A Multicenter Phase 2 Trial to Evaluate the Efficacy of mFOLFOX6 + Cetuximab as Induction Chemotherapy to Achieve R0 Surgical Resection for Advanced Colorectal Liver Metastases (NEXTO Trial).

BACKGROUND: The effect of cetuximab plus mFOLFOX on downsizing of the tumors for curative resection has yet to be assessed for patients with advanced colorectal liver metastases (CRLMs). This study aimed to assess the oncologic benefit of cetuximab plus mFOLFOX for wild-type KRAS patients with advanced CRLMs. METHODS: In this multicenter phase 2 trial, patients with technically unresectable tumor and/or five or more CRLMs harboring wild-type KRAS were treated with mFOLFOX plus cetuximab. The patients were assessed for resectability after 4 treatments, and then every 2 months up to 12 treatments. Patients with resectable disease were offered surgery after a waiting period of 1 month. The primary end point of the study was the R0 resection rate. The secondary end points were safety, progression-free survival (PFS), and overall survival (OS). The study is registered with the University Hospital Medical Information Network-Clinical Trials Registry Clinical Trials Registry (no. C000007923). RESULTS: Between 2012 and 2015, 50 patients from 13 centers were enrolled in this trial. Two patients were excluded because they had not received induction therapy. The 48 patients had a complete response rate of 0% and a partial response rate of 64.6%. For 26 R0 resections (54.2%) and 5 R1 resections (10.4%), no mortality occurred. During a median follow-up period of 31 months, the median OS for all the patients was calculated to be 41 months (95% confidence interval, 28-not reached). The 3-year OS rate was 59%. CONCLUSION: For patients with advanced CRLMs harboring wild-type KRAS, cetuximab administered in combination with mFOLFOX yields high response rates, leading to significantly high R0 resection rates and favorable prognoses.

[A multicenter survey of pediatric endotracheal tube management].

BACKGROUND: The goal of this multicenter survey was to examine the variety of pediatric endotracheal tube (PETT) management methods utilized by anesthesiologists. METHODS: A postal survey for PETT management methods was performed among anesthesiologists at Kyoto Prefectural University of Medicine and its affiliated hospitals. RESULTS: Age was the primary criteria for PETT size selection, followed by height and weight, while the surgical procedure was the primary criteria for PETT type selection, followed by age and then weight. Cuffed PETTs were routinely used for more than 70% of their patients by 57.1% of respondents; however, 55.7% of respondents had no criteria clearly defining when and how to inflate the cuff. Strategies for airway complications, including post-extubation stridor, vary amongst anesthesiologists. CONCLUSIONS: The present study revealed that practice of PETT management depends on anesthesiologists. PETT management should be sophisticated with wide use of cuffed PETTs.

[A Case of Effective Whole-Brain Irradiation and Lapatinib/Capecitabine Combination Therapy for HER2-Positive Breast Cancer with Multiple Brain Metastases].

We report the case of a 48-year-old female patient with HER2-positive and hormone receptor-negative breast cancer with multiple liver metastases. She underwent 6 cycles of FEC followed by docetaxel plus trastuzumab (TZB), resulting in a clinical complete response. After 15 cycles of a TZB-containing regimen, she complained of dizziness and nausea, and imaging examinations revealed multiple brain metastases. Whole-brain irradiation(33.6 Gy) was performed, and the chemotherapy regimen was changed to lapatinib (LAP: orally at 1,250 mg/day, every day) and capecitabine (CAP: orally at 2,000 mg/m2, every day for 2 weeks, followed by a 1-week rest interval, as 1 cycle). After 6 weeks of the new treatment, magnetic resonance imaging revealed marked shrinkage of brain metastases. A clinical complete response was maintained for 19 months. While brain metastasis is an important problem with treatment with TZB, LAP is drawing attention because of its ability to pass the blood-brain barrier because of its small molecular weight. LAP/CAP combination therapy may be an effective treatment option for brain metastases of HER2-positive breast cancer in which TZB essentially has no effect.

