A randomised controlled trial of pectoral nerve-2 (PECS 2) block vs. serratus plane block for chronic pain after mastectomy.

Thoracic interfascial plane blocks are effective for post-mastectomy acute analgesia. However, their effects on chronic pain are uncertain. We randomly allocated 80 women equally to pectoral nerve-2 (PECS 2) block or serratus plane block. The pectoral nerve-2 block reduced the rate of moderate or severe chronic pain from 13/40 (33%) with the serratus plane block to 4/40 (10%), p = 0.03, adjusted odds ratio (95%CI) 0.23 (0.07-0.80), p = 0.02. The rates of pain-free women at six postoperative months were indeterminate, 10/40 (25%) after serratus plane block vs. 19/40 (48%) after pectoral nerve-2 block, p = 0.06, adjusted odds ratio (95%CI) 2.9 (1.1-7.5), p = 0.03. Health-related quality of life at six postoperative months was similar after serratus plane and pectoral nerve-2 blocks, mean (SD) EQ-5D-3L scores 0.87 (0.15) vs. 0.91 (0.14), respectively, p = 0.21. The pectoral nerve-2 block reduced median (IQR [range]) morphine consumption in the first 24 postoperative hours from 6 (3-9 [1-25]) mg to 4 (2-7 [0-37]) mg, p = 0.04. However, acute pain scores after serratus plane and pectoral nerve-2 blocks were similar, median (IQR [range]) 23 (11-35 [0-70]) mm vs. 18 (11-27 [0-61]) mm, respectively, p = 0.44. Pectoral nerve-2 block reduced chronic pain 6 months after mastectomy compared with serratus plane block.

Brain structural changes as vulnerability factors and acquired signs of post-earthquake stress.

Many survivors of severe disasters, even those without posttraumatic stress disorder (PTSD), need psychological support. To understand the pathogenesis of PTSD symptoms and prevent the development of PTSD, the critical issue is to distinguish neurological abnormalities as vulnerability factors from acquired signs of PTSD symptoms in the early stage of adaptation to the trauma in the normal population. The neurological underpinnings of PTSD have been well characterized, but the causal relationships with the traumatic event are still unclear. We examined 42 non-PTSD subjects to find brain morphometric changes related to the severity of PTSD symptoms in a longitudinal magnetic resonance imaging study extending through the Great East Japan Earthquake. We found that regional grey matter volume (rGMV) in the right ventral anterior cingulate cortex (ACC) before the earthquake, and decreased rGMV in the left orbitofrontal cortex (OFC) through the earthquake were negatively associated with PTSD symptoms. Our results indicate that subjects with smaller GMV in the ACC before the earthquake, and subjects with decreased GMV in the OFC through the earthquake were likely to have PTSD symptoms. As the ACC is involved in processing of fear and anxiety, our results indicate that these processing are related to vulnerability for PTSD symptoms. In addition, decreased OFC volume was induced by failing to extinct conditioned fear soon after the traumatic event. These findings provide a better understanding of posttraumatic responses in early stage of adaptation to the trauma and may contribute to the development of effective methods to prevent PTSD.

Multi-drug-resistant Staphylococcus aureus and future chemotherapy.

Staphylococcus (S.) aureus silently stays as our natural flora, and yet sometimes threatens our life as a tenacious pathogen. In addition to its ability to outwit our immune system, its multi-drug resistance phenotype makes it one of the most intractable pathogenic bacteria in the history of antibiotic chemotherapy. It conquered practically all the antibiotics that have been developed since 1940s. In 1961, the first MRSA was found among S. aureus clinical isolates. Then MRSA prevailed throughout the world as a multi-resistant hospital pathogen. In 1997, MRSA strain Mu50 with reduced susceptibility to vancomycin was isolated. Vancomycin-intermediate S. aureus (VISA), so named according to the CLSI criteria, was the product of adaptive mutation of S. aureus against vancomycin that had long been the last resort to MRSA infection. Here, we describe the genetic basis for the remarkable ability of S. aureus to acquire multi-antibiotic resistance, and propose a novel paradigm for future chemotherapy against the multi-resistant pathogens.

