A Review of Current Flow Diverters.

Flow diverter (FD) devices are new-generation stents placed in the parent artery at the aneurysmal neck to obstruct intra-aneurysmal blood flow, thus favoring intra-aneurysmal thrombosis. In Japan, about eight years have passed since health insurance approval was granted for FD devices, and FD placement to treat aneurysms has become widespread. Treatment indications have also been expanded with the introduction of novel devices. At present, three types of FD (Pipeline, FRED, and Surpass Streamline) are available in Japan. This report represents a compilation of available FD technologies and describes the current consensus on this treatment.

Pathological changes in the lenticulostriate artery indicate the mechanisms leading to intracranial hemorrhage in Moyamoya disease: a case report.

This case report details the pathological findings of a vessel wall identified as the bleeding point for intracranial hemorrhage associated with Moyamoya disease. A 29-year-old woman experienced intracranial hemorrhage unrelated to hyperperfusion following superficial temporal artery-middle cerebral artery bypass surgery. A pseudoaneurysm on the lenticulostriate artery (LSA) was identified as the causative vessel and subsequently excised. Examination of the excised pseudoaneurysm revealed a fragment of the LSA, with a disrupted internal elastic lamina and media degeneration. These pathological findings in a perforating artery, akin to the circle of Willis, provide insights into the underlying mechanisms of hemorrhage in Moyamoya disease.

Consensus statement on smoking cessation in patients with pain.

Smoking is closely associated with the development of various cancers and tobacco-related illnesses such as cardiovascular and respiratory disorders. However, data are scarce on the relationship between smoking and both acute and chronic pain. In addition to nicotine, tobacco smoke contains more than 4000 different compounds. Although nicotine is not the sole cause of smoking-induced diseases, it plays a critical role in pain-related pathophysiology. Despite the acute analgesic effects of nicotine, long-term exposure leads to tolerance and increased pain sensitivity due to nicotinic acetylcholine receptor desensitization and neuronal plastic changes. The purpose of smoking cessation interventions in smoking patients with pain is primarily not only to reduce their pain and associated limitations in activities of daily living, but also to improve the outcomes of underlying pain-causing conditions and reduce the risks of tobacco-related disorders. This statement aims to summarize the available evidence on the impact of smoking on pain and to inform medical professionals of the significance of smoking cessation in patients with pain.

A case of severe sciatica caused by a lymphocele after renal transplantation.

BACKGROUND: Sciatica is commonly caused by lumbar spinal disease. However, it can also be caused by tumors, infectious diseases, or muscle entrapment. We present a case of sciatica caused by a lymphocele after renal transplantation. PRESENTATION: A 50-year-old man who had undergone renal transplantation presented with sciatica and low back pain without leg edema. The patient was diagnosed with lumbar disc herniation during the first medical examination. Regardless of the treatment, the symptoms were exacerbated and red flag signs of low back pain were observed. Compression of the sciatic nerve by the lymphocele was confirmed by computed tomography. The sciatica was improved by ethanol injection for the lymphocele. CONCLUSIONS: We encountered a rare case of severe sciatica without edema caused by lymphocele after renal transplantation. Careful examination is required to make a different diagnosis of lymphocele from other lumbar spinal diseases.

Single-Port Laparoscopic Duodenojejunostomy Employing Semi-Kocherization for a Young Female with Superior Mesenteric Artery Syndrome.

Single-port laparoscopic duodenojejunostomy employing semi-Kocherization performed for a patient with superior mesenteric artery (SMA) syndrome is presented in this report. A 24-year-old woman missed meals due to work pressure, and her body weight decreased from 42 kg to 27 kg within 6 months. After this severe weight loss, she suffered from postprandial abdominal pain. An enhanced computed tomography revealed that the aortomesenteric angle was 11° (narrow), and the distance was short at 4.5 mm. Duodenography also revealed dilatation of the proximal duodenum. These findings led to a diagnosis of SMA syndrome, and we performed single-port laparoscopic duodenojejunostomy. We first dissected the fusion between the duodenum and transverse mesocolon, such as Kocherization, enough to mobilize the duodenum; this procedure was termed semi-Kocherization. A gauze was placed in the dissected space for a landmark from the transverse mesocolon side. We confirmed the gauze at the duodenum's lateral side, then opened the transverse mesocolon, and pulled the duodenum out. We performed side-to-side duodenojejunostomy. The postoperative course was unremarkable, and she gained 4 kg within 2 months of discharge. Semi-Kocherization is shown to be an effective technique to increase duodenal mobility for performing anastomosis, and single-port laparoscopic surgery can reduce wounds and increase cosmesis.

