Mapping the Japanese orthopedic association national registry (JOANR) to the international classification of health interventions (ICHI).

BACKGROUND: The Japanese Orthopedic Association launched the Japanese Orthopedic Association National Registry (JOANR), Japan's first large-scale nationwide musculoskeletal disease registry, in 2020. The World Health Organization released the International Classification of Health Interventions (ICHI) Beta-3 version in the same year. This concurrence served as an impetus to examine the relationship between domestic and international classification for orthopedic interventions. Our objective was to evaluate the possibility of utilizing JOANR for international comparison and the potential usage of ICHI in the domestic medical fee reimbursement system. This study is a novel attempt at mapping a domestic orthopedic scheme to the ICHI. METHODS: We mapped 149 codes out of 581 orthopedic surgical codes, on JOANR's registration form, to the ICHI, and then classified the nature of JOANR codes' relationship, to both ICHI single stem codes and stem codes accompanied by other additional stem codes, extension codes, and International Classification of Diseases for Mortality and Morbidity Statistics (ICD) codes, into five categories: Equivalent (exact match), Narrower (compared to ICHI; can be smoothly incorporated into ICHI), Broader (compared to ICHI), Slipped (combination of both Narrower and Broader), and None (no appropriate code). Finally, debatable issues that arose during the mapping operation were noted. RESULTS: The domestic codes' relationship to ICHI single stem code by category were Equivalent: 27 (18.1%) and Narrower: 65 (43.6%), respectively. Further, the rate of Equivalent rose to 120 (80.5%) on adding other stem codes, extension codes, and ICD codes. Additionally, certain domestic titles, which were unsuitable for classification as they included diagnostic information, and arthroscopic surgeries without corresponding ICHI codes, were recoded. CONCLUSIONS: JOANR can be converted to an international comparison standard via ICHI to a certain extent, and ICHI accompanied by ICD codes has potential for deployment in the domestic medical fee reimbursement system.

Cardiopulmonary Resuscitation May Not Stop Glutamate Release in the Cerebral Cortex.

BACKGROUND: Cardiopulmonary resuscitation (CPR) may not be sufficient to halt the progression of brain damage. Using extracellular glutamate concentration as a marker for neuronal damage, we quantitatively evaluated the degree of brain damage during resuscitation without return of spontaneous circulation. MATERIALS AND METHODS: Extracellular cerebral glutamate concentration was measured with a microdialysis probe every 2 minutes for 40 minutes after electrical stimulation-induced cardiac arrest without return of spontaneous circulation in Sprague-Dawley rats. The rats were divided into 3 groups (7 per group) according to the treatment received during the 40 minutes observation period: mechanical ventilation without chest compression (group V); mechanical ventilation and chest compression (group VC) and; ventilation, chest compression and brain hypothermia (group VCH). Chest compression (20 min) and hypothermia (40 min) were initiated 6 minutes after the onset of cardiac arrest. RESULTS: Glutamate concentration increased in all groups after cardiac arrest. Although after the onset of chest compression, glutamate concentration showed a significant difference at 2 min and reached the maximum at 6 min (VC group; 284±48 µmol/L vs. V group 398±126 µmol/L, P =0.003), there was no difference toward the end of chest compression (513±61 µmol/L vs. 588±103 µmol/L, P =0.051). In the VCH group, the initial increase in glutamate concentration was suddenly suppressed 2 minutes after the onset of brain hypothermia. CONCLUSIONS: CPR alone reduced the progression of brain damage for a limited period but CPR in combination with brain cooling strongly suppressed increases in glutamate levels.

Depolarization time and extracellular glutamate levels aggravate ultraearly brain injury after subarachnoid hemorrhage.

