% (23/114), respectively. In paired single organ recipients, PGD in one of the pair was a significant risk factor for the development of PGD in the other [lung: odds ratio = 5.63 (1.72-18.43), p = 0.004; kidney: odds ratio = 3.19 (1.90-5.35), p < 0.0001]. In multivariate analysis, same donor heart PGD [3.37 (1.19-9.50), p = 0.02] was an independent risk factor for lung PGD and same donor lung PGD was significant risk factor for kidney PGD [1.94 (1.01-3.73), p = 0.04], if the PGD status of the paired kidney was not known. There was a significant association for the development of PGD across different organs transplanted from the same donor.

Early lung transplantation success utilizing controlled donation after cardiac death donors.

Donation-after cardiac death (DCD) donor organs have potential to significantly alleviate the shortage of transplantable lungs. However, only limited data so far describes DCD lung transplantation (LTx) techniques and results. This study aims to describe the Alfred Hospital's early and intermediate outcomes following DCD donor LTx. Following careful experimentation and consultation DCD guidelines were created to utilize Maastricht category III lung donors from either the ICU or operating room(OR), with a warm ischemic time(WIT) of <60 min. Between May 2006 and December 2007, 22 referred DCD donors led to 11 attempted retrievals after withdrawal, resulting in 8 actual bilateral LTx (2 donors did not arrest in prescribed period and 1 donor had nonacceptable lungs). ICU WIT = 38.4 min (range 20-54, OR WIT = 12.7 min (11-15), p < 0.05. Post-LTx, 1 pulmonary hypertensive patient required ECMO for PGD3. The mean group pO2/FiO2 ratio at 24 hours was 307.7 (240-507) with an ICU stay of 9.5 days (2-21) and ward stay of 21.5 days (11-76). All 8 survive at a mean of 311 days (10-573) with good performance status and lung function. In conclusion, the use of Maastricht category III lungs for human LTx is associated with acceptable early clinical outcomes.

[Second chondrosarcoma of the rib four years after the initial operation; report of a case].

Chondrosarcoma of rib origin is rare accounting for about 2% of all chondrosarcomas. A 63-year-old female with an anterior chest wall tumor was referred to our institution for surgical treatment of a 2nd chondrosarcoma in the right 2nd rib 4 years after the initial surgery for its primary lesion. Computed tomography (CT) showed a low density mass, 36 mm in diameter, arising from the 2nd rib. An extended excision of the chest wall including the tumor was performed followed by the reconstruction of the chest wall with double Marlex Mesh. As she had already undergone the reconstruction of the chest wall for its primary lesion, this reconstruction was her 2nd one. Nevertheless, her respiratory condition was well preserved with no significant chest deformity. Wide excision and reconstruction could be performed for the 2nd arising chondrosarcoma of the rib even after the initial lesion was already widely removed and reconstructed.

[Phrenic nerve paralysis following lung transplantation].

Phrenic nerve paralysis is a well-documented complication of cardiac operation, but there is less commonly reported after lung transplantation. A retrospective study of 49 lung transplantation was done at Okayama University Hospital. Phrenic nerve paralysis (unilateral in 3 patients and bilateral in 1) was found in 4 patients (8.2%). All of these paralyses were transiently recovered. The average length of ventilation, intensive care unit stay and hospitalization for recipients with phrenic nerve paralysis was not significantly longer than the other (no diaphragmatic paralysis) recipients, but there was a tendency to be longer. Diaphragmatic paralysis is most likely related to difficulty in detecting the phrenic nerve caused by adhesions, injury due to dissection, thermal injury by electrocartery, or local topical hypothermia using ice-slush. Therefore, it is important to take care of avoiding the injury of the nerve during the operation.

[Living-donor lobar lung transplantation for infectious lung diseases].

The rate of infection among lung transplant recipients is several times higher than that among recipients of other organs and is most likely related to the exposure of the allograft to the external environment. Meticulous peri-operative management is mandatory in performing living-donor lobar lung transplantation for patients with infectious lung diseases. All 5 patients with end-stage infectious lung diseases are currently alive for 17-104 months after receiving living-donor lobar lung transplantation at Okayama University Hospital.

Relation of interlobar collaterals to radiological heterogeneity in severe emphysema.