Boron analysis and imaging of cells with 2-hr BPA exposure by using micro-proton particle-induced gamma-ray emission (PIGE).

Particle-induced gamma-ray emission (PIGE), which measures prompt gamma rays at 428 keV from 10B (p, p'γ) 7Be, was used to confirm the boron distribution within 2hr-BPA-exposed cells. Distribution images of potassium, phosphate, and boron and the whole spectrum showed the ratios of boron counts to total (%) as follows: control group: 1.35 ± 0.073%; 2hr boron exposure group: 2.33 ± 0.35%; and boron exposure/wash group: 1.58 ± 0.095%. Micro-beam PIXE/PIGE can be a promising tool for visualization of intracellular Boron.

[Difficult Airway Management of a Patient with the Ossification of Anterior Longitudinal Ligament].

We report a case of difficult airway management (DAM) with the ossification of anterior longitudinal ligament (OALL). A 66-year-old man complained of pharyngeal discomfort. He was diagnosed with OALL, and planned to have a surgery under general anesthesia. We expected DAM due to the limitation of cervical mobility and airway obstruction caused by OALL. We succeeded in awake intubation with video laryngoscope and tracheal tube introducer.

Boron analysis for neutron capture therapy using particle-induced gamma-ray emission.

The neutron source of BNCT is currently changing from reactor to accelerator, but peripheral facilities such as a dose-planning system and blood boron analysis have still not been established. To evaluate the potential application of particle-induced gamma-ray emission (PIGE) for boron measurement in clinical boron neutron capture therapy, boronophenylalanine dissolved within a cell culture medium was measured using PIGE. PIGE detected 18 µgB/mL f-BPA in the culture medium, and all measurements of any given sample were taken within 20 min. Two hours of f-BPA exposure was required to create a boron distribution image. However, even though boron remained in the cells, the boron on the cell membrane could not be distinguished from the boron in the cytoplasm.

Visualization of regional cerebrospinal fluid flow with a dye injection technique in focal arachnoid pathologies.

Surgical lysis of the thickened arachnoid membrane is the first choice of treatment in spinal arachnoid pathologies that cause flow disturbances or blockage of CSF. However, it is important to consider that while extensive lysis of the arachnoid may temporarily provide a wide pathway for CSF, an extensive lytic procedure may later cause secondary adhesion. Thus, it is ideal for the proper extent of the arachnoid lysis to be determined after careful analysis of regional CSF flow. The authors report their limited experience with intraoperative visualization of CSF flow in spinal arachnoid pathologies. Two patients with a dorsal arachnoid web (DAW) with cervical syringomyelia and 1 patient with focal adhesive arachnoiditis causing edema of the spinal cord were surgically treated at the authors' institution between 2007 and 2013. In all cases, the presence of a DAW or focal adhesive arachnoiditis was suspected from the findings on MRI, namely 1) an indentation on the upper thoracic spinal cord and 2) syringomyelia and/or edema of the spinal cord above the indentation. Exploratory surgery disclosed a transversely thickened arachnoid septum on the dorsal side of the indented cord. To prove blockage of the CSF by the septum and to decide on the extent of arachnoid lysis, regional CSF flow around the arachnoid septum was visualized by subarachnoid injection of gentian violet solution close to the web. Injected dye stagnated just close to the arachnoid septum in all cases, and these findings documented CSF blockage by the septum. In 2 cases, a 2-minute observation showed that the injected dye stayed close to the web without diffusion. The authors performed not only resection of the web itself but also lysis of the thickened arachnoid on both sides of the spinal cord to make a CSF pathway on the ventral side. In the third case, the dye stagnated close to the web at first but then diffused through the nerve root to the ventral CSF space. The lysis procedure was completed after exclusive removal of the dorsal web. Postoperative MR images confirmed reduction of the syrinx and/or improvement of the edema in all cases, suggesting that the extent of arachnoid lysis was optimal in each case. No adverse effect was observed after subarachnoid injection of gentian violet. The authors believe that their technique of visualizing regional CSF flow will be helpful to decide the optimal extent of lysis in some local arachnoid pathologies.