A phase II trial of stereotactic body radiotherapy in 4 fractions for patients with localized prostate cancer.

PURPOSE/OBJECTIVE(S): To report results from our phase II study of stereotactic body radiotherapy (SBRT) delivering 36 Gy in 4 fractions for patients with localized prostate cancer. MATERIALS/METHODS: We enrolled 55 patients treated with SBRT delivering 36 Gy in 4 fractions between 2015 to 2018. All patients were categorized as low-risk (n = 4), intermediate-risk (n = 31) or high-risk (n = 20) according to National Comprehensive Cancer Network criteria. Median age was 73 years (range 54-86 years). Two-thirds of patients (n = 37) had received androgen-deprivation therapy for 3-46 months (median, 31 months). Median duration of follow-up was 36 months (range 1-54 months). We used Radiation Therapy Oncology Group and National Cancer Institute-Common Toxicity Criteria version 4 for toxicity assessments. Quality of life (QOL) outcomes were also evaluated using the Expanded Prostate Cancer Index Composite (EPIC). RESULTS: Protocol treatments were completed for all patients. Six patients experienced biochemical failures. Among these six patients, three patients experienced clinical failure. One patient showed bone metastasis before biochemical failure. One patient died of gastric cancer. The 3-year biochemical control rate was 89.8%. Acute grade 2 genitourinary (GU) and gastrointestinal (GI) toxicities were observed in 5 patients (9%) and 6 patients (11%), respectively. No grade 3 or higher acute toxicities were observed. Late grade 2 GU and GI toxicities were observed in 7 patients (13%) and 4 patients (7%), respectively. Late grade 3 GU and GI toxicities were observed in 1 patient (1.8%) each. EPIC scores decreased slightly during the acute phase and recovered within 3 months after treatment. CONCLUSION: Our phase II study showed that SBRT delivering 36 Gy in 4 fractions was safe and effective with favorable QOL outcomes, although this regimen showed slightly more severe toxicities compared to current standards.

A Report on the Positive Response to an Outdoor Nature Challenge of a Snow Camp for Young Liver Transplant Patients.

OBJECTIVES: More than two decades have passed since the first living donor liver transplantation was performed in Japan in 1989. There are many reports about problems in adherence to taking medication and medical follow-ups in children who received liver transplants, because there is no transition strategy for those children and parents or guardians. The objective of this study is to measure the effect of nature and outdoor activity to improve children's medical adherence. METHODS: We recruited participants from 9-year-old children who are attending the outpatient liver transplant clinic in a stable condition (no event such as rejection or surgical procedure within 6 months). We took participants to a snow camp and measured its effect by using the IKIRU CHIKARA (IKR) tool, which contain 28 items divided into 3 categories: psychosocial ability, moral fitness, and physical ability. Children were tested on three occasions, before, just after, and 1 month after the camp. RESULTS: Eight patients participated in the snow camp and 7 patients were eligible for the study. The average age was 12.6 with a range 10 to 17 years. There were 3 girls and 4 boys. The average IKR scores before, just after, and 1 month after the camp were 127.9, 131.5, and 126.6, respectively. CONCLUSION: An outdoor activity such as a snow camp can be safely conducted, and it is an acceptable option to incorporate within a pediatric liver transplant program. There were no significant changes in IKR scores during this short observation. Longer observation is needed to measure the effect of nature and outdoor activities.

Rotation-advancement flap method for correction of partial anomalous pulmonary venous drainage into the superior vena cava.

Three patients with partial anomalous pulmonary venous drainage into the superior vena cava underwent repair by a rotation-advancement flap method. The technique consisted of atrial partitioning, enlargement of the superior vena cava, and protection of sinus node function. Follow-up studies of all patients were done between 12 and 15 months after the operation. The superior vena cava was not stenosed and its diameter was normal, as demonstrated by cavograms. Pulmonary venous return appeared normal on angiograms, and sinus node function was normal by electrophysiologic studies.