Early brain injury after aneurysmal subarachnoid hemorrhage (SAH) worsens the neurological outcome. We hypothesize that a longer duration of depolarization and excessive release of glutamate aggravate neurological outcomes after SAH, and that brain hypothermia can accelerate repolarization and inhibit the excessive release of extracellular glutamate and subsequent neuronal damage. So, we investigated the influence of depolarization time and extracellular glutamate levels on the neurological outcome in the ultra-early phase of SAH using a rat injection model as Experiment 1 and then evaluated the efficacy of brain hypothermia targeting ultra-early brain injury as Experiment 2. Dynamic changes in membrane potentials, intracranial pressure, cerebral perfusion pressure, cerebral blood flow, and extracellular glutamate levels were observed within 30 min after SAH. A prolonged duration of depolarization correlated with peak extracellular glutamate levels, and these two factors worsened the neuronal injury. Under brain hypothermia using pharyngeal cooling after SAH, cerebral perfusion pressure in the hypothermia group recovered earlier than that in the normothermia group. Extracellular glutamate levels in the hypothermia group were significantly lower than those in the normothermia group. The early induction of brain hypothermia could facilitate faster recovery of cerebral perfusion pressure, repolarization, and the inhibition of excessive glutamate release, which would prevent ultra-early brain injury following SAH.

The triangular cord ratio and the presence of a cystic lesion in the triangular cord. Suggested new ultrasound findings in the early diagnosis of Biliary Atresia.

BACKGROUND: In biliary atresia (BA), the ultrasonic triangular cord (TC) sign is positive at ≥ 3 mm, but sometimes there is BA even if it is ≤ 3 mm. For improving the ultrasonographic diagnosis, we have established a new evaluation, adding the ratio of the anterior/posterior thickness (TC ratio) in the hyperechoic area and the presence of a cystic lesion in the triangular cord (TCC). METHODS: We examined 24 cases of suspected BA who demonstrated acholic stools from 2006 to 2020. We retrospectively reviewed the timing of ultrasonographic diagnosis, the gallbladder diameter, gallbladder mucosal irregularity, the TC sign, TCC, and the TC ratio. RESULTS: In the BA group (n = 10) vs the Non-BA group (n = 14), the age at ultrasonography was 75 ± 41.7 vs. 81 ± 39.1 days (p = 0.72), the gallbladder diameter was 12.1 ± 9.7 vs. 24.2 ± 6.96 mm (p = 0.02), irregularity of gallbladder mucosa was 7 cases vs. 1 case (p < 0.01), and TC sign was 3.9 ± 1.3 vs. 2.0 ± 0.49 mm (p = 0.01), respectively. TCC was observed in 8/10 cases in the BA group and none in the Non-BA group (p < 0.01). TC ratio was 3.40 ± 0.68 (BA group) and 1.59 ± 0.41 (Non-BA group) (p < 0.01). CONCLUSION: The ultrasonic TC ratio improves the diagnostic accuracy of BA. TCC is a specific finding in the BA group.

Extracellular Glutamate Concentration Increases Linearly in Proportion to Decreases in Residual Cerebral Blood Flow After the Loss of Membrane Potential in a Rat Model of Ischemia.

BACKGROUND: Brain ischemia due to disruption of cerebral blood flow (CBF) results in increases in extracellular glutamate concentration and neuronal cell damage. However, the impact of CBF on glutamate dynamics after the loss of the membrane potential remains unknown. MATERIALS AND METHODS: To determine this impact, we measured extracellular potential, CBF, and extracellular glutamate concentration in the parietal cortex in male Sprague-Dawley rats (n=21). CBF was reduced by bilateral occlusion of the common carotid arteries and exsanguination until loss of extracellular membrane potential was observed (low-flow group), or until CBF was further reduced by 5% to 10% of preischemia levels (severe-low-flow group). CBF was promptly restored 10 minutes after the loss of membrane potential. Histologic outcomes were evaluated 5 days later. RESULTS: Extracellular glutamate concentration in the low-flow group was significantly lower than that in the severe-low-flow group. Moreover, increases in extracellular glutamate concentration exhibited a linear relationship with decreases in CBF after the loss of membrane potential in the severe-low-flow group, and the percentage of damaged neurons exhibited a dose-response relationship with the extracellular glutamate concentration. The extracellular glutamate concentration required to cause 50% neuronal damage was estimated to be 387 µmol/L, at 8.7% of preischemia CBF. Regression analyses revealed that extracellular glutamate concentration increased by 21 µmol/L with each 1% decrease in residual CBF and that the percentage of damaged neurons increased by 2.6%. CONCLUSION: Our results indicate that residual CBF is an important factor that determines the extracellular glutamate concentration after the loss of membrane potential, and residual CBF would be one of the important determinants of neuronal cell prognosis.

