Cytological features of oral malignant lymphoma in scraping liquid-based cytology: Cases of plasmablastic lymphoma and anaplastic lymphoma kinase-positive anaplastic large cell lymphoma.

The main purpose of cytological examination in the oral region is to screen for squamous cell carcinoma or intraepithelial neoplasms; thus, the background tends to be considered a deterrent for microscopy. From this perspective, liquid-based cytology (LBC) is favorable for preparing clear samples with few backgrounds. However, background hemocytes are sometimes of critical importance in the diagnosis. We report two cases of oral malignant lymphoma, plasmablastic lymphoma, and anaplastic large cell lymphoma in which careful observation of the background in scraping LBC sample contributed to the early diagnosis. Atypical lymphoid cells were observed only in a very small part of the LBC samples from the presented patients; however, cytological findings, such as large lymphoid cells with outstanding nucleoli, large mitotic cells, or intermediate-to-large lymphoid cells with pleomorphic nuclei were sufficient for obtaining a cytological diagnosis of malignant lymphoma. Although the number and cell size of leukocytes in LBC with Papanicolaou staining were significantly different from those in air-dried conventional smears with Romanovsky staining, which are commonly preferred for the discrimination of hemocytes, the corresponding cytological features could be observed. Therefore, attention should be paid to the background as well as squamous epithelium to prepare for such unexpected cases. The LBC examination with Papanicolaou staining alone can suggest the possibility of malignant lymphoma.

TUBB3 immunostaining improves the diagnostic accuracy of oral liquid-based cytology in squamous cell carcinoma.

OBJECTIVE: Although class III beta-tubulin (TUBB3) is not expressed in normal epithelium, its expression in cancers of some organs has been reported. Herein, we investigated the expression pattern and expression levels of TUBB3 in oral squamous cell carcinoma (SCC), and assessed whether TUBB3 immunostaining could improve the diagnostic accuracy of oral scraping liquid-based cytology (LBC). METHODS: Paraffin sections of biopsies from 107 patients with primary SCC and 30 patients with squamous papilloma of the tongue or gingiva were immunostained for TUBB3. In addition, 15 LBC samples obtained from the study participants with SCC were immunostained for TUBB3. Seven LBC samples were false-negative. The TUBB3 expression level in each sample was evaluated and classified as 3+, 2+, 1+, or 0. RESULTS: TUBB3 expression was confirmed in 91.6% of paraffin-embedded SCC specimens. Clear and diffuse positivity (2+ or above) was observed in 77.6% of the total cases. In the well-differentiated type, tumour cells in the middle layer of the parenchyma specifically expressed TUBB3. In almost LBC samples, cancerous intermediate cells showed immunopositivity similar to that of paraffin samples, even if cellular atypia was not clear in Papanicolaou staining. CONCLUSIONS: TUBB3 immunostaining is useful for diagnosing oral SCC in scraping LBC, especially when samples consist of intermediate cells with little morphological change. Moreover, TUBB3 immunostaining could improve the diagnostic accuracy of oral scraping LBC by reducing false-negatives.

First dose-ranging study of remimazolam in Japanese patients undergoing gastrointestinal endoscopy: Phase II investigator-initiated clinical trial.

OBJECTIVES: Remimazolam, an ultra-short-acting benzodiazepine, has been used for procedural sedation in the United States. We conducted an investigator-initiated clinical trial to determine the appropriate dose of remimazolam required for sedation during gastrointestinal endoscopy in Japanese subjects. METHODS: In this single-center, open-label, uncontrolled, phase II trial, a three-stage cohort investigated the appropriate initial and additional doses of remimazolam required for gastrointestinal endoscopy. This study was designed with advice from the Pharmaceuticals and Medical Devices Agency. The initial and additional doses were 2 mg and 1 mg/dose, 3 mg and 1 mg/dose, and 5 mg and 2 mg/dose in cohorts 1, 2, and 3, respectively. Each cohort included 10 cases of upper gastrointestinal endoscopy and colonoscopy. The primary end-point was the success rate of sedation during gastrointestinal endoscopy. RESULTS: Sedation was successful in all gastrointestinal endoscopies in cohorts 1 and 2. In cohort 1, sedation was achieved in five (25.0%) and 10 (50.0%) participants with the initial dose and total dose (initial dose + additional dose ≤ the initial dose of the next cohort), respectively, before endoscopy. In cohort 2, sedation was achieved in 11 (55.0%) and 18 (90.0%) participants with the initial dose and total dose, respectively, before endoscopy. No patient in either cohort lost consciousness or required flumazenil or manual ventilation. CONCLUSION: Initial and additional doses of 3 mg and 1 mg/dose of remimazolam, respectively, were shown to be effective and safe for sedation during gastrointestinal endoscopy in Japanese patients.