[Anesthetic management for a patient with scoliosis combined with central core disease].

We gave general anesthesia to a patient with scoliosis combined with central core disease (CCD). CCD is a slowly progressive autosomal dominant congenital myopathy. CCD is presented typically in infancy with hypotonia and delay of motor development, characterized by predominantly proximal weakness pronounced in the hip girdle. Orthopedic complications are common with congenital dislocation of the hips, scoliosis and foot deformity. CCD is due to mutations in the skeletal muscle ryanodine receptor (RYR1) gene at chromosome 19q13.1, which is also implicated in the malignant hyperthermia (MH). A patient with CCD is at risk of MH, with an abnormal response to suxamethonium and volatile anesthetics. The anesthetist ought to be aware of the diagnosis of CCD and to plan anesthetic management accordingly, avoiding potentially MH-triggering agents. We used total intravenous anesthesia (TIVA) in this case, and he showed no MH symptoms perioperatively. This report demonstrates that anesthesia in a patient with CCD could be successfully maintained with TIVA.

Sleep, mental health status, and medical errors among hospital nurses in Japan.

Medical error involving nurses is a critical issue since nurses' actions will have a direct and often significant effect on the prognosis of their patients. To investigate the significance of nurse health in Japan and its potential impact on patient services, a questionnaire-based survey amongst nurses working in hospitals was conducted, with the specific purpose of examining the relationship between shift work, mental health and self-reported medical errors. Multivariate analysis revealed significant associations between the shift work system, General Health Questionnaire (GHQ) scores and nurse errors: the odds ratios for shift system and GHQ were 2.1 and 1.1, respectively. It was confirmed that both sleep and mental health status among hospital nurses were relatively poor, and that shift work and poor mental health were significant factors contributing to medical errors.

[Effects of propofol or sevoflurane on cerebral regional oxygen saturation (rSO2) during one-lung ventilation].

BACKGROUND: The present study was designed to evaluate the alteration of cerebral regional oxygen saturation (rSO2) associated with propofol or sevoflurane during one-lung ventilation (OLV). METHODS: Fifty patients scheduled for a lung lobectomy were randomly assigned to propofol or sevoflurane group. General anesthesia was maintained with propofol (target controlled infusion; 2-3 mcg x ml(-1)) in propofol group (n=25), and sevoflurane (end-tidal concentration 1-2%) in sevoflurane group (n=25), being adjusted to maintain BIS values between 40 and 60. BIS and rSO2 values were continuously monitored. Arterial blood gas analysis was performed as follows: during two-lung ventilation before OLV (baseline), during the first 120 minutes of OLV and at the end of OLV and surgery. RESULTS: During OLV rSO2 was significantly lower than baseline in both groups. The values of rSO2 were not significantly different between the groups at each time. We could not find accurate correlation between rSO2 and other factors monitored. CONCLUSIONS: We conclude OLV leads to the decrease of rSO2, but there is no difference in the alteration of rSO2 between propofol and sevoflurane group. To maintain adequate rSO2, we should consider together in combination with respiratory, circulatory or metabolic index and depth of anesthesia.

Comparative evaluation of re-epithelialization promoted by fresh or cryopreserved cultured dermal substitute.

