[The relation between the frequency of exercise oxygen desaturation following major lung resection and the predictions of postoperative pulmonary function].

The predictors of oxygen desaturation during exercise in patients submitted to major pulmonary resection for lung cancer are to be determined. We analyzed retrospectively the relation between the oxygen saturation by pulse oxymetry (Spo2) during exercise and the predictions of postoperative pulmonary function. A hundred twenty-two patients with lung cancer who underwent lung resection from January 1999 to May 2004 were included (79 men, 43 women, average age 66.9 +/- 9.2). A fall over 5% in Spo2 during exercise was termed 'desaturation'. Twenty-eight patients developed desaturation [group D(+)] and 94 patients did not [group D(-)]. We compared the predictions of postoperative pulmonary function (%ppoVC, %ppoFEV1.0, %ppoDLco) between these 2 groups. As a result, only %ppoDLco was significantly different between 2 groups [D(+) 68.7 +/- 19.1%, D(-) 83.8 +/- 24.9%]. Patients with poor %ppoDLco are at increased risk to develop a postoperative exercise oxygen desaturation.

Molecular epidemiologic analysis of a Pneumocystis pneumonia outbreak among renal transplant patients.

Between 18 November and 3 December 2011, five renal transplant patients at the Department of Nephrology, Toho University Omori Medical Centre, Tokyo, were diagnosed with Pneumocystis pneumonia (PCP). We used molecular epidemiologic methods to determine whether the patients were infected with the same strain of Pneumocystis jirovecii. DNA extracted from the residual bronchoalveolar lavage fluid from the five outbreak cases and from another 20 cases of PCP between 2007 and 2014 were used for multilocus sequence typing to compare the genetic similarity of the P. jirovecii. DNA base sequencing by the Sanger method showed some regions where two bases overlapped and could not be defined. A next-generation sequencer was used to analyse the types and ratios of these overlapping bases. DNA base sequences of P. jirovecii in the bronchoalveolar lavage fluid from four of the five PCP patients in the 2011 outbreak and from another two renal transplant patients who developed PCP in 2013 were highly homologous. The Sanger method revealed 14 genomic regions where two differing DNA bases overlapped and could not be identified. Analyses of the overlapping bases by a next-generation sequencer revealed that the differing types of base were present in almost identical ratios. There is a strong possibility that the PCP outbreak at the Toho University Omori Medical Centre was caused by the same strain of P. jirovecii. Two different types of base present in some regions may be due to P. jirovecii's being a diploid species.

[The last period of surgical site infection after pulmonary resection for lung cancer with hemodialysis; report of a case].

An 80-year-old man had been on maintenance hemodialysis for nondiabetic chronic renal failure from June 1996. He underwent investigation of an abnormal chest X-ray and was referred to our hospital with a diagnosis of squamous cell carcinoma in the upper lobe of the right lung. On February 20, 2003, right upper lobectomy was performed. The postoperative course was uneventful and he was discharged on postoperative day 13. Two weeks later he was readmitted with a wound infection. Although he received antibiotics, drainage, and wound lavage, his fever persisted and chest X-ray showed inflammatory changes in the right lower lung field. He was placed on mechanical ventilation for dyspnea. After this, his respiratory function became stable and he could be weaned from the ventilator within 2 weeks. The subsequent course was uneventful and he was discharged 1 month after re-admission. This patient needed ventilation due to weakness caused by wound infection. Such infection is uncommon but can be fatal for a compromised host, so we administered antibiotics for 3 days until the wound closed.

The capacity of dog lung to release prostaglandin I2 as a biochemical parameter for evaluating lung damage during preservation.

The release of prostaglandin I2 (PGI2) from the vasculature is thought to reflect damage to the vessels. Basal and bradykinin (BK)-stimulated release of PGI2 from isolated dog lungs after 6-hr preservation were investigated to evaluate lung damage after preservation. Maximal PGI2 release induced by BK decreased significantly after preservation at 24 degrees C (room temperature), but not after hypothermic preservation at 4 degrees C, although basal PGI2 release without BK stimulation did not change in either group of lungs after preservation. The function of allotransplanted lungs assessed by arterial oxygen tension was impaired by preservation at room temperature but not by hypothermic preservation. No differences were observed by light microscopy in either group in the pulmonary tissues, including the pulmonary artery, after preservation. In summary, damage to the lung after preservation may be reflected by the maximal PGI2 release from the lung after BK infusion. Therefore the maximal PGI2 releasing capacity induced by BK may be a useful biochemical parameter for estimating the viability of preserved lungs.