A novel method for ultrasound-guided radial arterial catheterization in pediatric patients.

BACKGROUND: Radial arterial catheterization in pediatric patients is occasionally difficult despite ultrasound guidance. We therefore assessed the factors affecting catheterization and tested an intervention designed to improve its success. METHODS: For initial assessment, we performed multiple logistic regression analyses using 102 pediatric patients. Dependent variables included first-attempt and overall success or failure; independent variables were systolic blood pressure, weight, ASA physical status, trisomy 21, arterial diameter, and subcutaneous depth of the radial artery (<2, 2-4, ≥4 mm). The effect of subcutaneous arterial depth on cannulation success was assessed using Kaplan-Meier curves with log-rank and Dunn tests. We then assessed catheterization success in 60 patients who were randomized to no treatment or subcutaneous saline injection, as necessary, to increase the subcutaneous arterial depth from <2 to 2 to 4 mm. RESULTS: Subcutaneous arterial depth of 2 to 4 mm was derived as a significant independent predictor of initial and overall success from the multiple logistic regression analyses. The 2 to 4 mm group had a significantly shorter catheterization time compared with the other 2 groups in the log-rank test (2-4 vs <2 mm group; P = 0.01, 2-4 vs ≥4 mm group; P < 0.001), and higher success rate in the first attempt (<2 [43.8%] vs 2-4 mm [76.9%], P = 0.02; 2-4 [76.9%] vs ≥4.0 mm [19.4%], P < 0.001), and the overall attempt (<2 [62.5%] vs 2-4 mm [89.7%], P = 0.04; 2-4 [89.7%] vs ≥4.0 mm [51.6%], P = 0.002). Injecting subcutaneous saline to bring arterial depth from <2 mm to 2 to 4 mm significantly shortened catheterization time (P = 0.002), and improved the success rate in the first-attempt (saline injection [85.0%] vs <2 mm [30.0%], P < 0.001), and the overall attempt (saline injection [90.0%] vs <2 mm [55.0%], P = 0.02). CONCLUSIONS: Ultrasound-guided radial artery catheterization in pediatric patients was fastest and most reliable when the artery was 2 to 4 mm below the skin surface. For arteries located <2 mm below the skin surface, increasing the depth to 2 to 4 mm by subcutaneous saline injection reduced catheterization time and improved the success rate.

Tracheal injury diagnosed by a sudden increase in end-tidal carbon dioxide levels during mediastinoscopic subtotal esophagectomy: a case report.

BACKGROUND: Mediastinoscopic surgery for esophageal cancer facilitates early postoperative recovery. However, it can occasionally cause serious complications. Here, we present the case of a patient with a tracheal injury diagnosed by a sudden increase in end-tidal carbon dioxide (EtCO2) during mediastinoscopic subtotal esophagectomy. CASE PRESENTATION: A 52-year-old man diagnosed with esophageal cancer was scheduled to undergo mediastinoscopic subtotal esophagectomy. During the mediastinoscopic procedure, the EtCO2 level suddenly increased above 200 mmHg, and the blood pressure dropped below 80 mmHg. We immediately asked the operator to stop insufflation and found a tracheal injury on the right side of the trachea near the carina by bronchoscopy. The endotracheal tube was replaced with a double-lumen tube, and the trachea was repaired via right thoracotomy. There were no further intraoperative complications. After surgery, the patient was extubated and admitted to the intensive care unit. CONCLUSIONS: Monitoring EtCO2 levels and close communication with the operator is important for safely managing sudden tracheal injury during mediastinoscopic esophagectomy.

Chronic treatment with novel GPR40 agonists improve whole-body glucose metabolism based on the glucose-dependent insulin secretion.