Evaluation of a point-of-care serum creatinine measurement device and the impact on diagnosis of acute kidney injury in pediatric cardiac patients: A retrospective, single center study.

BACKGROUND AND AIMS: Agreement between measurements of creatinine concentrations using point-of-care (POC) devices and measurements conducted in a standard central laboratory is unclear for pediatric patients. Our objectives were (a) to assess the agreement for pediatric patients and (b) to compare the incidence of postoperative acute kidney injury (AKI) according to the two methods. METHODS: This retrospective, single-center study included patients under 18 years of age who underwent cardiac surgery and who were admitted into the pediatric intensive care unit of a tertiary teaching hospital (Okayama University Hospital, Japan) from 2013 to 2017. The primary objective was to assess the correlation and the agreement between measurements of creatinine concentrations by a Radiometer blood gas analyzer (Cregas) and those conducted in a central laboratory (Crelab). The secondary objective was to compare the incidence of postoperative AKI between the two methods based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: We analyzed the results of 1404 paired creatinine measurements from 498 patients, whose median age was 14 months old (interquartile range [IQR] 3, 49). The Pearson correlation coefficient of Cregas vs Crelab was 0.968 (95% confidence interval [CI], 0.965-0.972, P < 0.001). The median bias between Cregas and Crelab was 0.02 (IQR -0.02, 0.05) mg/dL. While 199 patients (40.0%) were diagnosed as having postoperative AKI based on Crelab, 357 patients (71.7%) were diagnosed as having postoperative AKI based on Cregas (Kappa = 0.39, 95% CI, 0.33-0.46). In a subgroup analysis of patients whose Cregas and Crelab were measured within 1 hour, similar percentage of patients were diagnosed as having postoperative AKI based on Cregas and Crelab (42.8% vs 46.0%; Kappa = 0.76, 95% CI, 0.68-0.84). CONCLUSION: There was an excellent correlation between Cregas and Crelab in pediatric patients. Although more patients were diagnosed as having postoperative AKI based on Cregas than based on Crelab, paired measurements with a short time gap showed good agreement on AKI diagnosis.

Hyperchloremia Is Not an Independent Risk Factor for Postoperative Acute Kidney Injury in Pediatric Cardiac Patients.

OBJECTIVE: Hyperchloremia recently has been shown to have an association with the development of acute kidney injury (AKI) in critically ill patients. However, there is little information about the prevalence of an abnormal chloride concentration after pediatric cardiac surgery and its association with postoperative AKI. The aim of this study was to determine the prevalence of hyperchloremia and its association with AKI in pediatric patients after cardiac surgery. DESIGN: A retrospective single-center study. SETTING: Referral high-volume pediatric cardiac center in a tertiary teaching hospital. PARTICIPANTS: Patients under 72 months of age with congenital heart disease who underwent cardiac surgery with the use of cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was development of AKI diagnosed by Kidney Disease Improving Global Outcomes consensus criteria. The associations of outcomes with the highest serum chloride concentration ([Cl-]max) and time-weighted average chloride concentration ([Cl-]ave) within the first 48 hours after surgery were investigated. Of 521 patients included in the study, 463 patients (88.9%) had hyperchloremia at least 1 time within the first 48 hours after surgery. Postoperative AKI occurred in 205 patients (39.3%). [Cl-]ave and [Cl-]max in the AKI group were significantly higher than those in the non-AKI group (112 [110-114] mEq/L v 111 [109-113] mEq/L, p = 0.001 and 116 [113, 119] mEq/L v 114 [112-118] mEq/L, p = 0.002, respectively). After adjustment for other predictors of AKI by multivariable analyses, neither [Cl-]ave nor [Cl-]max was associated independently with the development of AKI (odds ratio [OR] = 1.040, 95% confidence interval [CI]: 0.885-1.220, p = 0.63; OR = 0.992, 95% CI: 0.874-1.130. p = 0.90). CONCLUSION: Postoperative hyperchloremia was common and was associated with the development of AKI in pediatric patients after congenital cardiac surgery in univariate analysis. After adjustment for predictors of AKI by multivariate analyses, there was no significant relationship between postoperative chloride concentration and AKI.