Proliferating cell nuclear antigen positive cells in the hippocampal subgranular zone decline after irradiation in a rodent model.

Four-week-old ICR mice were systemically exposed to 18Gy X-rays. Afterwards, the expression of proliferating cell nuclear antigen (PCNA) in the cerebrum was observed with time using Western blot analysis and immunohistochemical staining. As a result, PCNA-positive cells were observed in the subgranular zone (SGZ) of the hippocampus and subventricular zone (SVZ) of the lateral ventricles in unirradiated mice. The number of PCNA-positive cells decreased with time in all zones after irradiation, but the decrease was more marked in the hippocampal SGZ. We think that PCNA-positive cells are stem cells. The selective vulnerability to radiation in the hippocampus is considered to be attributed to the fact that stem cells in the SGZ selectively undergo radiation-induced apoptosis.

Donor-specific cytotoxic lymphocyte activity from bronchoalveolar lavage during acute canine lung allograft rejection.

OBJECTIVE: We investigated the relationship between acute lung rejection and donor-specific cytotoxic activity (DSCA) in recipient's lymphocytes obtained from bronchoalveolar lavage (BAL). METHODS: A total of 26 mongrel dogs underwent left lung allotransplantation. Dogs received either no immunosuppressive treatment (group I), cyclosporine (group II), or cyclosporine and methylprednisolone for evidence of acute rejection (group III). DSCA was measured by a 51Cr release assay, using lymphocytes from BAL samples as effector cells and 51Cr-labeled donor skin fibroblasts as target cells. The pathologic findings of the transplanted lungs were classified according to the working formulation for classification and grading of pulmonary rejection. In addition, the degree of cellular infiltration in the perivascular, peribronchial, interstitial, and intraalveolar areas was determined based on an infiltration score. RESULTS: DSCA in BAL samples was elevated during mild, moderate and severe acute rejection. The accuracy of the diagnosis of mild or moderate rejection was 92.3% at effector:target (E:T) ratios of 100:1 and 50:1. The DSCA in the BAL fluid and the total infiltration score were correlated closely with correlation coefficients of 0.859 and 0.828 at E:T ratios of 100:1 in group I and group II dogs, respectively. Lung aeration improved and DSCA decreased with methylprednisolone therapy in three of four dogs with grade 2 rejection. CONCLUSION: There is a direct relationship between the DSCA in BAL fluid and the degree of tissue damage caused by acute rejection. The DSCA can be detected by a 51Cr release assay which may hold promise for future clinical applications.

The effect of postoperative ataralgesia by manual therapy after pulmonary resection.

Muscle therapy, a form of manual therapy, was applied to control pain persisting for more than 1 week following posterolateral thoracotomy, and its efficacy for the alleviation of pain was investigated. Eight patients who underwent posterolateral thoracotomy and lung resection for cancer (n=7) or emphysema (n=1) received manual therapy to incised muscles and the muscles inserting into the ribs in the affected area for an average of 17 days postoperatively. Pressure-friction and stretching techniques were used. Treatment was continued until the intensity of the pressure-friction technique reached a level at which the patient complained of pain and a decrease in muscle tone was detected. Treatment was performed once a week for 3 weeks. Pain severity was measured using a visual analog scale (VAS) (0-10). Before the first treatment, the VAS was set at 10, and changes of the score were observed before and after the treatment as well as over time. After three sessions, all patients showed a decrease in pain from 10 to an average of 1.9 (range 1.3-2.6).

Association between high grade ventricular arrhythmia and extent of left ventricular hypertrophy in hypertrophic cardiomyopathy.

