[Perioperative Management of Acute Type-A Aortic Dissection in a 97-year-old Woman].

A 97-year-old woman with severe back pain was transferred to our hospital. She was able to perform activities of daily living independently and had no neu- rological deficit or dementia before her admission. Con- trast-enhanced computed tomography revealed a rup- ture in the descending aorta and thrombosed type A aortic dissection. We carefully explained the need for and the risks associated with surgery to the patient and her family. After an informed consent had been obtained, she was taken to the operating room for an emergency surgery. Anesthetic management was uneventful. Trans- esophageal echocardiography was useful to evaluate her cardiac function and aortic dissection. We per- formed replacement of the total aortic arch and descending aorta successfully. On the 55th postopera- tive day, she was transferred to another hospital to undergo further physical therapy. The total hospital- ization cost was nearly 9.8 million yen. The medical cost was high in our case. In cases of nonagenarians who require an emergency cardiac surgery, we should consider the patients' age, preoperative activities of daily living, and postoperative quality of life when making decisions on surgery. The patient in our case needed to be carefully treated for airway and swallow- ing management in the early perioperative period.

Caterpillar mimicry by plant galls as a visual defense against herbivores.

Plant galls, induced by arthropods and various other organisms have an intimate relationship with host plants, and gall-inducers have limited mobility. In addition to their own photosynthesis, galls are resource sinks rich with nutrients, with neighboring plant organs commonly serving as external photosynthate sources. Galls, if not well defended, may therefore be attractive food sources for herbivores. Galls produced by some aphids, jumping plant lice, thrips, and gall midges in Japan, Palearctic region and in the Middle East visually resemble lepidopteran caterpillars. I propose that such visual resemblance may reduce herbivory of galls and surrounding plant tissues, resulting in an increase in galler survival due to reduced gall damage and in enhanced galler growth due to improved nutrient inflow to the galls, when herbivores avoid colonizing or consuming plant parts that look as if they have been occupied by other herbivores. Potential predators and parasitoids of caterpillars may be attracted to the caterpillar-like galls and then attack real caterpillars and other invertebrate herbivores, which would also be beneficial for both gallers and their hosts.

The influence of American Society of Anesthesiologists Physical Status on patient morbidity and survival after total thyroidectomy.

In cases of thyroid papillary carcinoma, a less aggressive cancer, surgeons may hesitate to perform total thyroidectomy on patients with poor general condition because these may experience longer survival without undergoing surgery. To investigate the influence of general patient condition on the patients' survival who received total thyroidectomy, we utilized the American Society of Anesthesiologists Physical Status (ASA-PS). We retrospectively reviewed all patients undergoing total thyroidectomy under general anesthesia and graded by ASA-PS between 2004 and 2014. Patients with anaplastic carcinoma and metastatic thyroid renal cell carcinoma were excluded. There were 77 (30%), 149 (58%), and 30 (12%) ASA-PS 1, 2, and 3 cases, respectively. Patient age increased significantly with increasing ASA-PS score (median age of 53, 64, and 71 years for ASA-PS 1, 2, and 3). Hospitalization periods extended significantly for patients with ASA-PS 3. Twenty patients died during the study (3.89 median years). Five-year overall survival rates were 100%, 93%, and 79% for ASA-PS 1, 2 and 3, respectively. Patients in the ASA-PS 1 group had significantly better prognosis by log-rank test. Univariate analysis showed an increased risk of death as ASA-PS score increased (hazard ratio: 3.03, 95% confidence interval: 1.55-5.92, p=0.00). In multivariate analysis, including patient age and presence of malignancy, patient age was the only significant predictor of overall survival (hazard ratio: 1.09 by year, 95% confidence interval: 1.03-1.14, p=0.00). We concluded that a high ASA-PS score should not inhibit performance of total thyroidectomy if a patient's age is suitable for the surgery.

[Perioperative Airway Management in a Patient with Madelung's Disease: A Case Report].

Madelung's disease is a rare disorder characterized by multiple, symmetric fatty tissues. The patient, 72-year-old man was admitted to our hospital for abdominal surgery for liver cancer. He had extreme fatty accumulations involving head and neck. We expected difficult airway because of his fatty tissues, and we perfomed awake intubation by Airway Scope. We confirmed the airway by using tube exchanger at extubation. We should choose a proper airway management technique to reduce the incidences of airway complications.

Dense white trichome production by plants as possible mimicry of arthropod silk or fungal hyphae that deter herbivory.

