Perioperative management of severe anorexia nervosa.

As the prevalence of anorexia nervosa (AN) increased, surgery in severe AN patients also increased in the 2000s. We experienced a surgical case of a patient with severe AN, showing an extremely low BMI of 8.6 kg m(-2). We investigated the problems associated with this case and propose criteria to manage severe AN. We endeavour to report on the perioperative management of rare and severe symptoms and surgical indications of severely malnourished patients. All published reports were identified through comprehensive searches using PubMed, BioMedLib, and the Japan Medical Abstracts Society with the following terms and keywords: 'anorexia nervosa', 'eating disorder', 'hypoglycaemia', 'leucocytopaenia', 'gelatinous bone marrow', 'surgery', and 'operation'. In cases of AN with a BMI under 13 kg m(-2), marked hypoglycaemia, leucocytopaenia <3.0×10(9) litre(-1), or both, potentially fatal complications frequently occur. Accordingly, patients need strict nutritional support to avoid re-feeding syndrome until surgery. During the course of anaesthesia, careless loading of glucose or catecholamine may lead to disturbance of electrolytes or fatal arrhythmia. Intensive care and early feeding as soon as possible after surgery are important to prevent surgical site infection. Although not many perioperative cases of AN have been reported, clinicians must be aware of the danger and the causes of mortality in critical cases. Thus, the decision to undertake surgery must be taken carefully and close perioperative coordination among physicians, surgeons, psychiatrists, anaesthesiologists, and intensivists is essential.

Polymyxin-B hemoperfusion for acute exacerbation of idiopathic pulmonary fibrosis: serum IL-7 as a prognostic marker.

BACKGROUND: Acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF) has an extremely poor prognosis. Direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX-DHP) has been used to improve oxygenation for acute respiratory distress syndrome. The study aim was to retrospectively determine the predictive factors affecting the prognosis of AE of IPF treated with PMX-DHP. METHODS: We studied patients suffering from AE of IPF, treated with PMX-DHP combined with high-dose corticosteroid therapy. Stored serum taken before and after PMX-DHP therapy was analyzed for 27 cytokines and chemokines. RESULTS: Nineteen patients with AE of IPF were studied. The median survival time after diagnosis of AE was 22 days. Survival rates after diagnosis of AE were 47.4% at 30 days, 31.6% at 60 days, and 26.3% at 90 days. Serum levels of Interleukin (IL)-7, an anti-fibrotic cytokine, in survivors at day 30 following PMX-DHP therapy ('Survivors') significantly increased after the treatment, compared to serum levels of non-survivors at day 30 after the therapy ('Nonsurvivors'), which did not demonstrate a significant change. Serum levels of IL-1beta, interferon-y and chemokine ligand (CCL) 2 levels were not significantly altered in 'Survivors', but were significantly changed in 'Nonsurvivors.' Multivariate Cox proportional-hazards analysis showed that an increase in IL-7 levels after PMX-DHP therapy and treatment without intubation (other than invasive positive-pressure ventilation) were significantly better prognostic factors. CONCLUSION: The results suggest that serum IL-7 may be a useful prognostic factor for patients with AE of IPF treated with PMX-DHP, possibly reflecting underlying anti-fibrotic mechanisms.

A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA.

BACKGROUND: Delays in reporting of medical errors may signal deficiencies in the performance of hospital-based incident reporting. We sought to understand the characteristics of hospitals, providers and patient injuries that affect such delays. SETTING AND METHODS: All incident reports filed between May 2004 and August 2005 at the Kyoto University Hospital (KUH) in Japan and the Brigham and Women's Hospital (BWH) in the USA were evaluated. Lag time between each event and the submission of an incident report were computed. Multivariable Poisson regression with overdispersion, to control for previously described confounding factors and identify independent predictors of delays, was used. RESULTS: Unadjusted lag times were significantly longer for physicians than other reporters (3.6 vs 1.8 days, p < 0.0001), longer for major than minor events (4.1 vs 1.9 days, p = 0.0006) and longer at KUH than at BWH (3.1 vs 1.0 days, p < 0.0001). In multivariable analysis, lag times at KUH remained nearly three times longer than at BWH (incidence-rate ratio 2.95, 95% CI 2.84 to 3.06, p < 0.0001). CONCLUSIONS: Lag time provides a novel and useful metric for evaluating the performance of hospital-based incident reporting systems. Across two very different health systems, physicians reported far fewer events, with significant delays compared with other providers. Even after controlling for important confounding factors, lag times at KUH were nearly triple those at BWH, suggesting significant differences in the performance of their reporting systems, potentially attributable to either the ease of online reporting at BWH or to the greater attention to patient safety reporting in that hospital.