The association between the extent of left ventricular (LV) hypertrophy and severity of ventricular or atrial arrhythmias are examined. Two-dimensional echocardiography and 24-h Holter electrocardiography monitoring were performed in 60 patients with hypertrophic cardiomyopathy (HCM). According to the distribution of the LV hypertrophy, the patients were divided into three groups: 1. Apical hypertrophy (APH), 2. Septal hypertrophy, and 3. Extensive hypertrophy. Ventricular arrhythmias were found in 82% of the patients and supraventricular arrhythmias were detected in 70% of the patients. Lown grade III and IV arrhythmias occurred significantly more frequently in patients with extensive than with septal hypertrophy. Lown grade III to IV arrhythmias did not occur in patients with APH. Present results show a significant association between the extent of LV hypertrophy and the severity of ventricular arrhythmias in HCM.

[A case of surgical treatment of triple cancers in the stomach, rectum and lung].

A case of triple cancers involving the stomach, rectum and lung is reported. A 75-year-old male was admitted to our clinic for the treatment of lung cancer. Right upper lobectomy was performed. Histological diagnosis was small cell lung carcinoma intermediate cell type (pT2N1M0, stage II). At the age of 70-year-old (sixty-two months before the pulmonary resection), he had undergone the resection of gastric cancer. At the age of 74-year-old (fourteen months before the pulmonary resection), rectal cancer was resected. Twenty four resected cases of triple cancers including lung cancer have been reported in the Japanese literature.

[Surgical treatment to the lung cancer in a patient receiving hemodialysis].

We performed right lower lobectomy for lung cancer in a 62-year-old man who had been under hemodialysis for 4 years. During the operation, hyperkalemia occurred and was treated by GI therapy (continuous intravenous infusion of glucose + insulin). On the 3rd postoperative day, CVP was increased and hypotension occurred during hemodialysis. It was considered that heart failure had developed. Attention to the possibility of heart failure is important in the postoperative management of patient on chronic hemodialysis who require lung resection. He was discharged without bleeding of infection. There have been few reports on operations for lung cancer in such patients, so our experience is significant.

[A case of foreign body granuloma].

A 45-year-old man referred to our hospital complaining of dry cough. Chest X-ray and CT scan film indicated tumor shadow in the right anterior mediastinum. Although preoperative diagnosis was teratoma, the specimen extirpated by thoracotomy revealed macroscopically and microscopically foreign body granuloma originated from gauzes. He had undergone segmentectomy of right upper lobe for tuberculosis 28 years ago, so the gauzes were thought to be left in right thoracic cavity at the operation. The foreign body granuloma originated from gauzes are iatrogenic and few cases were reported previously, however, whirl like pattern demonstrated by MRI is retrospectively considered to be an important diagnostic finding in this case.

[Bronchopleural fistula after pneumonectomy following induction therapy for cT4N0M0 squamous cell lung cancer].

A 69-year-old man developed after thoracotomy for lung cancer. He had centrally located cT4N0M0 squamous cell lung cancer that was downstaged to cTxN0M0 by induction chemoradiotherapy with grade 3 hematologic toxicity. Two months after the finish of chemotherapy, right pneumonectomy with concomitant resection of the superior vena cava was performed. Three weeks later, he developed with a bronchopleural fistula and died of ARDS. This demonstrates increased risk of surgery following induction chemoradiotherapy.

[Experience with induction chemoradiotherapy for cT4N2M0 lung cancer].

The 42-year-old man with cT4N2M0 adenocarcinoma is reported. The primary tumor showed no change in size on chest X-ray film after chemoradiotherapy, but chest computed tomography revealed necrosis of the lesion and was supposed to be down staging to cT3N0M0. Right upper lobectomy and lymph node dissection (R 2) was performed. Pathological examination revealed histological CR, and he is still alive 34 months after the start of induction therapy.

[Two cases of patch closure of pericardial defects using fascia lata after pulmonary resection with pericardiectomy].

We reported two cases of patch closure of pericardial defects using fascia lata after pulmonary resection with pericardiectomy. We confirm many advantages of this method-cheap, low risk of infection, tight tissue and easy technique in a short time with no skilled hand.

[Tension hemopneumothorax complicated by severe hepatic and renal disorder; report of a case].

A 46-year-old man was admitted to our hospital because of dyspnea and chest pain. We diagnosed tension hemopneumothorax and chest tube drainage was performed. A large volume of bloody pleural fluid (1,200 ml) was removed, but severe liver and renal dysfunction were then recognized. He was treated conservatively because there was no more bleeding. Despite administration of methylprednisolone, re-expansion pulmonary edema occurred after 6 hours of drainage, but this was also treated conservatively. After 3 days, his pneumothorax recurrenced. It was successfully managed by video-assisted thoracoscopic surgery (VATS).