Some spiders are well-known to mimic flowers or other plant surfaces in order to be cryptic to both their prey and their predators. We propose that dense, thread-like white trichomes of some plants from Estonia, Greece, Israel and Japan visually mimic spider webs, lepidopteran and spider-mite web nests and plant-pathogenic fungi, and that it may result in reduced herbivory, since various herbivores avoid spider- or other arthropod webs to circumvent predation or toxic attacks, or refrain from colonizing plants that have already been occupied by other herbivores and pathogens. Spiders and other web-forming arthropods are also the prey of certain vertebrate predators and wasps, and therefore such predators may be attracted to these web-like plant structures and prey on the invertebrate herbivores occupying them. We do not dismiss the possibility that these web-like structures may also have other defensive or physiological functions or that they are not classic mimics but rather exploit the herbivore׳s perceptual state concerning the avoidance of potentially risky objects.

Phase II clinical trial of CD34+ cell therapy to explore endpoint selection and timing in patients with critical limb ischemia.

BACKGROUND: A prior phase I/IIa clinical trial provided evidence for safety, feasibility and potential efficacy of i.m. injection of granulocyte colony-stimulating factor (G-CSF)-mobilized CD34+ cells in patients with critical limb ischemia (CLI). METHODS AND RESULTS: A phase II trial of CD34+ cell therapy was conducted in patients with CLI to explore endpoint selection and timing. No-option CLI patients (n=11) underwent i.m. transplantation of G-CSF-mobilized CD34+ cells isolated by magnetic sorting. Ischemic rest pain scales improved from week 2 vs. baseline (P<0.05). Skin perfusion pressure (P=0.0175), transcutaneous partial oxygen pressure (P=0.0446) and pain-free walking distance (P=0.0056) improved from week 2, total walking distance from week 8 (P=0.0182) and toe brachial pressure index from week 12 (P=0.0174) vs. baseline. These parameters peaked at week 36 or 52. Rutherford's category improved from week 24 vs. baseline (P=0.0065). CLI-free ratio serially increased and peaked (85.7%) at week 36. Serial change in Rutherford's category correlated with that in Rest Pain Scale (P=0.0374), but not with that in any physiological parameters. CONCLUSIONS: Ischemic rest pain scales and physiological parameters improved relatively early after cell therapy, then plateaued later accompanied by recovery from the CLI state. Rutherford's category and CLI-free ratio at week 36 or later may be suitable endpoints in cell therapy clinical trials for CLI. Functional parameters should be evaluated independently of such clinical endpoints for ischemia severity. ( CLINICAL TRIAL REGISTRATION: URL: https://dbcentre3.jmacct.med.or.jp/jmactr/Default.aspx. Unique identifier: JMA-IIA00022)

Preoperative left atrial volume index predicts postoperative atrial fibrillation in patients with severe aortic valve stenosis.

PURPOSE: Left atrial enlargement correlates with the severity of diastolic dysfunction and is a predictor of cardiovascular complications such as atrial fibrillation. Aortic valve stenosis (AS) causes left atrial enlargement and progression of diastolic dysfunction. The aim of this study was to investigate the efficacy of the preoperative left atrial volume index (LAVI) in predicting postoperative outcome in patients with severe AS. METHODS: Forty-seven patients with severe AS who underwent aortic valve replacement were examined. Transthoracic echocardiography and LAVI measurement were performed on admission. Patients were divided into two groups according to optimal cut-off values of LAVI derived from receiver operating characteristic curves for postoperative atrial fibrillation (POAF) (group S: LAVI <52 ml/m(2), group L: LAVI ≥52 ml/m(2)). The incidence of POAF, ventilation time, inotropic support time, duration of stay in intensive care, and overall duration of hospital stay were evaluated. RESULTS: By univariate analysis, the incidence of POAF in group S was significantly lower than that in group L (25.9 and 65.0%, respectively; P < 0.01). Values for other parameters were higher in group L, although the differences were insignificant. CONCLUSION: In patients with severe AS, a preoperative LAVI of ≥52 ml/m(2) may be a useful predictor of POAF, although the efficacy of this index for predicting other postoperative outcomes has yet to be determined.

[Low dose vasopressin is effective for catecholamine-resistant hypotension after resection of pheochromocytoma].

The perioperative management of pheochromocytoma is challenging for anesthesiologists and persistent hypotension secondary to cathecholamine depletion after tumor resection can be refractory to treatment. A 64-year-old man underwent right adrenalectomy for treatment of massive pheochromocytoma. Doxazosin administration was started and increased gradually to 12 mg daily. He was premedicated with doxazosin on the day of the surgery. Induction was uneventful but there was a sudden increase of blood pressure with tachycardia on handling of tumor which was controlled by intravenous remifentanil, landiolol, diltiazem, and magnesium sulfate. With dissection of the tumor, the blood pressure dropped to 65/40 mmHg, which was resistant to fluid and cathecholamine treatment. After commencement of low dose vasopressin administration (two boluses of 0.08 U followed by 1.6 U x hr(-1)), blood pressure gradually recovered to normal ranges. Low dose vasopressin can be safely used to treat postadrenalectomy hypotension and also can reduce the cathecholamine dose.