Effect of anaesthesia maintained with sevoflurane and propofol on surgical site infection after elective open gastrointestinal surgery.

Perioperative increase in oxidative activity in surgical patients reportedly prevents postoperative surgical site infection (SSI). Several clinical studies have shown that oxidative activity under sevoflurane anaesthesia was higher than that under propofol anaesthesia. Therefore, we hypothesised that sevoflurane anaesthesia would discourage SSI compared with propofol anaesthesia. To examine the effect of anaesthesia maintained with sevoflurane and propofol on SSI, a total of 265 consecutive adult patients, with American Society of Anesthesiologists physical status 1-3, who underwent elective open gastrointestinal surgery under general anaesthesia, were surveyed for SSI between January 2007 and December 2008. Sevoflurane or propofol was selected to maintain anaesthesia in 95 and 170 patients, respectively. A propensity score was used for pairwise matching of these patients to avoid selection biases between the two methods of anaesthesia. Propensity matching yielded 84 pairs of patients. We compared standardised infection ratios (SIRs), i.e. the quotient of the number of SSI cases observed and the number of SSI cases expected, calculated using data from the National Nosocomial Infection Surveillance, between sevoflurane and propofol anaesthesia. After propensity matching, SIR after sevoflurane anaesthesia was 1.89 [95% confidence interval (CI): 1.46-2.32], which was significantly lower than after propofol anaesthesia (4.78; 95% CI: 4.30-5.27) (P=0.02). This study suggests that sevoflurane tends to suppress SSI after elective open gastrointestinal surgery compared with propofol.

[Mature teratoma in the posterior mediastinum showing the fatty density on the chest computed tomography].

We reported a case of posterior mediastinal mature teratoma. A 16-year-old woman was referred for further investigation of a left paravertebral mass detected on chest roentgenogram. The defined mass was located above the diaphragm and showed homogeneous fat density on computed tomography (CT) and hypersignal intensity on both T1 weighted images and T2 weighted images on magnetic resonance imaging (MRI). Radiologically, there was a mimicking foci of calcification. The mass was histologically diagnosed as mature teratoma.

Nivalenol and the targeting of the female reproductive system as well as haematopoietic and immune systems in rats after 90-day exposure through the diet.

Nivalenol (NIV) is considered to be an important trichothecene mycotoxin produced by Fusarium species because of its frequent contamination in wheat and barley worldwide. The present study examined the subchronic toxicity of NIV in male and female F344 rats fed diets containing 0, 6.25, 25 and 100 mg kg(-1) of the toxin for 90 days. During the experimental period there was a decrease in the white blood cell count at 100 mg kg(-1) in males and at > or =6.25 mg kg(-1) in females. Histopathologically, treatment-related changes were observed in the haematopoietic and immune systems in both sexes and in the female reproductive system at 100 mg kg(-1). Flow cytometric analysis of splenic cells revealed an elevation in the ratio of helper/cytotoxic T-lymphocytes at 100 mg kg(-1). In summary, NIV targets the female reproductive system as well as haematopoietic and immune systems in rats fed NIV for 90 days. Based on a significant decrease in white blood cells in female rats relative to controls, the lowest observable effect level was calculated as 0.4 mg kg(-1) body weight day(-1).

[Pleural covering method of polyglycolic acid felt with sodium alginate water solution for prevention of postoperative pulmonary fistula].

Sodium alginate is the main ingredient of the seaweed, and its water solution has moderate viscosity. The areas of the pleural defect and around the suture line were covered with polyglycolic acid felt by using 5% sodium alginate water solution in 41 patients who underwent pulmonary resection from November 2006 to April 2007. 28 patients were lung cancer, 6 patients were pulmonary metastasis, and 7 patients were pneumothorax. The duration of the postoperative air leakage was 0.7 days on average. Neither side effect nor complication was observed. This method is cheap, safe, and effective for prevention for postoperative pulmonary fistula.

[Pulmonary metastatic meningioma 26-years after craniotomy].