Evaluating the Accuracy of the Endoscopic ABC Classification System in Diagnosing Helicobacter pylori-Infected Gastritis.

AIMS: Evaluating the accuracy of the modified Endoscopic ABC (Endo ABC) classification with an electronic endoscopy with narrow band imaging without magnification in diagnosing Helicobacter pylori (H. pylori)-infected gastritis. METHODS: A total of 576 patients were enrolled and they underwent modified Endo ABC. They were stratified into 5 groups (A to E) based on the grades of endoscopic findings. H. pylori-infected gastritis status was determined in the following ways: current H. pylori gastritis was defined as active gastritis and/or chronic atrophic gastritis (CAG) seen on endoscopy and positive H. pylori test, naïve H. pylori gastritis was defined as regular arrangement of collecting venules in the angle of the lesser curvature without CAG and negative H. pylori test, and previous H. pylori gastritis was defined as negative H. pylori tests regardless of the presence of CAG. RESULTS: Endo A has 97% accuracy and 100% positive predictive value in diagnosing naïve H. pylori gastritis. Endo E has 97% accuracy and 100% positive predictive value in diagnosing previous H. pylori gastritis. The accuracy of Endo B and Endo C in diagnosing current H. pylori gastritis was 89 and 82% respectively. Endo D has 87% accuracy in diagnosing previous H. pylori gastritis. CONCLUSION: This study showed that the modified Endo ABC classification enables to accurately determine the H. pylori-infected gastritis status.

Mechanistic insights from sequential combination therapy with a sodium glucose co-transporter-2 inhibitor and a dipeptidyl peptidase-4 inhibitor: Results from the CANARIS Trial using canagliflozin and teneligliptin.

AIM: To elucidate the mechanisms involved in the sequential use of SGLT2 and DPP4 inhibitors (SGLT2i and DPP-4i). METHODS: Twenty-six type-2 diabetes mellitus patients were recruited into a stepped regimen of 100 mg of canagliflozin daily from day 1, supplemented with 20 mg of teneligliptin daily from day 4. Glucose (Glu), insulin and glucagon were measured at fasting and after ingesting a mixed meal on days 1, 4 and 6. RESULTS: Canagliflozin decreased fasting plasma glucose to an extent inversely proportional to the change in the glucagon-to-insulin (G/I) ratio. This correlation at fasting was maintained when adding teneligliptin, while the change in the area under the curve of Glu (GluAUC) correlated closely with that in the G/I ratio at fasting and 60 min with canagliflozin. Moreover, these correlations persisted at 60 and 120 min postprandially, but not at fasting on day 6 when teneligliptin was added. CONCLUSION: The result suggested that the dominant mechanism responsible for the glucose metabolism reflected in the G/I ratio was attributable to SGLT2i and that its active mechanism persisted, despite adding a DPP-4i.

Fulminant type 1 diabetes associated with Isolated ACTH deficiency induced by anti-programmed cell death 1 antibody-insight into the pathogenesis of autoimmune endocrinopathy.

Therapeutic blocking antibodies against programmed death 1 (PD1) and cytotoxic T-lymphocyte antigen 4 (CTLA4) are applied for advanced cancer therapy, but induce a wide range of immune-related adverse events. In our recent case of a 52-year-old female doctor suffering from breast cancer having metastasized to the lung and liver, it was decided to use nivolumab to prevent the disease progressing after excisional surgeries and multiple chemotherapies. One month after completing the nivolumab course, fatigue, hypoglycemia and hypotension developed and isolated ACTH deficiency (IAD) was diagnosed. A further month later, under steroid supplementation, hyperglycemia emerged alongside thirst and polydipsia, prompting a diagnosis of fulminant type 1 diabetes (FT1D). Her susceptibility to type 1 diabetes was examined by HLA haplotype and CTLA4 gene polymorphism analyses. Polymorphisms CT60G>A and +49G>A in CTLA4 both generated a GG genotype. Our patient manifested one of the rarest combinations of autoimmune disease induced by nivolumab. Whereas the HLA haplotype was unsusceptible to autoimmune type 1 diabetes, polymorphisms of CTLA4, the antibody of which frequently causes hypophysitis, were susceptible to FT1D. Peripheral modulation of activated T cells, mainly by PD-1 antibodies, induced FT1D associated with IAD in patients with CTLA4 polymorphism. This case reveals hints of the T-cell etiology in T1D and evidence of CTLA4 involvement in IAD.

