[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.

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.

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.

[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.

Pneumatosis cystoides intestinalis associated with toxic epidermal necrolysis: A case report.

Toxic epidermal necrolysis (TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis (PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography (CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.

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)

[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.

[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.

Synthesis of potent and selective inhibitors of Candida albicans N-myristoyltransferase based on the benzothiazole structure.

Two parallel synthetic methods using solid-supported reagents were established to examine the rapid optimization of weak hit compound 1. Several compounds showed high potency in the low nanomolar range against N-myristoyltransferase. The structure-activity relationship (SAR) and antifungal activities of a series of novel 2-aminobenzothiazole N-myristoyltransferase inhibitors are presented.

Newly developed T-wave inversion with cardiac wall-motion abnormality predominantly occurs in middle-aged or elderly women after noncardiac surgery.

PURPOSE: The study was done to determine the characteristics and prevalence of myocardial ischemia with inverted T waves after noncardiac surgery. METHODS: A list of patients who developed electrocardiogram (ECG) T-wave inversion associated with wall-motion abnormalities observed by transthoracic echocardiography (TTE) following noncardiac surgery was generated from the intensive care unit (ICU) medical records database between January 1, 1995, and December 31, 2000. The hospital records of these patients were analyzed retrospectively. RESULTS: Among 4219 patients (2187 men and 2032 women) who were admitted to the ICU after noncardiac surgery, 13 developed myocardial ischemia with inverted T waves postoperatively. All of the patients were middle-aged or elderly women with no history of coronary artery disease; nine of them had undergone intraabdominal surgery. Characteristic ECG findings included inverted T waves in the left precordial leads, which subsequently became prominent with QT prolongation. In all of these patients, wall-motion abnormalities were observed on the anterior wall, but these resolved within 60 days of the episode. Myocardial ischemia was asymptomatic, with neither hemodynamic changes nor adverse cardiac events. CONCLUSION: Newly developed giant negative T waves with QT prolongation in the ECG may indicate myocardial stunning, but do not in themselves imply a poor prognosis. The marked preponderance of middle-aged and elderly women with this type of myocardial ischemia remains to be explained.