Improved uniform persistence for partially diffusive models of infectious diseases: cases of avian influenza and Ebola virus disease.

Past works on partially diffusive models of diseases typically rely on a strong assumption regarding the initial data of their infection-related compartments in order to demonstrate uniform persistence in the case that the basic reproduction number $ \mathcal{R}_0 $ is above 1. Such a model for avian influenza was proposed, and its uniform persistence was proven for the case $ \mathcal{R}_0 > 1 $ when all of the infected bird population, recovered bird population and virus concentration in water do not initially vanish. Similarly, a work regarding a model of the Ebola virus disease required that the infected human population does not initially vanish to show an analogous result. We introduce a modification on the standard method of proving uniform persistence, extending both of these results by weakening their respective assumptions to requiring that only one (rather than all) infection-related compartment is initially non-vanishing. That is, we show that, given $ \mathcal{R}_0 > 1 $, if either the infected bird population or the viral concentration are initially nonzero anywhere in the case of avian influenza, or if any of the infected human population, viral concentration or population of deceased individuals who are under care are initially nonzero anywhere in the case of the Ebola virus disease, then their respective models predict uniform persistence. The difficulty which we overcome here is the lack of diffusion, and hence the inability to apply the minimum principle, in the equations of the avian influenza virus concentration in water and of the population of the individuals deceased due to the Ebola virus disease who are still in the process of caring.

[Investigation of the outcomes and complications in right thoracotomy approach for mitral valve reoperation].

BACKGROUND: Right thoracotomy is an alternative surgical technique for mitral valve reoperation. The purpose of this study is to determine whether right thoracotomy for mitral valve reoperation affects its perioperative outcomes and complications. METHODS: We investigated the perioperative events in consecutive mitral valve reoperations between January 2006 and November 2009. Demographic, intraoperative and postoperative data were collected and analyzed retrospectively. RESULTS: Five right thoracotomy cases and 22 repeated sternotomy cases were included. Thoracotomy group needed more platelet transfusion (median, 20 units in thoracotomy; 10 units in sternotomy; P=0.047). We had a higher frequency of adrenaline administration (60% in thoracotomy; 4.6% in sternotomy; P=0.005) and needed more doses of dobutamine in thoracotomy group (median, 16.0 microg x kg(-1) x min(-1) in thoracotomy ; 7.5 microg x kg(-1) x min(-1) in sternotomy; P=0.037) to wean them from cardiopulmonary bypass. Right thoracotomy did not reduce cardiopulmonary bypass time (median, 265 min in thoracotomy ; 199 min in sternotomy; P=0.126). We experienced two serious complications requiring reoperation in thoracotomy group, but diagnosed them with intraoperative transesophageal echocardiography. CONCLUSIONS: When we choose right thoracotomy for mitral valve reoperation, we should prepare more blood products and inotropic agents and should evaluate cardiac function by using intraoperative transesophageal echocardiography.

[Remifentanil prevents hyperglycemia and reduces insulin use during cardiopulmonary bypass in adult cardiac surgery].

BACKGROUND: Remifentanil may be beneficial in patients undergoing cardiac surgery, by attenuating the neurohumoral stress response to surgical stimulation and inflammation evoked by cardiopulmonary bypass (CPB). METHODS: We retrospectively examined blood glucose monitored every 30 minutes during CPB and insulin dose in patients during CPB under remifentanil anesthesia (remifentanil group) and those under low dose fentanyl anesthesia (fentanyl group) in adult cardiac surgery. Furthermore we also investigated incidence of atrial fibrillation within 72 hours after surgery in both groups. RESULTS: There were 35 patients in remifentanil group and 22 patients in fentanyl group. Although blood glucose at the beginning and the end of CPB in both groups were not different, remifentanil group showed lower maximum blood glucose (median 172 mg x dl(-1), interquatile range 156-205 mg x dl(-1)) during CPB than in fentanyl group (197 mg x dl(-1), 176-219 mg x dl(-1); P = 0.009). Significantly less insulin was administered during CPB in remifentanil group than in fentanyl group. Incidence of postoperative atrial fibrillation was similar between the groups. CONCLUSIONS: Maximum blood glucose was lower and less insulin was administered during CPB in remifentanil group. These data may suggest that remifentanil reduce stress response to surgical stimulation in cardiac surgery.

Parachuting behavior and predation by ants in the nettle caterpillar, Scopelodes contracta.