Relationship between changes in regional cerebral blood volume and oxygenation and changes in cardiac output and systemic vascular resistance during spinal anesthesia in women undergoing cesarean section.

PURPOSE: The decrease in maternal regional cerebral blood volume (rCBV) and oxygenation (rCBO) during spinal anesthesia for cesarean section depends on the severity of hypotension. We examined the relationships between changes in the systemic circulatory parameters, cardiac output (CO) and systemic vascular resistance (SVR), and rCBV and rCBO after induction of spinal anesthesia, evaluated by near-infrared spectroscopy (NIRS) and an arterial pressure-based cardiac output monitoring system (APCOs). METHODS: Seventeen patients undergoing elective cesarean section under spinal anesthesia were monitored every 1 min for mean arterial pressure (MAP), heart rate (HR), end-tidal carbon dioxide (EtCO2) and oxygen saturation (SpO2), and at 20 s intervals for CO, SVR, concentrations of oxy-hemoglobin (Hb), deoxy-Hb, total-Hb, and tissue oxygenation index (TOI), until 15 min after the intrathecal injection of bupivacaine. We investigated changes in the parameters from baseline and evaluated correlations between the changes in total-Hb and TOI and changes in CO and SVR, respectively, at the same timepoints. RESULTS: Oxy-Hb, total-Hb, TOI, and SVR significantly decreased and HR significantly increased with a decrease in MAP (P < 0.01). Deoxy-Hb, CO, SpO2, and EtCO2 levels did not change from baseline. There were statistically significant, although weak, positive correlations between both total-Hb and TOI with SVR (total-Hb; r = 0.18, P < 0.01, TOI; r = 0.38, P < 0.01). CONCLUSION: The decreases in both rCBV and rCBO after induction of spinal anesthesia for cesarean section are probably dependent on the decrease in SVR due to spinal anesthesia.

Utility of T1- and T2-Weighted High-Resolution Vessel Wall Imaging for the Diagnosis and Follow Up of Isolated Posterior Inferior Cerebellar Artery Dissection with Ischemic Stroke: Report of 4 Cases and Review of the Literature.

BACKGROUND: An accurate diagnosis of isolated posterior inferior cerebellar artery dissection (iPICA-D) is difficult due to the limitation of spatial resolution on conventional magnetic resonance imaging (MRI) techniques to detect subtle vessel wall abnormalities. The recent development of MRI techniques, including high-resolution vessel wall imaging (HRVWI), has resulted in the improved diagnostic accuracy and efficiency of iPICA-D. In fact, T1-weighted HRVWI, which can reveal intramural hematomas in the posterior inferior cerebellar artery (PICA), is useful for the diagnosis of iPICA-D. However, the utility of T2-weighted HRVWI has not been previously reported. The aim of this study was to investigate the diagnostic utility of T1- and T2-weighted HRVWI for the diagnosis of iPICA-D. METHODS: We retrospectively evaluated MRI findings including intramural hematomas, dilations, and chronological changes in 4 patients with iPICA-D admitted to our hospital and related facility from January 2015 to August 2016. In addition to T1-weighted HRVWI, T2-weighted HRVWI was performed on isovoxel three-dimensional (3D) fast spin-echo or 3D sampling perfection with application-optimized contrast using different flip-angle evolution. We also reviewed cases of nonhemorrhagic iPICA-D with ischemic onset in which the MRI findings were described. RESULTS: In all 4 patients, in addition to the intramural hematomas on T1-weighted HRVWI, T2-weighted HRVWI clearly showed the fusiform dilation of the external diameter of the PICA. T2-weighted HRVWI was more useful than other techniques, including T1-weighted HRVWI, for the evaluation of arterial shape changes. CONCLUSIONS: Like T1-weighted HRVWI, T2-weighted HRVWI is useful for the diagnosis and assessment of chronological changes in vessel wall abnormalities during the follow-up period.

[Analysis of the gray-zone cutoff values of new serum Helicobacter pylori antibody kits using latex immunoassay].