[Two surgical cases of pulmonary dirofilariasis].

Two surgical cases of pulmonary dilofilariasis (women aged 80 and 54 years old) were reported. They, who had no history of keeping dogs, were admitted to our hospital with complaining of cough and coin lesion on chest X-ray. On investigation, it was difficult to distinguish between pulmonary dilofilariasis and lung cancer. Wedge resection was performed by video-assisted thoracic surgery (VATS), and a definite diagnosis of pulmonary dilofilariasis was made. Nodes 2-3 cm in diameter are formed beneath the pleura in many cases of pulmonary dilofilariasis. Therefore, VATS is useful owing to its minimal invasiveness.

[Are we legally allowed to administer blood for lifesaving to a patient who refuses it?].

We surveyed the literatures and discussed the legal issues whether we should administer blood for lifesaving to a patient who refuses it. The valid refusal of the transfusion requires the distinct intention of a competent patient. Minors below fifteen years of age are incompetent and their parents make a substituted judgement. Anyone must not give priority to the parents' belief and blood ought to be transfused if necessary for the children's benefits. We could evade liability for withholding blood only when we manage an operation arranged to succeed without blood transfusion, undergoing the sufficient treatments to avoid the risks, as well as on the basis of the valid refusal of a patient. The release deed and the intervention of hospital directors, ethics committees and courts are invalid for the immunity from liability. Anesthesiologists have to take the responsibility on themselves of administering blood or not. A statute law should be established to define what is a patient's valid intention and who is responsible.

[Influence of thoracotomy and partial lung resection on pulmonary function: comparison with median sternotomy].

The influence of thoracotomy on respiratory function was examined in 49 patients: 22 with intercostal thoracotomy without lung resection (ICT), 11 with partial lung resection (PLR) and 16 with median sternotomy (MST). Respiratory function (FVC, FEV1.0 and FEV1.0%) was measured preoperatively, in the early stage (14 days) and in the stable stage (after 3 months) postoperatively. In each group, the FVC and FEV1.0 were decreased to 70-80% of preoperative respiratory function in the early stage and rose to 90-95% in the stable stage. There were no significant differences among the groups. FEV1.0% did not vary in the different stages in any of the three groups. The ICT group was classified according to the type of skin incision (axillary incision (AI), anterolateral incision (ALI) and posterolateral incision (PLI)). FVC and FEV1.0 in the ALI subgroup were higher (p < 0.05) than in the PLI subgroup in the early stage. These results suggest that the selection of the skin incision is important for preserving respiratory function.

[Antagonism of diazepam-induced sedative effects by flumazenil in patients after surgery under lumbar spinal or epidural anesthesia].

The efficacy and general safety of flumazenil (YM684), a specific benzodiazepine antagonist, have been evaluated. Forty-seven patients scheduled for surgery under lumbar spinal or epidural anesthesia with diazepam sedation received flumazenil at the end of the procedure. Criteria of efficacy were the degree of sedation and antegrade amnesia. Before injection all patients were heavily sedated with the mean dose of 27 mg of diazepam (range 10-50 mg). After the mean dose of 0.21 mg of flumazenil (range 0.2-0.4 mg), all patients were awake or drowsy within 1-6 min but sedation recurred in one patient 1 hour later. The amnesia was eliminated by flumazenil in 34 patients (72%). No serious side-effects or hemodynamic changes were observed after flumazenil. It is concluded that flumazenil is an effective antagonist of sedation induced by diazepam.

[A sensitivity test of UFT and FT-207 against human pulmonary cancer using nude mice].

Transplanted tumors of human pulmonary adenocarcinoma subcutaneously into nude mice were used, to investigate the effect UFT and FT-207. Concentration of 5-FU and uracil in tumors, measured by the gas chromatographic-mass fragment graphic method, was followed. 5-FU concentration in UFT group were higher than other group, and uracil concentration show no significant difference. In one of the lines, tumor growth was stopped in UFT group and regression rate was 68% in comparison with control group, pathologically revealed grade II b in classification of Simosato-Oohoshi. It was also indicated in this experiment, anticancer effect is related with specific anticancer drug sensitivity.