Usefulness of pulsatile bidirectional cavopulmonary shunt in high-risk Fontan patients.

BACKGROUND: A bidirectional cavopulmonary shunt has been performed for the high-risk Fontan patient. It is well known that in the presence of the bidirectional cavopulmonary shunt alone to secure pulmonary blood flow, the central pulmonary artery size decreases over time. We have performed pulsatile bidirectional cavopulmonary shunt (PBCPS), keeping pulmonary blood flow from the ventricle through the stenotic pulmonary valve, or a Blalock-Taussig shunt in patients who do not meet the criteria for the Fontan operation. METHODS: Eleven patients who underwent PBCPS between 1989 and 1993 were reviewed. We compared the results of cardiac catheterization immediately before PBCPS and during the postoperative observation period (310 +/- 257 days). RESULTS: Pulmonary blood flow and arterial oxygen saturation increased significantly after PBCPS (p = 0.01). Pulmonary artery area index showed a tendency to increase (p = 0.11). The mean number of risk factors for the Fontan procedure decreased significantly for 1.8 +/- 1.1 to 0.7 +/- 0.8 after PBCPS (p < 0.05). Overall, 5 of the 11 patients (45.5%) met the criteria for the Fontan procedure, and a fenestrated Fontan procedure was carried out in 4 of them. CONCLUSIONS: The PBCPS is useful for high-risk Fontan patients not only in the staged Fontan operation, but also as definitive palliation.

Direct closure of ostium primum defect in the repair of atrioventricular septal defect.

BACKGROUND: Patch closure is generally performed for atrial septation of an atrioventricular septal defect. We recently developed a new surgical technique for repairing atrioventricular septal defects that avoids the use of any patch material for closing the atrial septal defect. We report our experience with this procedure. METHODS: Seven patients (complete type: 5, partial type: 2) underwent this new operation. The diameters of the atrial septal defects were measured by transesophageal echocardiography. The preoperative electrocardiograms were compared with those taken after the operations. RESULTS: Diameters of the atrial defects ranged from 3 to 10 mm. Electrocardiograms before and after the operations did not change. No significant atrioventricular valve regurgitation and no residual shunts were detected by postoperative echocardiography. CONCLUSIONS: This method simplifies the repair of atrioventricular septal defects. In the short-term results, no arrhythmia and no valve regurgitation was seen.

Pulmonary atresia with intact ventricular septum: long-term results of "one and a half ventricular repair".

BACKGROUND: Between 1982 and 1984, we successfully performed "one and a half ventricular repair" using a Glenn shunt for 3 patients with pulmonary atresia with intact ventricular septum. Here we review the 10-year follow-up results. METHODS: In these patients, the preoperative Z scores of the tricuspid valve diameters ranged from -5.2 to -6.5. Right ventricular outflow tract reconstruction combined with a Glenn shunt were performed in all patients. Cardiac catheterization was done at least 10 years post-operatively. RESULTS: All 3 patients have maintained New York Heart Association functional class I status for more than 10 years. Angiography in 2 patients confirms sufficient left pulmonary artery pressure with pulsatile blood flow and good right ventricular contraction. A pulmonary arteriovenous fistula has developed in 1 patient. CONCLUSIONS: Although the lower limits of the tricuspid valve diameter for "one and a half ventricular repair" using a cavopulmonary shunt have not yet been determined, we successfully performed this procedure in 3 patients with severely hypoplastic right ventricles and tricuspid valve diameter Z scores of less than -5.0. The results up to 10 years postoperatively are acceptable.

A new pathway in the reaction of disilene with carbonyl compounds: an 'ene' reaction instead of cycloaddition.

The 3H-disilagermirene, (tBu2MeSi)4GeSi2, reacts with alpha-hydrogen containing carbonyl compounds (acetophenone, butane-2,3-dione) by an 'ene'-reaction pathway followed by isomerization or insertion reactions, representing a new mode in the reaction of disilenes with carbonyl compounds.

Mutagenicity of 1,2-dibromo-3-chloropropane (DBCP) in the mouse spot test.

