Mental and physical distress of field veterinarians during and soon after the 2010 foot and mouth disease outbreak in Miyazaki, Japan.

An outbreak of foot and mouth disease occurred in Miyazaki, Japan, in April 2010, and nearly 290,000 animals were culled to control the disease. This study was conducted to demonstrate the causes and intensity of mental distress felt by the field veterinarians participating in the control programme. A focus group discussion was conducted with ten veterinarians to understand their distress during the outbreak, and a questionnaire to quantify the degree of distress experienced each week was administered to 16 veterinarians. A detailed questionnaire was separately administered to 70 veterinarians six months after the outbreak was controlled, to assess mental distress status and to identify the risk factors for serious mental illness (SMI) using the six-item Kessler scale (K6). Overall, mental distress (mean 3.1) was significantly greater than physical distress (mean 1.9, p < 0.001). The risk factors for mental distress were categorised into three groups: culling, communication with farmers, and gender; each category was qualitatively described. Only two respondents (2.9%) had high K6 scores suggesting SMI. In the final generalised linear models with quasi-Poisson errors, the riskfactorsfor SMI that remained were: disinfecting vehicles (p = 0.01), distress (p <0.001), and increased alcohol consumption (p = 0.057), and a protective factor: participation in culling (p = 0.07), which suggested healthy worker bias. Sensitive individuals had been allocated to non-culling activities during disease control. In conclusion, human resource management was adequate during the outbreak from a public-health perspective. However, monitoring delayed symptoms of post-traumatic stress disorder is recommended.

Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: an alternative to endovascular stent-grafting.

OBJECTIVE: We have experienced transaortic stent-grafting for treating distal arch aneurysm or type B dissection. This paper is to mainly report the surgical aspect of these procedures. METHODS: Fifteen patients underwent this surgery, including 12 men and three women ranging from 47 to 83 years. Twelve had aneurysms and three aortic dissection. Concomitant surgery was necessary in seven patients (coronary artery bypass grafting in five, tricuspid annuloplasty in one, and replacement of ascending aorta and/or total arch replacement in three cases). A stent graft (Gianturco Z-stent and Intervascular prosthesis) was loaded in a 30-F sheath catheter. Under circulatory arrest, selective cerebral perfusion was established, and the sheath catheter was inserted through aortotomy into descending aorta and the stent graft was deployed at an appropriate level. The proximal end of graft was sutured to the aorta just distal to the left subclavian artery with inclusion method at the posterior wall. Concomitant surgery was done during cooling or rewarming period. TEE was utilized to visualize every endovascular manipulation to avoid unintended intimal injury or misplacement of graft and to assess the surgical results in the operative theater. RESULTS: Aneurysm was successfully excluded except in one patient who had a proximal endoleak and distal endoleak due to underestimation of aortic diameter. There was one operative mortality caused by cerebral infarction, possibly due to debris from femoral arterial cannulation. In the remaining patients, there was no enlargement of residual aneurysm. The excluded aneurysmal sac gradually regressed and disappeared within 2 years in five patients and the thrombosed false lumen completely shrunk within 1 year in two patients. One patient had paraplegia, possibly because the graft was intentionally advanced deeply to cover the thick and fragile atheromatous layer in order to avoid destruction of the atheroma by an expanded graft. CONCLUSIONS: Endovascular stent graft via the aortic arch is an acceptable treatment for distal arch aneurysms close to or involving left subclavian artery or type B dissections, especially for those cases requiring other cardiac procedures. It can lead to regression and disappearance of aneurysm or dissection in the mid-term follow-up.

[Serum cytokine levels response to cardiac surgery with cardiopulmonary bypass].

The response of tumor necrosis factor alpha (TNF alpha), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10), interleukin-1 receptor antagonist (IL-1ra), macrophage colony stimulating factor (MCSF), white blood cell (WBC), platelet (Plt), lactic acid (LAC) to cardiopulmnary bypass (CPB) were studied until 48 hours after aortic declamping in 11 patients who underwent elective CABG (n = 4), mitral valve plasty or replacement with modified maze procedure (n = 5), and both procedures (n = 2). The highest levels of the cytokines IL-6, IL-8, IL-10, and IL-1ra were observed after the removal of the cross clamp. These cytokines just after the aortic declamping are likely to be occurred not only by an interaction of the blood components with the artificial surfaces, but also by ischemia-reperfusion injury upon discontinuation of the aortic clamping. MCSF increased gradually in the late post-CPB phase and reached a peak at 48 hr after aortic declamping. MCSF may play an important role in regulating hematopoiesis on the postoperative days 1 and 2 in patients. In conclusion, the therapy based on the kinetics of these cytokines would be useful for patients undergoing CPB.