Allogeneic cultured dermal substitute (CDS) was prepared by plating cultured fibroblasts on a two-layered spongy matrix of hyaluronic acid and atelocollagen, followed by culturing for 1 week. The resulting fresh CDS was then cryopreserved in a freezer at -152 degrees C in accordance with conventional procedures. Fresh CDS was rinsed thoroughly with lactated Ringer's solution to remove fetal bovine serum (FBS) and was then used in the clinical study, whereas cryopreserved CDS was thawed and then rinsed with lactated Ringer's solution to remove cryoprotectant and FBS. The present study was designed to compare the efficacy of fresh and cryopreserved CDS in promoting reepithelialization at donor sites leaving behind split-thickness skin autografts. Fourteen donor sites were used for this comparative study. There were no differences in the period of complete re-epithelialization between the fresh and cryopreserved CDS. The results of this comparative study thus suggest that cryopreserved CDS is able to maintain the same level of potency to promote re-epithelialization as fresh CDS. This indicates that, although the release of growth factors is suppressed to some extent during the course of cryopreserving, thawing, and rinsing procedures, it is still sufficient to promote re-epithelialization.

A case report of neonatal onset multisystemic inflammatory disease in Japan treated with continuous hemodiafiltration and steroid pulse therapy.

Neonatal onset multisystem inflammatory disease (NOMID), which is also known as chronic infantile neurological cutaneous and articular syndrome, is a rare disease that is characterized by the triad of cutaneous rash, chronic meningitis and arthropathy. The long-term prognosis is poor, with progressive deafness and visual impairment, and worsening of the central nervous system manifestations. Some fatal cases have been reported secondary to infection, vasculitis and amyloidosis. We recently managed a typical case of NOMID where the combined treatment of continuous hemodiafiltration and steroid pulse therapy was effective. The patient showed repeated flare ups of fever, arthralgia and meningitis accompanied with high levels of cytokines. The effect was temporary, but useful in recovery from such a serious condition.

Novel mutations of the HOXD13 gene in hand and foot malformations.

Homeobox genes encode a set of transcription factors of fundamental importance for body patterning during embryogenesis. Hoxa9-a13 and Hoxd9-d13 play an especially important part in vertebrate limb development. Synpolydactyly (SPD) is characterized by various malformations of the limbs. The expansion of the polyalanine tract in 1OXD13 is one of its major causes. Recently, there have been many analysis studies of HOXD13 in patients with SPD and limb malformations. We analyzed HOXD13 in 100 patients with limb malformations, which affects the limbs in the distal parts of the metacarpal and/or metatarsal bones. Seven mutations in the coding region and two mutations in the 5'-untranslated region were identified. All were novel mutations. In this study, the mutations were located upstream in the homeobox. Thus, translation of the homeobox was affected by upstream mutations. Consequently, this suggested the possibility that abnormalities in the hands and feet could be caused by novel HOXD13 gene mutations.

Benign infantile neurogenic muscle atrophy predominantly involving the upper extremities.

An eight year-old girl was first noted to be hypotonic at 4 months of age. She had a delay in achieving developmental milestones and showed apparent weakness predominantly affecting muscles of the upper extremities. In the left biceps brachii muscle biopsy at the age of 5 months, there were groups of atrophic fibers and marked fiber type grouping, but intramuscular nerves were well myelinated and there were few type 2C fibers. She improved with age and learned to walk at 1 year and 4 months and had minimal weakness of the forearm muscles and mild atrophy of the muscles of the right upper extremity. She recently developed a mild scoliosis. Since the EMG was not neurogenic and no mutations were found in the survival motor neuron (SMN) gene, we believe that she does not have a degenerative neurogenic disorder but rather has an abnormal innervation of the skeletal muscles due either to anterior horn cell dysgenesis or anomalous peripheral nerve branching.

A case of Reye syndrome with rotavirus infection accompanied with high cytokines.

We report on a 23-month-old boy with a rare complication of rotavirus gastroenteritis. He was diagnosed as acute encephalopathy with DIC accompanied with high levels of cytokines. The liver pathology also revealed mild infiltration and fatty changes. He was suspected to be suffering from a cytokine storm followed by Reye syndrome.