GPR40 is a free fatty acid receptor that has been shown to regulate glucose-dependent insulin secretion. This study aimed to discover novel GPR40 agonists and investigate the whole-body effect on glucose metabolism of GPR40 activation using these novel GPR40 agonists. To identify novel GPR40-specific agonists, we conducted high-throughput chemical compound screening and evaluated glucose-dependent insulin secretion. To investigate the whole-body effect on glucose metabolism of GPR40 activation, we conducted repeat administration of the novel GPR40 agonists to diabetic model ob/ob mice and evaluated metabolic parameters. To characterize the effect of the novel GPR40 agonists more deeply, we conducted an insulin tolerance test and a euglycemic-hyperinsulinemic clamp test. As a result, we discovered the novel GPR40-specific agonists, including AS2034178 [bis{2-[(4-{[4'-(2-hydroxyethoxy)-2'-methyl[1,1'-biphenyl]-3-yl]methoxy}phenyl)methyl]-3,5-dioxo-1,2,4-oxadiazolidin-4-ide} tetrahydrate], and found that its exhibited glucose-dependent insulin secretion enhancement both in vitro and in vivo. In addition, the compounds also decreased plasma glucose and HbA1c levels after repeat administration to ob/ob mice, with favorable oral absorption and pharmacokinetics. Repeat administration of AS2034178 enhanced insulin sensitivity in an insulin tolerance test and a euglycemic-hyperinsulinemic clamp test. These results indicate that improvement of glucose-dependent insulin secretion leads the improvement of whole-body glucose metabolism chronically. In conclusion, AS2034178 and other GPR40 agonists may become useful therapeutics in the treatment of type 2 diabetes mellitus.

Ultrasound-guided radial artery catheterization in infants and small children.

OBJECTIVE: To determine whether ultrasound guidance increases the success rates, decreases the complication rates, and shortens the time to successful radial artery catheterization in infants and small children. DESIGN: Randomized study. SETTING: Single university-affiliated hospital. PATIENTS: Infants and children weighing 3-20 kg, undergoing cardiac surgery for congenital heart disease. INTERVENTION: We randomly assigned the right and left radial arteries of patients undergoing arterial catheterization to ultrasound-guided technique versus the usual palpation technique. MEASUREMENTS: The primary study endpoints were the rates of successful cannulation at first and within three attempts. The secondary endpoints were time to radial artery identification, number of attempts for successful cannulation, and rate of complications. MAIN RESULTS: Compared with palpation, ultrasound-guided radial artery catheterization was successful in 76.3% versus 35.6% of first attempts and in 94.9% versus 50.8% of arteries after three attempts (both comparisons, p < 0.01). The median time [interquartile range] to identification of the arteries (18.5 seconds [11.25-27.25] vs 30 seconds [17.75-39.5]) was significantly shorter (p < 0.01), the number of attempts [interquartile range] at successful cannulation (1 [1-1] vs 2 [1-2]) was significantly fewer (p < 0.01), and the proportion of hematomas (5.1% vs 25.4%) was significantly lower (p < 0.01) in the ultrasound group than those in the palpation group. CONCLUSIONS: In infants and small children, ultrasound-guided radial artery catheterization was more successful and expeditious than the usual palpation technique.

Pharmacological Characterization of YM543, a Newly Synthesized, Orally Active SGLT2 Selective Inhibitor.

BACKGROUND AND AIM: Sodium-glucose cotransporter (SGLT) 2 is a specifically expressed transporter in the kidney that plays an important role in renal glucose reabsorption, and its inhibition may present a novel therapeutic strategy for treating diabetes. Here, we pharmacologically characterized YM543, a newly synthesized SGLT2 selective inhibitor to test this theory. RESULTS: In vitro studies revealed that YM543 potently and selectively inhibited mouse and human SGLT2 activities at nanomolar ranges. In vivo single oral administration of YM543 dose-dependently and significantly reduced blood glucose levels and improved glucose tolerance with a concomitant increase in urinary glucose excretion in KK/Ay type 2 diabetic mice, effects that were sustained even after 12 h. Repeated once-daily oral administration of YM543 for 5 weeks significantly reduced hyperglycemia in type 2 diabetic mice. In addition, combination treatment of YM543 with rosiglitazone or metformin additively improved diabetic symptoms. In contrast, YM543 did not affect normoglycemia at pharmacological doses in normal mice. CONCLUSIONS: Results from the present study suggest that YM543 is an orally active SGLT2 selective inhibitor which reduces hyperglycemia with a concomitant increase in urinary glucose excretion, indicating its promise as an effective treatment against type 2 diabetes.