Incidence of Pulmonary Complications with the Prophylactic Use of High-flow Nasal Cannula after Pediatric Cardiac Surgery: Prophylactic HFNC Study Protocol.

We will investigate the incidence of postoperative pulmonary complications (PPCs) with the prophylactic use of a high-flow nasal cannula (HFNC) after pediatric cardiac surgery. Children < 48 months old with congenital heart disease for whom cardiac surgery is planned will be included. The HFNC procedure will be commenced just after extubation, at a flow rate of 2 L/kg/min with adequate oxygen concentration to achieve target oxygen saturation ≥ 94%. This study will reveal the prevalence of PPCs after pediatric cardiac surgery with the prophylactic use of HFNC.

Determination of the Target Temperature Required to Block Increases in Extracellular Glutamate Levels During Intraischemic Hypothermia.

This study aimed to determine a target temperature for intraischemic hypothermia that can block increases in extracellular glutamate levels. Two groups of 10 rats each formed the normothermia and intraischemic hypothermia groups. Extracellular glutamate levels, the extracellular potential, and the cerebral blood flow were measured at the adjacent site in the right parietal cerebral cortex. Cerebral ischemia was induced by occlusion of the bilateral common carotid arteries and hypotension. In the intraischemic hypothermia group, brain hypothermia was initiated immediately after the onset of membrane potential loss. In the normothermia group, extracellular glutamate levels began to increase simultaneously with the onset of membrane potential loss and reached a maximum level of 341.8 ± 153.1 µmol·L-1. A decrease in extracellular glutamate levels was observed simultaneously with the onset of membrane potential recovery. In the intraischemic hypothermia group, extracellular glutamate levels initially began to increase, similarly to those in the normothermia group, but subsequently plateaued at 140.5 ± 105.4 µmol·L-1, when the brain temperature had decreased to <32.6°C ± 0.9°C. A decrease in extracellular glutamate levels was observed simultaneously with the onset of membrane potential recovery, similarly to the findings in the normothermia group. The rate of decrease in extracellular glutamate levels was the same in both groups (-36.6 and -36.0 µmol·L-1 in the normothermia and intraischemic hypothermia groups, respectively). In conclusion, the target temperature for blocking glutamate release during intraischemic hypothermia was found to be 32.6°C ± 0.9°C. Our results suggest that the induction of intraischemic hypothermia can maintain low glutamate levels without disrupting glutamate reuptake. Institutional protocol number: OKU-2016146.

NADH fluorescence imaging and the histological impact of cortical spreading depolarization during the acute phase of subarachnoid hemorrhage in rats.