The serum Helicobacter pylori titers are good markers for population-based H. pylori screening and treatment programs because the tests used to estimate these titers are noninvasive, inexpensive, and convenient. However, the reference range of 3-10U/mL, which is used as a standard in commercially available serum H. pylori antibody kit E plate Eiken H. pylori antibody II, is regarded as a gray-zone cutoff value to indicate H. pylori infection status. We aimed to clarify the gray-zone cutoff values of H. pylori infection status with new serum H. pylori antibody kits using latex immunoassay. We enrolled 256 patients who underwent endoscopic examination and H. pylori tests at the Inui Clinic of Internal Medicine or IMS Ota Central General Hospital between January 2013 and December 2015. Serum H. pylori titers were measured using Type L Wako H. pylori antibody J (Wako-LIA), H. pylori-latex Seiken (Denka-LIA), and LZ test Eiken H. pylori antibody (Eiken-LZ). In patients with a positive diagnosis of H. pylori infection, the positive diagnostic values (sensitivity, specificity, and positive predictive value) using Wako-LIA, Denka-LIA, and Eiken-LZ were (94.6%, 86.0%, and 79.1%), (95.7%, 90.2%, and 84.6%), and (85.9%, 92.1%, and 85.9%), respectively;in patients with a negative diagnosis of H. pylori infection, the diagnostic values (sensitivity, specificity, and negative predictive value) using Wako-LIA, Denka-LIA, and Eiken-LZ were (96.9%, 83.5%, and 85.6%), (96.9%, 78.7%, and 82.2%) and (95.3%, 67.7%, and 75.0%), respectively. In this study, the gray-zone cutoff value indicating H. pylori infection status was between 4.0 and 8.7U/mL for Wako-LIA, between 10.0 and 15.2U/mL for Denka-LIA, and between 5.6 and 10.0U/mL for Eiken-LZ. Therefore, we propose that lower titers of the positive antibody are important to diagnose H. pylori infection using Wako-LIA and Denka-LIA. However, when using Eiken-LZ, high titers of the negative antibody should be considered diagnostically important.

Oxygen Supplementation is Effective in Attenuating Maternal Cerebral Blood Deoxygenation After Spinal Anesthesia for Cesarean Section.

The purpose of this study was to measure changes in maternal cerebral blood oxygenation using near-infrared spectroscopy (NIRS) for 15 min after spinal anesthesia performed for cesarean section, and to determine the efficacy of supplemental oxygen in maintaining maternal cerebral blood oxygenation. Thirty patients were randomly assigned to either receive 100% oxygen via a facemask at a constant flow rate of 3 l/min throughout the study (O2 group), or were evaluated without supplemental oxygen (Air group). Changes in cerebral blood oxygenation were evaluated using the following parameters: oxy-hemoglobin (Hb), deoxy-Hb, and total-Hb concentrations, as well as tissue oxygen index (TOI), measured over the forehead by NIRS. Mean arterial pressure (MAP) and heart rate (HR) were also recorded throughout the study. Mean oxy-Hb, total-Hb, TOI, and MAP in both groups decreased significantly from baseline values (P<0.05). The reduction in oxy-Hb and TOI in the Air group was significantly greater than that in the O2 group (oxy-Hb: -4.72 vs. -2.96 µmol/l; P<0.05, TOI: -6.82 vs. -1.68%; P<0.01); however, there were no significant differences in the reduction of total-Hb and MAP between the groups. Mean deoxy-Hb in the Air group was significantly higher than that in the O2 group (0.02 vs. -1.01 µmol/l; P<0.05). The results of the present study demonstrate that oxygen supplementation attenuates cerebral blood deoxygenation secondary to the reduction in cerebral blood flow following spinal anesthesia.

Changes in Cerebral Blood Flow and Oxygenation During Induction of General Anesthesia with Sevoflurane Versus Propofol.

Sevoflurane and propofol are widely used for induction and maintenance of general anesthesia. Although the effects of sevoflurane and propofol on cerebral hemodynamics during maintenance of general anesthesia have been demonstrated, the effects during induction of general anesthesia have still not been clarified. We therefore compared changes in cerebral blood flow (CBF) and oxygenation (CBO) during induction of anesthesia using sevoflurane (group S: n=9) or propofol (group P: n=9). CBF and CBO were evaluated using the following variables: oxy-, deoxy-, and total-hemoglobin (Hb) concentrations and tissue oxygen index (TOI), measured on the forehead by near-infrared spectroscopy. The variables were recorded immediately before administration of sevoflurane or propofol and at every 10 s for 4 min after administration of the induction agent. Patients received 8% sevoflurane in 100% oxygen via an anesthesia mask in group S, and an IV bolus of 2 mg/kg of propofol during oxygenation in group P. We found that oxy-Hb, total-Hb, and TOI were significantly higher in group S than in group P (P>0.05). Changes in deoxy-Hb, MBP, and HR did not differ between the groups. The results of the present study demonstrated that sevoflurane increases CBF and CBO during induction of general anesthesia.