The RACHS-1 risk category can be a predictor of perioperative recovery in Asian pediatric cardiac surgery patients.

PURPOSE: The Risk Adjustment for Congenital Heart Surgery (RACHS-1) classification was originally designed to facilitate the prediction of in-hospital mortality for pediatric cardiac surgery patients. However, there have been few reports on clinical outcomes predicted by the RACHS-1 category, especially in an Asian population. The aim of this study was to determine whether RACHS-1 classification can predict patient outcomes. METHODS: A total of 580 pediatric cardiac surgery procedures performed from January 2005 to December 2009 were retrospectively classified into the six RACHS-1 categories. The association between RACHS-1 category and clinical outcomes, including length of catecholamine requirement, mechanical ventilation time, intensive care unit stay, and in-hospital mortality, were examined. RESULTS: The frequencies of RACHS-1 categories in the study population were: category 1, 10.7 %; category 2, 36.7 %; category 3, 42.8 %; category 4, 6.6 %; category 5, 0.0 %; category 6, 3.3 %. There was a significant linear correlation between RACHS-1 category and in-hospital mortality (r = 0.96, p < 0.001). Kaplan-Meier analysis demonstrated that length of catecholamine infusion, mechanical ventilation time, and ICU stay were significantly different (p < 0.05) in the different RACHS-1 categories, except for those between category 4 and 6 (p = 0.09). CONCLUSIONS: Based on the results of our analysis, we conclude that the RACHS-1 stratification system can predict in-hospital mortality and patient outcomes in patients undergoing pediatric cardiac surgery.

[Preformed pediatric endotracheal tubes].

BACKGROUND: The goal of this investigation was to evaluate the details of preformed pediatric endotracheal tubes (PPETTs, I. D. 3.0-6.0 mm). METHODS: Dimensions of all PPETTs were measured as follows: the distance from tube tip to the distal border of depth markings, length and the number of depth markings, outer diameter and length of the tubes, the distance from tube tip to the bent section, the number of the Murphy eyes and calculated cross sectional area of the Murphy eyes, the distance from tube tip to the distal/proximal border of the cuff, cuff diameter and cuff volume at 20 cmH2O cuff pressure. RESULTS: A total of 80 PPETTs, including 18 brands from 5 manufacturers, were investigated, of which 30% of PPETTs are cuffed tubes. There are significant variability in the distance from tube tip to the bent section, the number and position of depth markings, the number of the Murphy eyes and position and diameter of cuff at 20 cmH2O cuff pressure for a given I. D. CONCLUSIONS: There are no uniformity in the details of PPETTs. The details of PPETTs including those with high volume low pressure cuff should be updated.

Epicardial pacing lead implantation for congenital complete atrioventricular block immediately after birth: a case report.

BACKGROUND: The incidence of congenital complete atrioventricular block is estimated to be 1 per 20,000 deliveries. In the fetal period, the fetal mortality rate is high, but the treatment strategy has not yet been established. In severe cases, early postnatal pacing therapy is necessary. CASE PRESENTATION: A 0-day-old Japanese baby girl was diagnosed with fetal congenital complete atrioventricular block during a prenatal physical examination. A joint conference was held preoperatively among multidisciplinary departments, and a cesarean section was performed at 37 weeks pregnancy, immediately followed by scheduled internal ventricular pacing lead implantation in an adjacent room. Percutaneous pacing was ineffective. The epicardial pacing lead was sutured at 17.5 minutes after birth, and perioperative management was successful with a heart rate and pulse rate of 150 beats per minute. CONCLUSION: The infant with a congenital complete atrioventricular block was rescued by an uneventful epicardial lead implantation.