OBJECTIVE Although cortical spreading depolarization (CSD) has been observed during the early phase of subarachnoid hemorrhage (SAH) in clinical settings, the pathogenicity of CSD is unclear. The aim of this study is to elucidate the effects of loss of membrane potential on neuronal damage during the acute phase of SAH. METHODS Twenty-four rats were subjected to SAH by the perforation method. The propagation of depolarization in the brain cortex was examined by using electrodes to monitor 2 direct-current (DC) potentials and obtaining NADH (reduced nicotinamide adenine dinucleotide) fluorescence images while exposing the parietal-temporal cortex to ultraviolet light. Cerebral blood flow (CBF) was monitored in the vicinity of the lateral electrode. Twenty-four hours after onset of SAH, histological damage was evaluated at the DC potential recording sites. RESULTS Changes in DC potentials (n = 48 in total) were sorted into 3 types according to the appearance of ischemic depolarization in the entire hemisphere following induction of SAH. In Type 1 changes (n = 21), ischemic depolarization was not observed during a 1-hour observation period. In Type 2 changes (n = 13), the DC potential demonstrated ischemic depolarization on initiation of SAH and recovered 80% from the maximal DC deflection during a 1-hour observation period (33.3 ± 15.8 minutes). In Type 3 changes (n = 14), the DC potential displayed ischemic depolarization and did not recover during a 1-hour observation period. Histological evaluations at DC potential recording sites showed intact tissue at all sites in the Type 1 group, whereas in the Type 2 and Type 3 groups neuronal damage of varying severity was observed depending on the duration of ischemic depolarization. The duration of depolarization that causes injury to 50% of neurons (P50) was estimated to be 22.4 minutes (95% confidence intervals 17.0-30.3 minutes). CSD was observed in 3 rats at 6 sites in the Type 1 group 5.1 ± 2.2 minutes after initiation of SAH. On NADH fluorescence images CSD was initially observed in the anterior cortex; it propagated through the entire hemisphere in the direction of the occipital cortex at a rate of 3 mm/minute, with repolarization in 2.3 ± 1.2 minutes. DC potential recording sites that had undergone CSD were found to have intact tissue 24 hours later. Compared with depolarization that caused 50% neuronal damage, the duration of CSD was too short to cause histological damage. CONCLUSIONS CSD was successfully visualized using NADH fluorescence. It propagated from the anterior to the posterior cortex along with an increase in CBF. The duration of depolarization in CSD (2.3 ± 1.2 minutes) was far shorter than that causing 50% neuronal damage (22.4 minutes) and was not associated with histological damage in the current experimental setting.

Storage duration of transfused red blood cells is not significantly associated with postoperative adverse events in pediatric cardiac surgery patients.

The aim of this study was to evaluate the association of storage duration of transfused red blood cells with the risk of postoperative serious adverse events in pediatric cardiac surgery patients. We studied 517 patients and found that 22 patients (4.3%) had at least one serious adverse event. The maximum and mean storage duration of transfused red blood cells did not differ significantly between patients with and without serious adverse events (maximum, p = 0.89; mean, p = 0.81). In our study of pediatric cardiac surgery patients, the storage duration of transfused red blood cells was not significantly associated with the risk of serious adverse events.

Urinary Albumin Levels Predict Development of Acute Kidney Injury After Pediatric Cardiac Surgery: A Prospective Observational Study.

OBJECTIVE: Mortality and morbidity of acute kidney injury (AKI) after cardiac surgery still remain high. The authors undertook the present study to evaluate the utility of early postoperative urinary albumin (uAlb) as a diagnostic marker for predicting occurrence of AKI and its severity in pediatric patients undergoing cardiac surgery. DESIGN: A prospective observational study. SETTING: A single-institution university hospital. PARTICIPANTS: All patients<18 years of age who underwent repair of congenital heart disease with cardiopulmonary bypass between July 2010 and July 2012 were included in the study. Neonates age<1 month were excluded from the study population. INTERVENTIONS: The association between uAlb and occurrence of AKI within 3 days after admission to the intensive care unit was investigated. Criteria from pediatric-modified Risk Injury Failure Loss and End-stage kidney disease (pRIFLE) were used to determine the occurrence of AKI. The value of uAlb was measured at intensive care unit admission immediately after cardiac surgery in all participants from whom a 5-mL urine sample was obtained. MEASUREMENTS AND MAIN RESULTS: Of 376 patients, AKI assessed by pRIFLE was identified in 243 (64.6%): 172 for risk (R; 45.7%), 44 for injury (I; 11.7%), and 27 for failure (F; 7.2%). One hundred thirty-three patients (35.4%) were classified as being without AKI (normal [N]) by pRIFLE. The concentration of uAlb was significantly higher in AKI patients than in non-AKI patients (median [interquartile range]): uAlb (µg/mL): 13.5 (6.4-39.6) v 6.0 (3.4-16), p<0.001; uAlb/Cr (mg/gCr): 325 (138-760) v 121 (53-269), p< 0.001. CONCLUSIONS: The utility of uAlb for prompt diagnosis of AKI was shown. Obtaining uAlb measurements early after pediatric cardiac surgery may be useful for predicting the occurrence and severity of AKI.

