[Anesthesia for total hip arthroplasty in a patient with C1 inhibitor deficiency].

C1 inhibitor (INH) deficiency is characterized by the presence of angioedema of the extremities, face, airway and the gastrointestinal tract. Airway obstruction is the most common cause of mortality. A 78-year-old woman presented with repeated episodes of angioedema. These episodes were triggered by general anesthesia, dental extraction, venipuncture, vaccination and loxoprofen. The familiy history of similar symptoms was negative. C1 inhibitor concentrate was administered perioperatively for prophylaxis of attacks. Operation was performed under neurolept anesthesia and combined spinal-epidural anesthesia in order to avoid airway manipulation. Postoperative pain was controlled by patient-controlled epidural anesthesia to prevent attacks triggered by pain. The patient had angioedema on both lower extremities perioperatively but did not develop further attacks. Anesthesia was safely performed in a patient with C1 inhibitor deficiency scheduled for total hip arthroplasty.

Efforts to reduce the length of stay in a low-intensity ICU: Changes in the ICU brought about by collaboration between Certified Nurse Specialists as head nurses and intensivists.

Certified Nurse Specialists (CNS) are advanced practice nurses that often play a role in management. This study aims to investigate whether cooperation between CNSs in the position of Intensive Care Unit (ICU) head nurse and intensivists change the length of stay for ICU patients. A single centered retrospective cohort study design was followed. A multivariable regression analysis was performed to determine whether there is a difference in patients' length of ICU stay for two years before and after CNS as ICU head nurse and an intensivist started collaborating. The patients' diagnosis, age, gender, scheduled/emergency admission, surgical history, length of ICU stay, usage of ventilator, and details of ICU treatment were collected from the institution's electronic medical records. During the study period (April 2015 to March 2019), 3,135 patients were admitted to ICU, with 1,471 in the before collaboration group and 1,664 in the after-collaboration group. Collaboration between the CNS as head nurse and intensivists was significantly associated with shorter length of ICU stay (coefficient -0.03 [95% CI, -0.05-0.01], p < 0.001, t-statistic -3.29). Our main finding illustrates that in low-intensity ICUs, collaboration between CNSs as head nurses and intensivists may reduce patients' length of ICU stay.

Impact of having a certified nurse specialist in critical care nursing as head nurse on ICU patient outcomes.

OBJECTIVES: This study evaluated the impact of the presence of a certified nurse specialist in critical care (CNS) as ICU head nurse in an open ICU on clinical outcomes. METHODS: The presence of a CNS as ICU head nurse was implemented in practice in April 2017. To evaluate the impact on patient outcomes before and after the implementation, patients were divided into two groups: before (April 2014 to March 2017; 1988 patients) and after (April 2017 to March 2019; 1664 patients). Patients' demographic data were collected from the ICU database. RESULTS: Multivariable logistic regression analysis revealed that the presence of a CNS as ICU head nurse was associated with lower ICU mortality (odds ratio (OR): 0.52, 95% CI: 0.36-0.73, p < .001) and fewer patients receiving mechanical ventilation in the ICU (OR: 0.20, 95% CI: 0.15-0.26, p < .001). CONCLUSION: CNSs are defined as one type of advanced practice nurses. Having a CNS as a head nurse in the ICU may have helped improve patient outcomes by leveraging these practical skills in nursing management.

[Endoscopic ligation of maxillary and sphenopalatine artery for intractable epistaxis].

We report the endoscopic ligation of the maxillary and sphenopalatine arteries for the treatment of intractable epistaxis. From March 2003 to February 2005, 17 patients (12 men, 5 women) with epistaxis were hospitalized in our department. Patient age ranged from 25 to 83 years, with an average age of 62 years. 8 patients were successfully treated using the conventional packing method, 2 patients were treated using electrocauterization, and 1 patient with macroglobulinemia was treated using plasma exchange therapy. 6 patients underwent endoscopic ligation of the maxillary and sphenopalatine arteries while under general anesthesia. The post operative courses were uneventful, and no recurrent bleeding has been noted. Endscopic ligation of the maxillary and sphenopalatine arteries is safer than intraarterial embolization and less invasive than conventional surgical approach for the ligation of maxillary artery. This technique appears to be a safe and effective surgical treatment for patients with intractable epistaxis.

[Image-guided endoscopic sinus surgery: a comparison of two navigation systems].

We evaluated the effectiveness of two navigation systems with optical tracking in endoscopic sinus surgery (ESS). The Signa SP/i Intraoperative navigation system (General Electric Co., Intraoperative NS) is advantageous in acquiring both real time and high-resolution images during surgery, compared to conventional image-guided navigation (Stealth Station TREON, Medtronic Inc., IGNS) that rely entirely on preoperative three-dimensional images. We studied the following in 14 patients treated with intraoperative NS and 19 treated with IGNS: 1) additional time for navigation system implementation, 2) available instrumentations in ESS, and 3) navigation system accuracy. Navigation systems required additional time to prepare ESS. The time lapse from admittance to the operating room to ESS onset was measured in patients under both systems and controls undergoing ESS without any image guidance. Preparation of the intraoperative NS required an additional 52 min and IGNS required 17 min compared to the control group. Based on operative instruments, the intraoperative NS has some limitations arising from the application of a high magnetic field. Surgical instruments must not be attracted by the magnetic field in the operating room. So those used in our study were thoroughly examined and some remanufactured using MR safe materials. All instruments in ESS could be used in surgical guidance during surgery in the IGNS. Anatomic landmarks were accurately visualized using intraoperative NS and IGNS. Intraoperative NS renews the image during surgery, so surgeons could confirm the surgical outcome during ESS. Since the average distant error in both systems was between 1 mm and 2.5 mm, we confirmed that accuracy obtained with both navigation system was suitable for ESS completion. The intraoperative NS renewed the image during navigation. In conclusion, both navigation systems are sufficient for accurate image navigation in ESS, but navigation systems must be selected based on the individual case.