Antidiabetic effects of SGLT2-selective inhibitor ipragliflozin in streptozotocin-nicotinamide-induced mildly diabetic mice.

Sodium-glucose cotransporter (SGLT) 2 plays an important role in renal glucose reabsorption, and inhibition of renal SGLT2 activity represents an innovative strategy for the treatment of hyperglycemia in diabetic patients. The present study investigated the antidiabetic effects of ipragliflozin, a SGLT2-selective inhibitor, in streptozotocin-nicotinamide-induced mildly diabetic mice, which exhibited a mild decline in glucose tolerance associated with the loss of early-phase insulin secretion. Oral administration of ipragliflozin increased urinary glucose excretion in a dose-dependent manner, an effect which was significant at doses of 0.3 mg/kg or higher and lasted over 12 h. In addition, ipragliflozin dose-dependently improved hyperglycemia and glucose intolerance with concomitant decreases in plasma insulin levels without causing hypoglycemia. Once-daily dosing of ipragliflozin (0.1 - 3 mg/kg) for 4 weeks attenuated hyperglycemia, glucose intolerance, and impaired insulin secretion. These results suggest that the SGLT2-selective inhibitor ipragliflozin increases urinary glucose excretion by inhibiting renal glucose reabsorption, improves hyperglycemia in streptozotocin-nicotinamide-induced mildly diabetic mice, and may be useful for treating type 2 diabetes.

Downregulation of vasopressin V1A receptors and activation of mitogen-activated protein kinase in rat mesangial cells cultured under high-glucose conditions.

SUMMARY: In the present study we examined the effects of high extracellular glucose concentrations on vasopressin (AVP) V(1A) receptor kinetics and signal transduction in cultured rat mesangial cells. Scatchard analysis of [(3) H]-AVP binding to mesangial cell plasma membranes showed that although high glucose (30 mmol/L) decreased V(1A) receptor numbers relative to cells cultured in normal glucose (10 mmol/L), receptor affinity was not affected. This V(1A) receptor downregulation was associated with an attenuated increase in AVP-stimulated cytosolic free calcium concentrations ([Ca(2+) ](i) ). In addition, high glucose increased both the basal and AVP-stimulated activity of the classic mitogen-activated protein kinase, namely extracellular signal-regulated kinase (ERK). Furthermore, high glucose induced activation of protein kinase C (PKC) in mesangial cells that could be inhibited by coincubation with the PKC inhibitor staurosporine (10 nmol/L). Staurosporine also markedly attenuated the high glucose-induced downregulation of V(1A) receptors on mesangial cells and blocked the depressed [Ca(2+) ](i) response and increased ERK activity induced by AVP. The results indicate that high extracellular glucose downregulates V(1A) receptors on rat mesangial cells and modulates their signal transduction properties via PKC activation.

Effects of high glucose on AVP-induced hyperplasia, hypertrophy, and type IV collagen synthesis in cultured rat mesangial cells.