The spot test with 1,2-dibromo-3-chloropropane (DBCP) was carried out using male PW and female C57BL/6 mice. DBCP induced recessive colour spots in offspring with a significantly high frequency of 2.9%, showing that this chemical is mutagenic for somatic cells of mice in vivo.

Long-term results of the fenestrated Fontan operation. Progress of patients with patent fenestrations.

The fenestrated Fontan operation was introduced as a modification of the "completed" Fontan operation for patients with high risk factors, and low operative mortality has frequently been reported. However, use of the umbrella device is now restricted, and this procedure should be performed without subsequent closure. In this paper, we review our clinical experience with this procedure and discuss ongoing problems. Sixteen patients (4 tricuspid atresia and 12 other cardiac anomalies including 5 cases of univentricular heart) underwent the fenestrated Fontan operation (7 atriopulmonary and 9 total cavopulmonary connection). All of them have some risk factors for a completed Fontan operation. There were three early deaths of the 16. Two experienced an anticipated thromboembolic accident, one of which involved the pulmonary aspect while the other involved the arterial aspect. Patients who survived the operation have progressed well and have a clinical status of New York Heart Association class I, with the exception of one late death due to congestive heart failure. There have been no thromboembolic accidents in this group during the late follow-up period. Spontaneous closures of the fenestrations were noted in two patients. The late mean Qp/Qs value in patients with patent fenestrations was 0.80 +/- 0.1, SaO2 was 88.8 +/- 5.6%, and right atrial pressure was 9.7 +/- 3.8 mmHg. No major problems have been encountered in patients with a patent fenestration over extended periods. A modified Fontan operation to fit a permanently open fenestration may be considered as a final surgical option for certain high-risk patients.

Successful surgical management of a tracheopulmonary artery fistula caused by an intratracheal expandable metal stent.

We describe a boy who underwent slide tracheoplasty and relocation of the left pulmonary artery at 3 months of age to treat pulmonary artery sling with congenital tracheal stenosis. Persisting tracheal stenosis required that he have a Palmaz stent inserted on postoperative day 77. He developed massive hemoptysis after the fourth attempt to expand the stent balloon and immediate computed tomography showed a tracheopulmonary artery fistula. Using cardiopulmonary bypass, we conducted emergency surgery to successfully manage the fistula. He currently depends on mechanical ventilation.

[Modified extended septoplasty for left ventricular outflow tract obstruction after repair of double-outlet right ventricle report of a case].

A three-year-old boy with residual VSD and LVOTO after repair of double outlet right ventricle underwent modified extended septoplasty successfully. Preoperative left ventriculography showed a residual VSD and LVOTO. The peak systolic pressure gradient between the left ventricle and aorta was 38 mmHg. Operation aimd not only at relief of the obstruction, but also at streamlining of the LVOT by removal of protrusions. We modified the extended septoplasty reported by Belli et al in 1996. The postoperative course was uneventful and patient was discharged at 15 postoperative day. The most recent echocargiogram revealed no residual LVOTO.

[Surgical repair of complete atrioventricular septal defect: annuloplasty by using a smaller VSD patch].

Recent policy for the intracardiac repair of complete atrioventricular septal defect (CAVSD) is demonstrated on the basis of the following theoretical background. In the normal heart, the originating portion of the ascending aorta and the crux intrude between the mitral and tricuspid orifices each from the anterior and from the posterior, separating both the orifices together with a short fibrous septal junction. In CAVSD, however, the common A-V orifice takes an elliptic form without any septal junction. It is considered beneficial, therefore, to surgically produce a short septal junction by using a smaller patch to close the ventricular portion of the AVSD. When the left lateral leaflet is larger, two leaflets valve plasty is suggested and when it is smaller, three leaflets valve plasty is suggested to reconstruct the left-sided A-V valve, although competence of the valve leaflets must be finally secured by doing repeated water injection tests. The size of the orifices of the reconstructed left-sided as well as right-sided A-V valve should also be confirmed not to be stenotic by using Hegar sizers. Since 1991, we have applied this surgical concept in 7 patients with CAVSD. Postoperatively, there was no left A-V valve regurgitation in one and slight regurgitation remained in 6 patients. The result is considered to be satisfactory. Although one patient died due to PH crisis, the cause of death was not related to valve regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of large congenital right ventricular outflow aneurysm].