Are there reliable indicators predicting post-operative complications in acute appendicitis?

PURPOSE: To clarify the predictors of post-operative complications of pediatric acute appendicitis. METHODS: The medical records of 485 patients with acute appendicitis operated on between January 2006 and November 2014 were retrospectively reviewed. Age, sex, preoperative WBC, CRP, and appendix maximum short diameter on diagnostic imaging (AMSD) were compared retrospectively with the complications group (Group C) vs the non-complication group (Group NC) by Student's T test, Fisher exact test and Multivariate analysis. Regression analysis with p less than 0.01 was considered significant. We analyzed the most recent 314 laparoscopic appendectomy patients similarly. RESULTS: Complications were found in 29 of the 485 appendectomies (6.0%). Comparing Group C to Group NC, preoperative WBC (×10(3)/µl) 16.4 ± 5.6 vs 14.1 ± 4.1 (p < 0.01), CRP (mg/dl) 8.3 ± 7.1 vs 3.3 ± 4.6 (p < 0.01), AMSD (mm) was 12.1 ± 3.7 vs 9.9 ± 2.8 (p < 0.01). The CRP was significantly different by Multivariate analysis, but the WBC and AMSD wasn't. The results following laparoscopic appendicectomy data were identical. CONCLUSION: Preoperative WBC, CPR and AMSD all indicated an increased risk of complications. If WBC (/µl) >16,500, CRP >3.1 mg/dl and AMSD >11.4 mm, complications increased sixfold.

The current strategy for urachal remnants.

BACKGROUND: Optimal therapy for urachal remnant (UR) in children is controversial. Nonoperative management for symptomatic UR is an alternative. Many papers support the laparoscopic approach but the indication for this is unclear. We review our experience to determine the optimal management of UR. MATERIALS AND METHODS: A retrospective chart review of patients from 1990 to 2013 with UR was performed. Patients were analyzed according to age, gender, initial symptoms, type of UR, treatment, and outcome. RESULTS: We identified 27 patients (M:F = 17:10). A urachal sinus was found in 16 cases (59%), a urachal cyst in 5 (18%) and a urachal duct in 6 (22%). Eleven (A) were under 1 year, with 16 over 1 year (B). In Group A, the commonest symptom was umbilical granulation (n = 6, 54%). Group B was dominated by abdominal pain (n = 12, 75%). Six cases in Group A needed operation for repeated infections. In 5 cases, the UR disappeared. In Group B, 2 cases were followed conservatively. The others required surgery. From 2009, we utilized a laparoscopic approach (LA, n = 7) rather than the classical umbilical approach (UA, n = 13). The operation time was not significantly different (LA = 124 min: UA = 110 min, P > 0.05). There was a tendency for shorter hospital stay following LA (LA = 7.5 days: UA = 10.9 days). Complete resection was always possible using UA in Group A but a more caudal incision (mean 3.6 cm) was required in group B. LA enabled confirmation of the complete resection with three 5 mm ports in Group B. There were no operative complications after LA against two wound infections, one of which suffered a disruption, after UA. CONCLUSION: Conservative follow-up is recommended for UR under 1-year old except when there are repeated infections. The umbilical approach is enough for infants. Laparoscopic surgery is recommended in older children.