INTRODUCTION: Hyperglycemia is a principal characteristic of diabetes and influences many cellular functions. Diabetic nephropathy is characterized by glomerular mesangial expansion which could result from increased mesangial cell extracellular matrix synthesis induced by hyperglycemia. METHODS: To investigate whether the physiological functions of mesangial cells are altered in a diabetic environment, we evaluated the effect of high extracellular glucose concentration on thymidine/leucine incorporation, hyperplasia/hypertrophy, and type IV collagen synthesis, induced by vasopressin (AVP), in cultured rat mesangial cells. RESULTS: The exposure of mesangial cells to a high glucose concentration (30 mM) significantly reduced AVP-induced thymidine incorporation and hyperplasia compared with normal glucose (10 mM). By contrast, treatment of mesangial cells with AVP in the presence of high extracellular glucose significantly increased leucine incorporation, hypertrophy, and type IV collagen synthesis compared with those at normal glucose levels. The administration of staurosporine, a protein kinase C inhibitor, reversed these effects of high-glucose conditions. Furthermore, the nonpeptide AVP V(1A) receptor-selective antagonists potently inhibited these AVP-induced physiological responses in mesangial cells cultured in high-glucose conditions. CONCLUSIONS: These results demonstrate that high glucose suppresses mesangial cell proliferation but enhances hypertrophy and type IV collagen synthesis induced by AVP. This increased mesangial cell hypertrophy and extracellular matrix synthesis may play a crucial role in the glomerular mesangial expansion common to diabetic nephropathy.

Prediction of optimal endotracheal tube cuff volume from tracheal diameter and from patient height and age: a prospective cohort trial.

PURPOSE: Endotracheal tube intra-cuff pressure should be maintained between 20 and 30 cmH(2)O to prevent damage to the tracheal wall. However, cuff pressure is rarely measured, and clinicians estimate cuff pressure poorly. The goal of the present study was to predict the cuff volume that produces optimal cuff pressure either from tracheal diameter or from patient height and age. METHODS: In the development phase, initial cuff pressure and cuff volume were measured in 240 patients. Optimal cuff volume, defined as the volume halfway between the volumes required to produce cuff pressures of 20 and 30 cmH(2)O, was determined in each patient. Then, regression equations relating optimal cuff volume to tracheal diameter on chest X-ray, and between optimal cuff volume and a combination of height and age, were calculated. The primary outcome was the proportion of patients in a validation set (n = 104) who achieved a cuff pressure of 20-30 cmH(2)O when cuff volume was selected by each regression formula. RESULTS: Only 28% of the cuffs were optimally inflated using clinical criteria during the development phase. There was good correlation between optimal cuff volume and tracheal diameter and moderate correlation between optimal cuff volume and both height and age. Predicted cuff volume was more likely to provide optimal cuff pressure when based on tracheal diameter (65% of patients) than when based on both height and age (45% of patients). CONCLUSIONS: Optimal cuff volume was better estimated from tracheal diameter and patient height and age than from the manual palpation method.

[Cuffed pediatric endotracheal tubes].

BACKGROUND: The goal of this investigation was to evaluate the details of cuffed pediatric endotracheal tubes (PCETTs, I.D. 3.0-6.0 mm) available in Japan. METHODS: Following dimensions of all PCETTs were measured; the distance from the tube tip to the distal/proximal border of cuff, cuff length, cuff volume and cuff diameter at 20 cmH2O cuff pressure, outer diameter and length of tubes, the distance from tube tip to the distal border of depth markings, length and the number of depth markings, calculated cross sectional area of the Murphy eyes, and the number of the Murphy eyes. RESULTS: A total of 73 PCETTs, including 20 brands from 10 manufacturers, were investigated, in which 82.2% of PCETTs are larger than I. D. 5.0. There are significant differences in the distance from tube tip to the distal/proximal border of the cuff, and the cuff length at 20 cmH2O cuff pressure for a given I.D. Some tubes have no depth markings, others have multiple ones, and depth markings are positioned differently. Eighty-three point six % of PCETTs have one Murphy eye. CONCLUSIONS: There is no uniformity in the details of PCETTs available in Japan. The details of PCETTs including cuff design and depth marking should be updated.

Comparison of axon extension: PTFE versus PLA formed by a 3D printer.