BACKGROUND: A study was undertaken to assess the prevalence of interlobar collateral ventilation in patients with severe emphysema to identify factors that may help to predict patients with significant collateral ventilation. METHODS: Between April 2002 and August 2003, ex vivo assessment of the lungs 17 consecutive patients with smoking related severe emphysema was performed. To assess collateral flow, all lobes of explanted specimens were selectively intubated using a wedged cuffed microlaryngeal intubation tube and then manually ventilated using a bagging circuit. Interlobar collateral ventilation was defined as the ability to easily inflate a non-intubated lobe at physiological pressures. Pre-transplant demographic characteristics, physiological data, radiological results, and explant histology were assessed for retrospective relationships with the degree of interlobar collateral ventilation in the explanted lung. RESULTS: A total of 23 lungs were evaluated, 15 of which (66%) had significant collateral interlobar airflow. There were no significant differences in any demographic, physiological, or pathological variables between patients with collateral ventilation and those with no collateral ventilation. However, there was a significant relationship between the presence of interlobar collateral ventilation and radiological scores (p<0.05). CONCLUSIONS: Interlobar collateral ventilation occurs to a much greater extent in patients with radiologically homogeneous emphysema than in those with heterogeneous emphysema. Heterogeneity of emphysema may predict patients with a significantly reduced risk of interlobar collateral ventilation.

Peripheral lung volume reduction improved early graft function in severe size mismatched living donor lobar lung transplantation.

BACKGROUND: Lung transplantation from adults to infants or small children is still challenging because of concerns related to size disparity. Peripheral lung volume reduction for size disparity in cadaveric donor lung transplantation has been widely performed; however, little is known about the efficacy and the functional outcomes of downsizing the implanted lobes for severe size disparity in living donor lobar lung transplantation. METHODS: Thirteen size-mismatched (donor/recipient lung volume ratio > 2.82) bilateral living donor lobar lung transplants were performed with (reduction group, n = 6) or without (no-reduction group, n = 7) peripheral lung volume reduction. RESULTS: On spontaneous respiration, PaO2 in the reduction group was significantly higher than that in the no-reduction group (P < .01) and PaCO2 in the reduction group was significantly lower than that in the no-reduction group (P < .001). Pulmonary vascular resistance in the reduction group remained significantly lower than that in the no-reduction group throughout the assessment periods after chest closure (P < .05). Peak airway pressure in the no-reduction group increased significantly at the time of chest closure (P < .001) and remained significantly higher than that in the reduction group throughout the assessment period on mechanical ventilation (P < .01). The percentage of weight reduced from implanted grafts significantly correlated with donor/recipient lung volume ratio (r = 0.82, P < .05). CONCLUSIONS: Peripheral lung volume reduction is useful to improve early graft function in severe size mismatched experimental living donor lobar lung transplantation. The technique might allow for further flexibility in donor size and for increasing the donor pool for small recipients.

Endoscopic saphenous vein harvesting for hemodialysis vascular access creation in the forearm: A new approach for arteriovenous bridge graft.

UNLABELLED: When superficial arm veins are not suitable to create a native arteriovenous (AV) fistula, an arterio-venous bridge graft by native and/or prosthetic graft is the next best alternative. However, harvesting a native vein, such as the saphenous vein (SV), is invasive and requires a large incision. We report an endoscopic saphenous vein harvesting (ESVH) technique combined with forearm bridge grafting as a new approach for vascular access (VA). METHODS: We used the Clearglide, Endoscopic Vessel Harvesting System (Eticon, Inc.) for a less invasive SV harvesting technique. Five patients had a SV graft implant and 10 patients had a polytetrafluoroethylene (PTFE) graft implant in the forearm. RESULTS: The SV was harvested easily in all patients in 46 +/- 2 min. There were no wound complications. All SV and PTFE grafts provided satisfactory access within 1 month; however, two declotting procedures in the SV group and five in the PTFE group were required. The PTFE group had two graft infections. CONCLUSIONS: It is possible that a combination of ESVH and SV forearm grafting will be one of the new approaches for hemodialysis (HD) access.

Experimental study of oversized grafts in a canine living-donor lobar lung transplantation model.