Relationship between regional cerebral blood volume and oxygenation and blood pressure during spinal anesthesia in women undergoing cesarean section.

PURPOSE: During spinal anesthesia for cesarean section, cerebral oxygenation decreases may be related to an abrupt drop in cerebral blood flow due to hypotension. We measured the changes in maternal regional cerebral blood volume (rCBV) and oxygenation (rCBO) using near-infrared spectroscopy (NIRS) to evaluate whether a decrease in arterial blood pressure during spinal anesthesia diminishes rCBV and rCBO. METHODS: Forty patients scheduled for elective cesarean section under spinal anesthesia were monitored for mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), and concentrations of oxy-hemoglobin (Hb), deoxy-Hb, total-Hb, and tissue oxygenation index (TOI), before spinal anesthesia (baseline) and for 20 min after intrathecal injection of bupivacaine. We investigated changes in the values from baseline and evaluated whether the maximum changes in total-Hb (Δ-total-Hb) and TOI (Δ-TOI) correlate with changes in MAP at the same time point. RESULTS: The mean oxy-Hb, total-Hb, TOI, and MAP significantly decreased from baseline after intrathecal injection of bupivacaine (P < 0.01). There were significant positive correlations between both Δ-total-Hb and Δ-TOI and the decrease in MAP (Δ-total-Hb: r = 0.53, P < 0.01; Δ-TOI: r = 0.59, P < 0.01). CONCLUSIONS: Maternal rCBV and rCBO decrease significantly during spinal anesthesia for cesarean section. Reductions in rCBV and rCBO may be associated with the severity of hypotension induced by subarachnoid sympathetic block with bupivacaine.

Loss of Pax3 causes reduction of melanocytes in the developing mouse cochlea.

Cochlear melanocytes are intermediate cells in the stria vascularis that generate endocochlear potentials required for auditory function. Human PAX3 mutations cause Waardenburg syndrome and abnormalities of skin and retinal melanocytes, manifested as congenital hearing loss (~ 70%) and hypopigmentation of skin, hair and eyes. However, the underlying mechanism of hearing loss remains unclear. Cochlear melanocytes in the stria vascularis originated from Pax3-traced melanoblasts and Plp1-traced Schwann cell precursors, both of which derive from neural crest cells. Here, using a Pax3-Cre knock-in mouse that allows lineage tracing of Pax3-expressing cells and disruption of Pax3, we found that Pax3 deficiency causes foreshortened cochlea, malformed vestibular apparatus, and neural tube defects. Lineage tracing and in situ hybridization show that Pax3+ derivatives contribute to S100+, Kir4.1+ and Dct+ melanocytes (intermediate cells) in the developing stria vascularis, all of which are significantly diminished in Pax3 mutant animals. Taken together, these results suggest that Pax3 is required for the development of neural crest cell-derived cochlear melanocytes, whose absence may contribute to congenital hearing loss of Waardenburg syndrome in humans.

Effect of spinal anesthesia for elective cesarean section on cerebral blood oxygenation changes: comparison of hyperbaric and isobaric bupivacaine.

We used near-infrared spectroscopy (NIRS) to evaluate cerebral blood oxygenation changes in subjects undergoing cesarean section under spinal anesthesia (SP) with hyperbaric bupivacaine (group H, 27 subjects) or isobaric bupivacaine (group I, 15 subjects). In group H, total-Hb, oxy-Hb, and mean blood pressure (MBP) within 20 min after SP were significantly lower than the baseline values. In contrast, there was no significant change from baseline in total-Hb, oxy-Hb, or MBP in group I after SP. Total-Hb and MBP in group H were significantly lower than those in group I within 10 min after SP. There was no significant change of deoxy-Hb, tissue oxygen index, or heart rate from baseline in either of the groups. These results suggest that isobaric bupivacaine may be superior to hyperbaric bupivacaine for preventing a decrease of maternal cerebral blood flow after SP for cesarean section.

Accuracy of the Contour® Next Link 2.4 blood glucose monitoring system in Japanese individuals: a single-center study.