Cardiac papillary fibroelastoma on the pulmonary valve: a rare cardiac tumor. okaken@mcai.med.hiroshima-u.ac.jp.

We report the case of a patient with a rare papillary fibroelastoma on the pulmonary valve visualized before surgical intervention. The tumor was an encapsulated, rounded mass. The gelatinous membrane on the surface tore easily, and multiple fronds appeared. This case emphasizes that when there is an encapsulated mass attached to a valve, the initial excision of valve tissue should be as minimal as possible. To avoid unnecessary injury to the valve, it is simple and practical to confirm that the tumor has the appearance of a sea anemone, thus identifying it as a papillary fibroblastoma, a benign tumor.

Pulmonary vein orifice isolation for eliminating paroxysmal atrial fibrillation after ICD implantation.

We treated a patient with dilated cardiomyopathy (DCM) and sustained ventricular tachycardia by an implantable cardioverter defibrillator (ICD). He then suffered from inappropriate ICD shocks triggered by paroxysmal atrial fibrillation (AF). We successfully performed pulmonary vein orifice isolation to eliminate paroxysmal AF. The pulmonary vein orifice isolation was a simple and useful procedure for eliminating paroxysmal AF in patient with decreased left ventricular (LV) function after ICD implantation.

Kinetics of pro-inflammatory cytokines release in cardiac surgery with cardiopulmonary bypass.

OBJECTIVE: Cytokine induction can occur routinely in cardiac surgery with cardiopulmonary bypass. We have studied the relationships between the kinetics of pro-inflammatory cytokine release and the postoperative organ function. METHODS: Ten adult patients (6 men and 4 women) undergoing elective cardiac surgery with cardiopulmonary bypass, at Hiroshima University Hospital were studied. Patients with acute infection, insulin-dependent diabetes, acute or chronic respiratory failure, renal or hepatic failure, acute cardiogenic shock, and emergency patients were not included. The age of the patient ranged from 44 to 78 years (mean 69 +/- 2.0 years). The type of surgical intervention performed was coronary artery bypass grafting in four patients, mitral valve plasty or replacement with modified maze procedure in another five patients, and both procedures in the other one patient. Plasma cytokine levels until 48 hours after aortic declamping were measured in blood samples. The Respiratory Index and the serum levels of choline esterase and creatinine were also measured. The plasma levels of the pro-inflammatory cytokines (interleukin-6 and interleukin-8) were measured. RESULTS: The highest interleukin-6 levels were significantly correlated with hepatic dysfunction (r = -0.80, p = 0.006) and with renal dysfunction (r = 0.78, p = 0.009). The highest interleukin-8 levels were significantly correlated with respiratory dysfunction (r = 0.86, p = 0.001). CONCLUSION: The highest proinflammatory cytokines levels at 1 hour after aortic declamping were related to damage to postoperative organ functions, involving the lung, kidney and liver.

Efficacy of pulmonary vein isolation for the elimination of chronic atrial fibrillation in cardiac valvular surgery.

BACKGROUND: Haissaguerre and colleagues emphasize the importance of the pulmonary veins as a source of ectopic foci for initiating paroxysmal atrial fibrillation (AF). We hypothesized that ectopic foci from the pulmonary veins could also act as drivers for maintaining chronic AF, and that surgical ablation of the pulmonary vein orifices could terminate chronic AF. METHODS: Using a computerized 48-channel mapping system, we performed intraoperative atrial mapping in 12 patients with chronic AF associated with mitral valve disease. Patient age ranged from 24 to 82 years (mean, 60.4 years). AF duration ranged from 3 to 240 months (mean, 92+/-84 months). Simple surgical isolation of the pulmonary vein orifices was performed during the mitral valve operation. RESULTS: Regular and repetitive activation was found in the left atria of 9 out of 12 patients, and irregular and chaotic activation was found in both atria of 3 out of 12 patients. Chronic AF in the 9 patients (75%) with regular and repetitive activation of their left atria was successfully treated by a simple surgical isolation of the pulmonary vein orifices. The other 3 patients did not recover sinus rhythm after this procedure. In 1 case of recurrent AF, the patient recovered sinus rhythm during the follow-up period (AF-free rate, 83%). CONCLUSIONS: Surgical ablation of the pulmonary vein orifices was effective in the treatment of chronic AF associated with mitral valve disease. Intraoperative mapping may be useful in predicting the efficacy of a single pulmonary vein orifice isolation procedure.