BACKGROUND: For infants and small children, organ transplantation is limited by the size discrepancy between donor and recipient. To address this problem, the use of over-sized grafts from living-relative donors could potentially expand the donor pool. The aim of this experimental study was to evaluate the effect of oversized grafts on early pulmonary function and to identify an indicator for acceptable size discrepancy. METHODS: Fourteen bilateral lobar lung allotransplant operations were performed without cardiopulmonary bypass in weight mismatched pairs of dogs. Animals were divided into 2 groups: Group I (n = 7), donor/recipient lung volume ratio < 2.85; Group II (n = 7), donor/recipient lung volume ratio >2.85. Pulmonary function of the recipient was measured before chest closure, after chest closure, and after the ventilator was removed. RESULTS: Pulmonary vascular resistance and airway pressure significantly increased in Group II after chest closure (1493 +/- 195 dynes sec cm(-5) and 14.4 +/- 0.9 mm Hg vs 2784 +/- 140 dynes sec cm(-5) and 23.4 +/- 1.2 mm Hg, p < 0.001). After the ventilator was removed, all recipients in Group I showed PaO2 > 239 mm Hg and PaCO2 < 76 mm Hg, whereas, all recipients in Group II showed PaO2 < 116 mm Hg and PaCO2 > 169 mm Hg. The donor/recipient chest circumference ratio was less than 1.3 in all but 1 dog in Group I. CONCLUSIONS: Acceptable, oversized grafts provide adequate pulmonary function, although excessively oversized grafts cause significant impairment in pulmonary function after chest closure. Chest circumference provides useful size-match criteria when oversized grafts are used in this canine experimental model.

Intracerebral haematomas with agenesis of the internal carotid artery and tetralogy of Fallot.

We report a rare case with tetralogy of Fallot (TOF) and agenesis of the internal carotid artery (ICA) who presented serious intracerebral haematomas. In the literature, this is the first documented case having these complications simultaneously. Extreme hypoxic insults followed by recovery were detected by O2 saturation monitor before two bleeds. Chronic brain hypoxia could make the vasculature weak, which was shown in the histological examination. A 2-year-old girl was transferred to us with a general convulsion due to intracerebral haematoma. She had been showing general cyanosis from birth due to TOF. Repeated intracerebral haemorrhages ended her life. Histological study showed dilated vascular channels in the subarachnoid space and necrotizing vasculature obstructed by fibrinous thrombi adjacent to the haematoma. Fibrosis of the vessel wall with infiltration of macrophages suggested subacute or chronic lesions rather than acute necrosis due to the multiple haemorrhages. The intracerebral haematomas and agenesis of the ICA were observed as unilateral hemispheric vascular complications of TOF. Chronic brain hypoxia could play an important role in weakening the vessel wall and erythrocytosis caused obstructing thrombi. We speculate these factors generated the intracerebral haematomas.

Effects of inhaled nitric oxide in a canine living-donor lobar lung transplant model.

OBJECTIVE: In living-donor lobar lung transplantation, early severe graft dysfunction can occur if the size or amount of transplanted lung tissue is insufficient. The purpose of this study was to evaluate the effects of inhaled nitric oxide on early pulmonary function in a canine bilateral living-donor lobar lung transplant model. METHODS: Sixteen pairs of mongrel dogs with a donor/recipient weight ratio less than 1.2 were used. The donor lung bloc was extirpated after heparinization. Right middle, lower and cardiac lobes were implanted as a right lung of the recipient and left lower lobe was implanted as a left lung without cardiopulmonary bypass. In Group 1 (n = 9), nitric oxide gas was administered continuously at a concentration of 40 parts per million prior to reperfusion of the right lung throughout the 6-hour assessment period after transplantation. In Group 2 (n = 7), nitrogen gas was administered in the same manner as nitric oxide, for control. RESULTS: At the end of assessment, the survival rate was 89% (8/9) in Group 1 and 57% (4/7) in Group 2. The arterial oxygen tension in Group 1 was significantly higher than that in Group 2. The pulmonary arterial pressure and pulmonary vascular resistance index were significantly lower in Group 1 than in Group 2. The aortic pressure and cardiac index did not differ significantly between the two groups. The wet-to-dry weight ratio and myeloperoxidase activity were significantly lower in Group 1 than in Group 2. CONCLUSIONS: These data suggested that inhaled nitric oxide improved early pulmonary function in living-donor lobar lung transplantation by vasodilatating the pulmonary vasculature and inhibiting neutrophil activation.