A 68-year-old male, pointed out of bilateral lung tumors, was hospitalized for the evaluation of multiple lung tumors. Chest computed tomography demonstrated 10 x 10 mm and 30 x 60 mm tumors in left lower lung and a 16 x 16 mm tumor in right lower lung. He was operated under the diagnosis of intracranial meningioma 26-years ago. For purpose of diagnosis, partial resections of left lower lung were performed, and then these tumors were diagnosed as pulmonary metastasis of intracranial meningioma. This is a very rare case of pulmonary metastasis of meningioma 26-years after craniotomy.

[Giant mediastinal thyroid follicular carcinoma with tracheal stenosis].

A 76-year-old female was admitted to the hospital with dyspnea and hypertention. She had the giant thyroid tumor which had been awared but not treated for 40 years. On a computed tomography (CT) scan and magnetic resonance imaging (MRI), the tumor was 14 x 10 cm and the tracheal stenosis was completely intrathoracic, which was 5 x 7 mm. Tracheal incubation was performed safety by using percutaneous cardiopulmonary support. A subtotal thyroidectomy was performed by midsternotomy with cervical incision. The weight of the resected specimen was 340 g and the pathological diagnosis was follicular thyroid carcinoma. The postoperative course was uneventful and the patient suffered no hoarseness and dyspnea.

Evaluation of toxicity of green tea catechins with 90-day dietary administration to F344 rats.

Green tea catechins (GTC), polyphenols extracted from the stalks and leaves of Camellia sinensis, are found in the different types of tea beverages and as antioxidant additives to many foods, snacks, fats and fatty oils. As a part of their safety assessment, subchronic toxicity was investigated in male and female F344 rats with dietary administration at concentrations of 0 (control), 0.3%, 1.25% and 5.0% for 90 days. The average daily intakes of GTC in each group were 180, 764 and 3525mg/kg body weight/day, respectively for males, and 189, 820 and 3542mg/kg body weight/day, respectively for females. No mortality or obvious clinical signs were observed throughout the experimental period but body weights were reduced from week 1 to the end of the experiment in 5.0% males. In serum biochemistry, alanine transaminase and alkaline phosphatase in 5.0% males and females and aspartate transaminase in 5.0% females were increased, together with the relative liver weights in both sexes receiving 5.0%. Although decreases were evident for total cholesterol in 0.3-5.0% males and triglycerides in 1.25% and 5.0% males and 5.0% females, these changes were not considered to be adverse. Hematology and histopathological observation revealed no GTC-related toxicological changes. Based on above findings, the no observed adverse effect level (NOAEL) of GTC was estimated to be 1.25% (764mg/kg body weight/day for males and 820mg/kg body weight/day for females).

[Postoperative penicillin-resistant streptococcus pneumonia in lung cancer patient].

A 78-year-old man underwent a left lower sleeve lobectomy and lymph node dissection for lung cancer. His postoperative course had been uneventful until postoperative day (POD) 3, but severe dyspnea occurred suddenly and the chest X-p showed infiltration shadow on POD 3. Streptococcus pneumonia antigen in the urine was elevated, suggesting pneumonia caused by Streptococcus pneumonia. The patient was treated with double dose of imipenem/cilastatin sodium and supported with a mechanical ventilator in an intensive care unit. Although the patient recovered from penicillin resistant Streptococcus pneumonia, he was suffered from Klebsiella sepsis and expired on the POD 26.

[Experience of complete Carney's triad showing pulmonary hamartoma associated with gastrointestinal stromal tumor and para-arotic paraganglioma].

A 34-year-old man, who had undergone the gastrectomy for gastrointestinal stromal tumor (GIST) and para-aortic paraganglioma 3 years before, was found to have a left lung tumor on a computed tomography. The tumor was revealed to be a pulmonary hamartoma, and diagnosed as Carney's triad. This is a rare case of complete type Carney's triad of an adult male.

[Video-assisted thoracoscopic surgery for ligation of anomalous systemic arterial supply to pulmonary sequestration].

A 52-year old female with anomalous systemic arterial supply to pulmonary sequestration was reported. The patient was admitted because of an abnormal lung shadow on chest X-ray film. Computed tomography (CT) showed an anomalous systemic arterial supply to pulmonary sequestration of the left lower lung without lung infection. Video-assisted thoracoscopic surgery for ligation of the anomalous systemic artery was performed. Postoperative course has been uneventful for 14 months after surgery. Blood supply increased to the left lower lung by 3-dimensional CT after surgery. The ligation of anomalous systemic arterial is enough for this disease.