Three-dimensional (3D) printers mainly create 3D objects by stacking thin layers of material. The effect of the tools created using the fused deposition modeling (FDM) 3D printer on nerve cells remains unclear. In this study, the effects of polytetrafluoroethylene (PTFE) models and two different types of polylactic acid (PLA) models (white or natural), were created using the FDM 3D printer on axon extension were compared using the Campenot chamber. Neurons were isolated from the dorsal root ganglia and added to the central compartment of the Campenot chambers after isolation, processing, and culturing. On day 7, after the initiation of the culture, the difference of the axon extensions to the side compartments of each group was confirmed. We also compared the pH and the amount of leakage when each of these chambers was used. The PLA was associated with a shorter axon extension than the PTFE (white p = 0.0078, natural p = 0.00391). No difference in the pH was observed (p = 0.347), but there was a significant difference on multiple group comparison (p = 0.0231) in the amount of leakage of the medium. PTFE was found to be a more suitable material for culturing attachments.

Application of fluorescent cholangiography to single-incision laparoscopic cholecystectomy.

BACKGROUND: Although the use of single-incision laparoscopic cholecystectomy (SILC) is spreading rapidly, this technique has disadvantages. It does not allow for sufficient surgical views to be obtained or for intraoperative radiographic cholangiography to be performed. Fluorescent cholangiography using a preoperative intravenous injection of indocyanine green (ICG) may be useful for identifying the biliary tract during both SILC and conventional laparoscopic cholecystectomy. METHODS: For seven patients undergoing SILC, 1 ml of ICG (2.5 mg) was administered by intravenous injection before the surgery. The prototype fluorescent imaging system consisted of a xenon light source and a 30° laparoscope (diameter, 10 mm) equipped with a charge-coupled device camera capable of filtering out light with wavelengths shorter than 810 nm. The laparoscope was introduced through an umbilical trocar. Fluorescent cholangiography then was performed by changing the color images to fluorescent images using a foot switch during dissection of the triangle of Calot. RESULTS: Fluorescent cholangiography identified the confluence between the cystic duct and the common hepatic duct in all seven patients before and throughout the dissection of the triangle of Calot. The interval from the injection of ICG to the first obtained fluorescent cholangiography before dissection of the triangle of Calot ranged from 35 to 75 min. CONCLUSIONS: Fluorescent cholangiography enabled real-time identification of the extrahepatic bile ducts during SILC without necessitating catheterization of the bile duct. Such properties of fluorescent cholangiography are expected to be helpful for ensuring the safety of SILC and expanding the indications for the procedure.

[Case report of TGA-1 neonate with hyponatremia].

A neonate with transposition of the great arteries (TGA) was scheduled for arterial switch operation (ASO) and entered to Pediatric ICU on day 4. Although mainly fed with mother's and formula milk, the serum natrium concentration decreased extremely to 104 mEq x l(-1) on day 9. We prioritized treatment of electrolyte disorders, and the operation was postponed on day 13. After the operation, he was diagnosed as syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and post operative course was uneventful. Electrolyte control is very important even if the infant is fed with mother's milk.

Difficult Airway Management in Neonates and Infants: Knowledge of Devices and a Device-Oriented Strategy.

Difficult airway management (DAM) in neonates and infants requires anesthesiologists and critical care clinicians to respond rapidly with appropriate evaluation of specific situations. Therefore, organizing information regarding DAM devices and device-oriented guidance for neonate and infant DAM treatment will help practitioners select the safest and most effective strategy. Based on DAM device information and reported literature, there are three modern options for DAM in neonates and infants that can be selected according to the anatomical difficulty and device-oriented strategy: (1) video laryngoscope (VLS), (2) supraglottic airway device (SAD), and (3) flexible fiberoptic scope (FOS). Some VLSs are equipped with small blades for infants. Advanced SADs have small sizes for infants, and some effectively function as conduits for endotracheal intubation. The smallest FOS has an outer diameter of 2.2 mm and enables intubation with endotracheal tubes with an inner diameter of 3.0 mm. DAM in neonates and infants can be improved by effectively selecting the appropriate device combination and ensuring that available providers have the necessary skills.