Clinical analysis of results of a simple left atrial procedure for chronic atrial fibrillation.

BACKGROUND: We have performed a simple left atrial procedure for eliminating chronic atrial fibrillation (AF) associated with mitral valve disease. This article analyzes the midterm results of this procedure. METHODS: Thirty-two patients were enrolled in this study concomitant with mitral valve operations. Patients were divided into two groups (AF- and AF+). We examined the efficacy of this operation and atrial function for more than 12 months of follow-up. RESULTS: In a total of 98.5 patient years of follow-up, AF was absent 3 years after operation in 74%. Of preoperative and intraoperative variables, only long duration o

Clinical implication of orbital ultrasound monitoring during selective cerebral perfusion.

BACKGROUND: We evaluated clinical relevance of orbital ultrasound (OUS) monitoring to neurological events in aortic surgery associated with selective cerebral perfusion (SCP). METHODS: In 24 consecutive cases, blood flow was monitored at central retinal artery (CRA) and retrobulbar vessels. The threshold perfusion pressure for detecting CRA flow in the color Doppler mode (BPt) was determined in individual eyes. RESULTS: The BPt ranged from 25 to 71 mm Hg. Events (infarction, anisocoria, delirium) occurred in 8 cases. Infarction occurred in all 3 cases when retrobulbar flow was severely impaired for 40 minutes or longer, while none of the remaining 21 cases had infarction (p = 0.0005). Among the latter cases, perfusion pressure was below BPt for longer than 100 minutes in all 5 cases with events, and in 5 of 16 cases without events (p = 0.0124). No significant difference was found in age, duration of cardiopulmonary bypass, SCP, and circulatory arrest, and duration of blood pressure below 50 mm Hg. CONCLUSIONS: Sustained hypoperfusion detected with OUS monitoring is related to an occurrence of neurological events.

Pulmonary vein orifice isolation for elimination of chronic atrial fibrillation.

We present a 61-year-old woman with chronic atrial fibrillation (AF) associated with mitral valve disease. Chronic AF was successfully treated by simple isolation of pulmonary vein orifices concomitant with mitral valve replacemen

The extra domain A of fibronectin activates Toll-like receptor 4.

Cellular fibronectin, which contains an alternatively spliced exon encoding type III repeat extra domain A (EDA), is produced in response to tissue injury. Fragments of fibronectin have been implicated in physiological and pathological processes, especially tissue remodeling associated with inflammation. Because EDA-containing fibronectin fragments produce cellular responses similar to those provoked by bacterial lipopolysaccharide (LPS), we examined the ability of recombinant EDA to activate Toll-like receptor 4 (TLR4), the signaling receptor stimulated by LPS. We found that recombinant EDA, but not other recombinant fibronectin domains, activates human TLR4 expressed in a cell type (HEK 293 cells) that normally lacks this Toll-like receptor. EDA stimulation of TLR4 was dependent upon co-expression of MD-2, a TLR4 accessory protein. Unlike LPS, the activity of EDA was heat-sensitive and persisted in the presence of the LPS-binding antibiotic polymyxin B and a potent LPS antagonist, E5564, which completely suppressed LPS activation of TLR4. These observations provided a mechanism by which EDA-containing fibronectin fragments promote expression of genes involved in the inflammatory response.

Endovascular stent-grafting through the aortic arch: an alternative approach for distal arch aortic aneurysm.

BACKGROUND: Endovascular stent-grafting is an innovative procedure; we have developed a novel approach to treat distal arch aortic aneurysm through a small incision in the aortic arch. METHODS: Eight patients with thoracic aortic aneurysms were treated with an endovascular stent-graft that was introduced into the thoracic aorta through a small incision in the aortic arch. Of these patients, 7 had distal arch aortic aneurysms, and 1 had chronic aortic dissection of Stanford type B. Four of these patients had received concomitant coronary artery bypass grafting, and 1 patient had undergone tricuspid valvular annuloplasty. The stent-graft was introduced into the distal arch aorta and descending aorta through a small incision in the aortic arch, under selective cerebral perfusion and hypothermic circulatory arrest. RESULTS: The selective cerebral perfusion time ranged from 52 to 86 minutes (mean, 68 minutes) and the operating time from 289 to 422 minutes (mean, 318 minutes). There was no endoluminal leakage into the aneurysm. Seven patients survived and were discharged, but 1 patient suffered a cerebral infarction and died during the follow-up period. CONCLUSIONS: Placing an endovascular stent-graft through the aortic arch is an acceptable alternative treatment for distal arch aortic aneurysms.