[Is adjuvant chemotherapy necessary for the peripherally located stage I adenocarcinoma of the lung?].

OBJECTIVE: This study was done for the purpose of picking out the cases of poor prognosis from the peripherally located stage I adenocarcinoma of the lung. METHODS: Between January 1989 and December 2004, 235 patients with peripherally located stage I adenocarcinoma of the lung were resected curatively in our hospital. Relation between the 5-year survival rate and lymphatic and/or blood vessel invasion (from now on ductal invasion) was examined in these cases. RESULTS: The 5-year survival rate was 99% in ly0v0 cases, 86% in ly0v1 cases, 85% in ly1v0 cases, 72% in ly1v1 cases, and 80% in ly2, 3 and/or v2, 3 (lyv 2-3) cases, respectively. Obviously the outcome of the cases without ductal invasion was good. The ratio of the cases without ductal invasion was 61% in stage IA, and 31% in stage IB. The 5-year survival rate was 99% in the cases without ductal invasion in stage IA, 100% in the cases without ductal invasion in stage IB, 90% in the cases with ductal invasion in stage IA, and 65% in the cases with ductal invasion in stage IB, respectively. And the 5-year survival rate without recurrence was 94% in the cases without ductal invasion in stage IA, 76% in the cases without ductal invasion in stage IB, 76% in the cases with ductal invasion in stage IA, and 54% in the cases with ductal invasion in stage IB, respectively. CONCLUSIONS: Ductal invasion is significant prognostic factor in stage I adenocarcinoma of the lung. Adjuvant chemotherapy is unnecessary for the case without ductal invasion in stage IA. But we think that adjuvant chemotherapy is necessary for the case with ductal invasion in stage IA and for the case in stage IB, because there is much recurrence.

[Pulmonary metastasis from hepatic epithelioid hemangioendothelioma; report of a case].

A 30-year-old female complaint of epigastralgia was diagnosed hepatic epitheloid hemangio endothelioma (EHE) by liver biopsy. The multiple nodules in bilateral lungs and liver were revealed on computed tomography (CT). The tumors of the left lung were resected under video-assisted thoracoscopic surgery. Pathologically these lesions were diagnosed as metastasis from EHE of the liver, and the patient was treated with interleukin-2 from hepatic artery for 12 months.

[Mediastinal recurrence of breast cancer suspecting mediastinal fibrosis].

A 63-year-old female, who had undergone a modified radical mastectomy for breast cancer at the age of 45, was suffered from trachyphonia due to left recurrent nerve paralysis at the age of 53. She presented left phrenic nerve paralysis and dysphagia at the age of 61. Computed tomography (CT) revealed mediastinal fibrosis, stenosis of esophagus and superior vena cava, and slight lymph nodes swelling. Video-assisted thoracoscopic mediastinal biopsy was performed and the mediastinal fibrosis was diagnosed as recurrence of breast cancer 17 years after the breast cancer operation. She underwent mediastinal radiation and chemotherapy for mediastinal recurrence and stenting for esophageal stenosis.

[Blunt tracheal transection].

Blunt tracheobronchial injuries are rare, but can be life-threatening. A precise preoperative diagnosis and well recognized plan of surgical treatment, which may be unique for each patient are needed to restore the continuity of tracheobronchial tree in a one-stage intervention. We encountered 2 patients with complete tracheal transection of neck and 1 patient with complete tracheal transection in mediastinum and 15 cm tear in the posterior membranous trachea, whose tracheal injury was difficult to repair using direct intubation of distal airway by bronchoscopy. We achieved a good result of repair using a percutaneous cardiopulmonary support system (PCPS).

[Pulmonary benign metastasizing leiomyoma from uterine myoma; report of a case].

A 46-year-old female with benign metastasizing leiomyoma was reported. The patient had undergone a lobectomy of thyroid for adenomatous goiter at the age of 30, and a myomectomy for uterine myoma and a modified radical masmectomy for breast cancer at the age of 32. The chest X-ray on health screening revealed multiple nodules in the bilateral lung. Computed tomography (CT) revealed 6 nodules in the right side and 3 nodules in the left side of the lung. The tumors of the right lung were resected under thoracoscopic surgery. Pathologically these lesions were diagnosed as benign metastasizing leiomyoma. Left lung nodules have been followed-up.