[Increase in serum vecuronium concentration following sugammadex administration in a pediatric patient after prolonged sedation].

It is known that blood concentration of rocuronium increases after administration of sugammadex, but this is not clear in the case of vecuronium. We report a pediatric case in which serum vecuronium concentration increased following sugammadex administration after prolonged sedation using vecuronium. A 19-month-old girl weighing 7.8 kg had a history of aortic valvuloplasty at 4 months of age due to truncus arteriosus. She presented again to our hospital due to aortic regurgitation. She underwent aortic valvuloplasty and then aortic valve replacement. The postoperative course was complicated with severe heart failure and acute kidney injury requiring peritoneal dialysis. For that reason she required long-term sedation including administration of a large amount of muscle relaxant due to severe low cardiac output syndrome after aortic valvuloplasty. A total of 615 mg (79 mg x kg(-1)) of vecuronium was administered over a period of 24 days. On weaning from mechanical ventilation, 125 mg (16 mg x kg(-1)) of sugammadex was given. Vecuronium concentration measured by high-performance liquid chromatography (HPLC) was 5.03 ng x ml(-1) before sugammadex administration and increase to 13.98 ng x ml(-1) after that. However, blood concentration of metabolic products of vecuronium did not exceed the lower limits of measurement in each sample. She was successfully weaned from mechanical ventilation without recurarizarion. Serum concentration of vecuronium increased after administration of sugammadex because extravascular vecuronium was redistributed to intravascular space according to the concentration gradient induced by binding and clathration of vecuronium. The measured values of vecuronium after sugammadex administration on HPLC represented the total amount of free vecuronium and vecuronium combined with sugammadex. Recurarization might occur after sugammadex reversal in patients after long-term administration of vecuronium, especially if relatively smaller doses of sugammadex were given. We experienced a pediatric case in which serum vecuronium concentration increased following sugammadex administration after prolonged sedation using vecuronium. There is a risk of recurarization after sugammadex reversal in patients after long-term administration of vecuronium.

Japanese guidelines for the management of intussusception in children, 2011.

BACKGROUND: The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death. METHODS: Literature was collected systematically via the Internet using the key words "intussusception" and "children." The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels. RESULTS: Three criteria of "diagnostic criteria,""severity assessment criteria," and "criteria for patient transfer" were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referral to a tertiary hospital in severe cases. Barium is no longer recommended for enema reduction (recommendation D) because the patient becomes severely ill once perforation occurs. Use of other contrast media, such as water-soluble iodinated contrast, normal saline, or air, is recommended under either fluoroscopic or sonographic guidance. Delayed repeat enema improves reduction success rate, and is recommended if the initial enema partially reduced the intussusception and if the patient condition is stable. CONCLUSIONS: The guidelines offer standards of management, but it is not necessarily the purpose of the guidelines to regulate clinical practices. One should judge each individual clinical situation in accordance with experiences, available devices, and the patient's condition.

The long-term prognosis of two-flap anoplasty for mucosal prolapse following anorectoplasty for anal atresia.