[Mortality and prognostic factors in patients with community-acquired pneumonia: an analysis of 231 cases].

We prospectively analyzed the mortality and prognostic factors in 231 patients with community-acquired pneumonia. The patients were enrolled between May 1996 and April 1998. The average patient age was 67.6 +/- 17.5 years, and 68% were male. The mean hospital length of stay was 21.9 +/- 21.7 days. The mortality was 6.5% at the 30th day, 13.9% at hospital discharge, and 19.9% at 1 year later. Stepwise logistic regression analysis showed that liver cirrhosis, diastolic hypotension (< 60 mmHg), hypoxemia (< 50 Torr) were significantly correlated with death at the 30th day, and that alcoholism, malignancy, diastolic hypotension, hypoxemia, hypoalbuminemia (< 3.0 g/dl), and increased creatinine (> 1.2 mg/dl) were significantly correlated with discharge mortality. Furthermore, the prognostic factors at 1 year later were the same as those at hospital discharge, with the exception of alcoholism, which was replaced by ischemic heart disease in the 1-year mortality. We conclude that liver cirrhosis, diastolic hypotension, and hypoxemia are very important prognostic factors during the acute stage of pneumonia, and that alcoholism, malignancy, hypoalbuminemia and renal complications are significantly correlated with hospital death and 1-year mortality.

Ruptured sinus valsalva with infectious endocarditis: a technique of defect closure with an autologous-xenologous pericardial sandwich patch.

We report a case of ventricular septal defect with acquired rupture of sinus Valsalva induced by infectious endocarditis. After irrigati on of all infectious tissues, the defect was closed twice using two different patches. One was an autologous pericardial patch from the right ventricle and the other was a composite patch made of an autologous pericardium and axenologous pericardium from the left ventricle. As a result, the xenologous pericardium was sandwiched between autologous pericardiums. We thought that this "sandwiched patch" would compensate for the shortcomings of each type of pericardium and resist left ventricular pressure and infection. Despite the development of antibiotic therapy, infectious endocardit is (IE) is still one of the most difficult disease to cure. In the case of a rupture of sinus Valsalva, because of the rapid spread of infection into any of the cardiac chambers, surgical intervention is necessary. In this report, we describe a case treated successfully.

Echocardiography-assisted surgery in transaortic endovascular stent grafting: role of transesophageal echocardiography.

OBJECTIVE: Transesophageal echocardiography was applied to visualizing endovascular procedures during transaortic stent grafting for aneurysm and dissection at the distal arch, and the use of transesophageal echocardiography was evaluated. METHODS: The 16 consecutive patients (13 with aneurysms and 3 with dissections) were examined. Transesophageal echocardiography was used for (1) determining graft size, (2) guiding placement of the catheter in the descending aorta at an appropriate position without intimal damage, (3) guiding graft tailoring with a balloon catheter, and (4) examining the results after the procedures. RESULTS: Visualization was disturbed in one patient who had undergone a previous operation. The graft size was appropriate, except in one patient as a result of underestimation. Transesophageal echocardiography was helpful for navigating the graft placement and tailoring without intimal damage. We tried to keep a distance from the diaphragm of 9 cm and an attachment portion of 4 cm. In one patient the graft was placed too distally (7 cm from the diaphragm) to cover the thick atheromatous plaque with the graft. The patient had paraplegia. Transesophageal echocardiographic assessment of endoleak and thromboexclusion was identical to that of postoperative computed tomography or angiography, with a sensitivity of 100% (1/1) and a specificity of 100% (13/13). Leakage at the proximal suture and graft kinking were found in 3 patients. Successful thromboexclusion by transesophageal echocardiographic assessment (13 patients) was predictive of subsequent regression of aneurysm and dissection in the midterm follow-up period: there was complete and partial regression in 5 and 8 patients, respectively. CONCLUSION: Transesophageal echocardiography enables echocardiography-assisted operations with secure step-by-step endoluminal procedures and immediate intraoperative assessment, which is predictive of the postoperative results.