A rare case of large congenital right ventricular outflow aneurysm is reported. A 5-year-old girl had been diagnosed as having atrial septal defect and pulmonary valvular stenosis. A large cavity in front of right ventricular outflow was noticed by her follow-up echocardiography. The non-contracting cavity was confirmed as an aneurysm originating from right ventricular outflow tract by angiocardiogram. Surgical resection was performed successfully with concomitant atrial septal defect closure and pulmonary valvular commissurotomy. Histological examination revealed that the wall of the ventricular outflow aneurysm consisted of dense fibrous tissue, contained no myocardium, and the cavity was lined with endocardium. It is reported that rupture of congenital ventricular aneurysm may occur even if there is no symptom. Surgical resection will be recommended especially when increasing in size is diagnosed.

[A role of valvuloplasty in surgical treatment of isolated tricuspid regurgitation].

Seven surgical cases of isolated tricuspid regurgitation were reviewed. From pathological point of view, the patients were classified into three groups. Two were due to abnormalities of subvalvular system, four to annular dilatation and one to anomalous leaflet. Among four cases of annular dilatation, two were diagnosed as dilated cardiomyopathy. In one, it was very rare myopathy confined to right ventricle. Three cases, two subvalvular and one leaflet abnormalities, underwent valvuloplasty which included chordal reconstruction using Gore-Tex suture. Among annular dilatation group, three underwent valve replacement (two with mechanical valve and one with bioprosthetic valve), while fourth underwent annuloplasty. When We look at 89 surgical patients with secondary tricuspid regurgitation, thrombosed mechanical valve was seen in two cases, one of them necessitating re-valve replacement. On the other hand, late results of tricuspid annuloplasty with Carpentier-Edwards ring was excellent without re-operation. Although isolated tricuspid regurgitation has very complicated pathological features, we now think it very important to manage to repair regurgitant tricuspid valve utilizing all available techniques including redundant valve tissue resection, chordal reconstruction, and annuloplasty, thus avoiding valve replacement especially with mechanical valve.

[Superior vena cava-right atrial appendage direct anastomosis for repair of partial anomalous pulmonary venous connection to superior vena cava].

Successful repair was performed for a 7-year-old male with a diagnosis of partial anomalous pulmonary venous connection (PAPVC) to superior vena cava (SVC) and superior sinus venosus atrial septal defect (ASD). The SVC was divided above the orifice of the anomalous pulmonary vein and the cephalad end of the SVC was anastomosed directly to the right atrial appendage. A patch was used to divert pulmonary venous flow from the orifice of the SVC through superior sinus venosus ASD into the left atrium. Postoperative course was uneventful with normal sinus rhythm. There was no evidence of vena caval or pulmonary venous obstruction. At 3-month after surgery, sinus node function was confirmed to be normal by electrophysiological study. This is useful alternative method for repair of PAPVC to high or middle SVC.

[A case of metastatic lung tumor of the colon cancer with ova of schistosoma japonicum in the resected lung specimen].

A 69-year-old man underwent right middle lobectomy because of the tumor lesion in the right middle lung. He had ever been in Celebes and China (riverside area of the Yangtze), the infected area of schistosomiasis japonica, for military service during the World War II. Resected lung specimen was carefully examined at the department of pathology in our hospital. Several ova of Schistosoma japonicum were discovered scattered in the specimen, and the pathological feature of the lung lesion was revealed to be metastasis of the sigmoid colon cancer which was resected 4 years ago at a certain hospital. The ova of Schistosoma japonicum were also distributed near the colon lesion. Recently in Japan, it is said, acute infected case of schistosomiasis japonica has been ceased, however, in cases of chronic stage of this disease, hepatoma or lower intestinal cancers are still discovered through the careful follow up study.