Aims: Self-monitoring of blood glucose is a useful method for monitoring blood glucose. It is often a key role of a management plan to reduce glycemic variability and diabetic complications. Wireless monitoring systems to connect blood glucose and insulin pumps can facilitate glycemic control. In this study, we evaluated the accuracy of Contour® Next Link 2.4, a blood glucose monitoring system that cooperates wirelessly with most insulin pumps, in Japanese individuals. Methods: In this study, finger-stick samples from 59 individuals were collected at the Tokyo Saiseikai Central Hospital. Blood glucose concentrations were measured with the monitoring systems against an available reference. We evaluated the accuracy of the system based on the ISO 15197:2013 Section 6.3 accuracy criteria. Results: In the present study, 100% of the results fulfilled the ISO 15197:2013 Section 6.3 accuracy criteria (95% within ± 15 mg/dL or ± 15% of reference for glucose < 100 and ≥ 100 mg/dL, respectively). The Parkes-Consensus Error Grid analysis showed that 100% of the results fulfilled within Zone A. Conclusions: The Contour® Next Link 2.4 blood glucose monitoring system fulfilled the ISO 15197:2013 accuracy criteria limit and the consensus error grid criterion. Therefore, this monitoring system for observing blood glucose levels is accurate for Japanese individuals.

Pax3 deficiency diminishes melanocytes in the developing mouse cochlea.

Cochlear melanocytes are intermediate cells in the stria vascularis that generate endocochlear potentials required for auditory function. Human PAX3 mutations cause Waardenburg syndrome and abnormalities of melanocytes, manifested as congenital hearing loss and hypopigmentation of skin, hair and eyes. However, the underlying mechanism of hearing loss remains unclear. During development, cochlear melanocytes in the stria vascularis are dually derived from Pax3-Cre+ melanoblasts migrating from neuroepithelial cells including neural crest cells and Plp1+ Schwann cell precursors originated from also neural crest cells, differentiating in a basal-apical manner. Here, using a Pax3-Cre mouse line, we found that Pax3 deficiency causes foreshortened cochlea, malformed vestibular apparatus, and neural tube defects. Lineage tracing and in situ hybridization show that Pax3-Cre derivatives contribute to S100+ , Kir4.1+ and Dct+ melanocytes (intermediate cells) in the developing stria vascularis, all significantly diminished in Pax3 mutant animals. Taken together, these results suggest that Pax3 is required for the development of neural crest cell-derived cochlear melanocytes, whose absence may contribute to congenital hearing loss of Waardenburg syndrome in human.

Rocuronium and sugammadex used effectively for electroconvulsive therapy in a patient with Brugada syndrome.

We report the successful anesthetic management of a patient with Brugada syndrome who underwent electroconvulsive therapy to treat bipolar disorder. Suxamethonium and neostigmine were contraindicated to avoid the vagotonic effects that can precipitate ventricular fibrillation during anesthesia in patients with Brugada syndrome. The combination of 1.2 mg/kg rocuronium and 10 mg/kg sugammadex was effectively and safely used to induce and antagonize neuromuscular block for 8 consecutive electroconvulsive therapy sessions in this patient.

[Comparison of postoperative pain relief by continuous femoral nerve block and that by epidural block during physiotherapy after minimally invasive surgery of total knee arthroplasty and uni-condylar knee arthroplasty].

BACKGROUND: We compared postoperative pain relief during physiotherapy after minimally invasive surgery (MIS) of total knee arthroplasty (TKA) and unicondylar arthroplasty (UKA). METHODS: Ninety-five patients scheduled for TKA or UKA under spinal anesthesia were divided into continuous femoral nerve block (0.1-0.12% ropivacaine 4 ml x hr(-1)) combined with a single sciatic block (Group CFNB) and epidural block (0.1-0.19% ropivacaine 4 ml x hr(-1)) combined with a single femoral block (Group EP). Visual analogue scale (VAS) at rest, walking, maximal knee flexion, extension, and maximal pain on POD 1 were recorded. Patient's satisfaction of analgesia and supplemental analgesics on POD 1 were recorded. We compared VAS and satisfaction of TKA with UKA during CFNB or EP. RESULTS: VAS at physiotherapy was higher than VAS at rest. VAS at maximal knee flexion was higher than VAS at rest, walking or maximal knee extension in UKA of Group CFNB (n = 29) or EP (n = 19). VAS at flexion and extension were higher than VAS at walk- ing in TKA of Group CFNB (n = 20) or EP (n = 27). VAS, patient's satisfaction and supplemental analgesics on POD 1 were comparable in both groups. CONCLUSIONS: VAS at physiotherapy after TKA or UKA during CFNB or EP was very severe than VAS at rest.