[Endoscopic resection of benign and malignant tumors in the nasal cavity and paranasal sinus].

Endoscopic resection of nasal and paranasal sinus tumors is more aesthetic and less invasive than conventional resection, such as Luc's operation and lateral rhinotomy. We clarified the effect of radical endoscopic tumor excision and the control of local bleeding hazardous in endoscopic surgery. Subjects were patients with benign lesions in the nasal cavity, medial wall of the maxillary sinus, ethmoid sinus, and/or sphenoid sinus without concurrent malignant lesions. Although patients selection for malignant tumor excision was based on (1) possible en bloc resection, (2) low-grade malignant tumors, and (3) tumors in the nasal cavity and adjoining paranasal sinus, the final decision was made individual. Subjects were 23 patients with benign tumor (10 inverted papilloma, 9 hemangioma, 2 juvenile angiofibroma, and 2 other tumors) and 4 with malignant tumor (olfactory neuroblastoma, acinic cell carcinoma, squamous cell carcinoma, and chondroid chordoma) in the nasal and paranasal sinus. The tumor was resected en bloc except for patients with inverted papilloma (2 cases) and chondroid chordoma. Recurrence in benign tumors was zero during a mean observation of 21 months. One with chondroid chordoma, however, suffered a recurrent lesion 7 months after the initial operation. The lesion was successfully salvaged by a similar endoscopic procedure and subsequently treated with electron beam irradiation. Preoperative arterial embolization, laser coagulation, and ligation of the sphenopalatine artery were very useful in reducing blood loss during surgery and maintaining a clear endoscopic view. In intraoperative bleeding volume, less than 100 ml of bleeding occurred during surgery in 23 of 27 patients. The endoscopic excision of benign lesions in the nasal and paranasal sinus is thus as effective as conventional radical surgery. Endoscopic removal of malignant lesions remains controversial because of the small number of patients and short postoperative observation.

Endoscopic ligation of the sphenopalatine artery and the maxillary artery for the treatment of intractable posterior epistaxis.

BACKGROUND: Intractable posterior epistaxis sometimes requires intensive treatment, such as surgery or embolization. Maxillary artery ligation has been widely used for the treatment of intractable posterior epistaxis. It is highly effective, but significant complications may occur, including an oroantral fistula and damage to the infraorbital nerve. Embolization is less invasive and can be performed in poor surgical candidates. However, it has more serious complications, such as facial nerve paralysis and hemiplegia. This investigation evaluates the effectiveness and complications of endoscopic ligation of the sphenopalatine or maxillary artery for the treatment of intractable posterior epistaxis. METHODS: Between April 2003 and March 2007, 46 patients were hospitalized for the treatment of severe posterior epistaxis in our University Hospital. Thirty patients were successfully treated by anterior and/or posterior nasal packing, and five patients were treated by electrocoagulation. Endoscopic ligation was performed under general anesthesia in 11 patients (6 men and 5 women; age range, 50-80 years). RESULTS: Eight patients underwent endoscopic ligation of the sphenopalatine artery, and three patients underwent endoscopic ligation of the maxillary artery through the middle meatus and posterior antral wall opening. There were no complications, and the patients' postoperative courses were uneventful. Recurrent epistaxis occurred in one patient on oral anticoagulants 15 months after ligation of the sphenopalatine artery, and it was successfully treated by anterior nasal packing. CONCLUSION: Endoscopic ligation of the sphenopalatine or maxillary artery is safer than arterial embolization and is less invasive than transantral ligation of the maxillary artery. This technique appears to be a simple and highly effective surgical treatment for patients with intractable posterior epistaxis.

Lack of reported mutations in a Japanese case of toxic multinodular goiter.

We describe a toxic multinodular goiter that was subjected to genomic sequencing of the thyroid-stimulating hormone receptor and the alpha-subunit of the stimulatory guanine nucleotide-binding protein. No mutation was detected in either gene. While frequent occurrence of thyroid-stimulating hormone receptor gene mutations in toxic multinodular goiters has been reported in areas such as part of Europe with a relatively high prevalence of iodine deficiency, toxic multinodular goiters in areas with an abundance of dietary iodine such as Japan seem unlikely to involve mutations of this gene.

Sex pheromone of the persimmon fruit moth, Stathmopoda masinissa: identification and laboratory bioassay of (4E, 6Z)-4,6-hexadecadien-1-ol derivatives.

Three electroantennogram (EAG)-active components were detected by gas chromatography coupled to an electroantennographic detector (GC-EAD) analysis of a hexane extract of the pheromone glands of the persimmon fruit moth, Stathmopoda masinissa. These compounds were identified as (4E,6Z)-4,6-hexadecadienal (E4,Z6-16:Ald) and the corresponding acetate (E4,Z6-16:OAc) and alcohol (E4,Z6-16:OH) by mass spectral, GC retention time (RT), and microchemical test data. The characteristic base peak of the aldehyde at m/z 84 provided a crucial piece of information suggesting the possibility of a 4,6-diene structure. The (4E,6Z)-isomer elicited the strongest EAG responses among the four geometrical isomers of each synthetic 4,6-hexadecadienyl compound. In a laboratory bioassay, only E4,Z6-16:OAc elicited male moth behavioral activity significantly different from the control; the activity of the acetate was not affected by addition of the aldehyde and alcohol. A preliminary field trial confirmed that E4,Z6-16:OAc as a single component attracted male moths. The possible roles of E4,Z6-16:Ald and E4,Z6-16:OH as components of lures for field use remain to be determined.