This paper documents the bizarre descending behavior from the tree crown to the ground of the larvae of the moth, Scopelodes contracta Walker (Lepidoptera: Limacodidae) and the interaction of the larva with predatory ants. S. contracta larvae infest leaves of many tree species in urban areas and orchards in Japan. Mature larvae and leaves without basal leaf parts were found under trees of four species infested with S. contracta larvae in Osaka, Japan. Individual larvae riding on leaves were observed falling from tree crowns to the ground. Many S. contracta cocoons were found in the soil below the trees two weeks after the observed parachuting. These observations indicate that S. contracta larvae parachuted to the ground where they spin their cocoons in the soil. When a larva that had just parachuted down was returned to an arboreal twig, the larva repeated the parachuting behavior. This parachuting behavior appears to be adaptive, because larvae can descend to the ground safely and with low energy cost. Worker ants of Tetramorium tsushimae Emery (Hymenoptera: Formicidae) and Pristomyrmex punctatus Mayr (Hymenoptera: Formicidae) occasionally attacked larvae on the ground before they had a chance to burrow in the soil.

Global well-posedness of infectious disease models without life-time immunity: the cases of cholera and avian influenza.

We study the systems of partial differential equations with diffusion that model the dynamics of infectious diseases without life-time immunity, in particular the cases of cholera from Wang & Wang (2015, J. Biol. Dyn., 9, 233-261) and avian influenza from Vaidya et al. (2012, Discrete Contin. Dyn. Syst. Ser. B, 17, 2829-2848). In both works, similarly to all others in the literature on various models of infectious diseases and more, it had to be assumed for a technical reason that the diffusivity coefficients of the susceptible, infected and recovered individuals, humans or birds, had to be identical in order to prove the existence of their unique solutions for all time. Considering that such uniform diffusivity strengths among the susceptible, infected and recovered hosts may not always be plausible in real world, we investigate the global well-posedness issue when such conditions are relaxed. In particular for the cholera model from Wang & Wang (2015, J. Biol. Dyn., 9, 233-261), we prove the global well-posedness with no condition on the diffusivity coefficients at all. For the avian influenza model from Vaidya et al. (2012, Discrete Contin. Dyn. Syst. Ser. B, 17, 2829-2848), we prove the global well-posedness with no condition on the diffusivity coefficients if the spatial dimension is one, and under a partial condition that the diffusivity coefficients of the susceptible and the infected hosts are same otherwise.

Global stability and uniform persistence of the reaction-convection-diffusion cholera epidemic model.

We study the global stability issue of the reaction-convection-diffusion cholera epidemic PDE model and show that the basic reproduction number serves as a threshold parameter that predicts whether cholera will persist or become globally extinct. Specifically, when the basic reproduction number is beneath one, we show that the disease-free-equilibrium is globally attractive. On the other hand, when the basic reproduction number exceeds one, if the infectious hosts or the concentration of bacteria in the contaminated water are not initially identically zero, we prove the uniform persistence result and that there exists at least one positive steady state.

Successful recovery without any neurological complication after intraoperative cardiopulmonary resuscitation for an extended period of time in the lateral position: a case report.

No successful resuscitation has ever been reported about intraoperative cardiopulmonary resuscitation (CPR) for an extended period of time in the lateral position. Here we report a case of successful resuscitation without any neurological complication after cardiac arrest due to massive hemorrhage and 25 min of CPR in the lateral position. The patient was a 65-year-old man. During open hemostasis for the postoperative hemorrhage, the patient's rhythm changed sinus to ventricular fibrillation (VF), followed by asystole. We started CPR immediately with the patient in the left lateral position. Chest compression was performed by two practitioners, one pressing patient's sternum and the other pressing simultaneously patient's mid-thoracic spine from his back. During CPR, though the value of end-tidal CO2 (EtCO2) was significantly low (around 5-20 mmHg), the value of systolic arterial pressure was kept about 35-50 mmHg, and diastolic pressure about 20-30 mmHg. After the 25 min of lateral CPR, he achieved the return of spontaneous circulation (ROSC). He was hemodynamically stable after ROSC. He regained his consciousness at the next postoperative day. He was discharged from our hospital on the 60th day of operation without any cardiac and neurological complication. Successful neurological outcome suggests that we may expect satisfactory neurological outcome even in the case of lateral position and prolonged CPR if we perform effective CPR with the feedback of arterial blood pressure and EtCO2 and with the immediate intervention to culprit injuries.

Immobilized alpha-diazophosphonoacetate as a versatile key precursor for palladium catalyzed indole synthesis on a polymer support.

Rh(II)-catalyzed N-H insertion reaction of immobilized alpha-diazophosphonoacetate with 2-haloanilines followed by Horner-Emmons reaction gave immobilized enaminoesters, which were efficiently cyclized to indoles via intramolecular palladium catalyzed reaction on a polymer support.