AIM: Mucosal prolapse is a common complication following anorectoplasty for anorectal malformation. The symptoms such as soiling, staining, and pain significantly reduce the patients' quality of life. Millard et al. (Plast Reconst Surg 69(3):399-411, 1982) reported the two-flap anoplasty that creates an anal canal using two perineal pedicle skin flaps to form a "deep anus". We have used this procedure for mucosal prolapse since 1990. This study evaluated the long-term benefits of this method. METHODS: From 1990 to 2009, 18 patients suffering mucosal prolapse following anorectoplasty for high imperforate anus were treated using a two-flap anoplasty (TFARP) or just mucosal resection (MR). For each procedure, the long-term clinical follow-up (maximum of 20 years) was assessed by review of medical records against the frequency of recurrence, and the recurrence of preoperative symptoms postoperatively. RESULTS: Of the 18 patients, 8 presented with simple mucosal prolapse, 4 with bleeding, 3 with staining, 2 with incontinence, and 1 with pain. TFARP was performed for 14 patients and MR for 6 patients. In the MR group, during the maximum of 15 years follow-up, two patients (33 %) suffered a recurrence or failed to improve their symptoms such as bleeding and/or soiling. In the TFARP group, during the maximum of 20 years follow-up, there were no recurrences and their preoperative symptoms resolved completely. Furthermore, two patients in the TFARP group gained normal sensation prior to defecation. CONCLUSION: The advantages of this procedure were no recurrences and complete resolution of preoperative symptoms. Moreover, it provides the possibility of gaining sensate defecation, possibly because the skin flap around the anus might help develop sensation.

Tracheoinnominate artery fistula after laryngotracheal separation: prevention and management.

AIM: Tracheoinnominate artery fistula (TIF) is an often fatal complication of laryngotracheal separation (LTS) for which there has been no systematic therapeutic strategy for prevention or management of TIF. The aim of this study was to establish such a strategy based on our clinical experience. MATERIALS AND METHODS: From 2000 to 2010, 14 patients received LTS. We reviewed these patients to develop a therapeutic approach to prevent or manage TIF. RESULTS: Three patients had major bleeding, and another 3 received preventive treatment before major bleeding. In the major bleeding group, 1 patient died of choking from uncontrollable hemorrhage, but the others were rescued by brachiocephalic trunk separation and/or endovascular embolization. At operation, median sternotomy with its high risk of mediastinitis was avoided. In the preventive treatment group, prophylactic brachiocephalic trunk separation was performed for 2 patients because their severe scoliosis narrowed the mediastinum, compressing the innominate artery on computed tomography. Another avoided major bleeding by converting the tracheostomy tube to a length-adjustable type. CONCLUSION: Tracheoinnominate artery fistula is a dramatic, often lethal complication. The strategic approach should be designed to prevent it and includes evaluation of the spinal deformity on computed tomography, brachiocephalic trunk separation at the same time as LTS, and recognizing the importance of "herald" or warning minor bleeds.

[Case of external cephalic version under combined spinal-epidural anesthesia followed by vaginal delivery].

For a parturient with breech presentation, an external cephalic version is sometimes done to enable vaginal delivery. Usually external cephalic version has been done without anesthesiologist's management. However there have been several reports indicating a benefit of anesthesia for external cephalic version. We report successful case of external cephalic version under combined spinal-epidural anesthesia followed by vaginal delivery.

[Bowel perforation in the newborn baby].

The pattern of neonatal gastrointestinal perforation has changed with the previous high frequency of gastric rupture being replaced by necrotizing enterocolitis (NEC) in recent years. NEC has become the most common cause of gastrointestinal perforation resulting in a surgical emergency in the Neonatal Intensive Care Unit (NICU). Over the last 20 years, the infant mortality rate attributable to NEC has not decreased. However, in our institutions, more than 70% of babies with NEC are premature infants weighing less than 1,000g, which is one of the main reasons why the mortality rate due to neonatal gastrointestinal perforation has not improved in recent years. NEC totalis or massive necrosis of nearly all of the intestine is uniformly fatal. Limited resection followed by second-look laparotomy after abdominal drainage is one method used to limit the length of intestinal resection but most of these infants died from sepsis with cardiovascular collapse and multisystem organ failure. Among extremely low birth weight infants surviving after NEC significant growth delay and adverse neurodevelopmental outcome are common sequelae. More recently, many extremely low birth-weight infants are commenced on early low-volume feeds of breast milk or probiotics. This appears to be reducing the incidence of NEC and may explain a drop in the mortality rate over the last five years.