Amputation-free Home Management of Infected Lower Extremity Pressure Ulcer through Shared Decision-making: Enhancing the Quality of Life and Highlighting Societal Significance in Home Care.

Home healthcare is important for allowing patients to live their lives. However, home-care bedridden patients often experience pressure ulcers in the lower extremities, which can lead to life-threatening infections requiring decisions on the need for amputation. We herein report a patient with an infected lower-limb pressure ulcer with a history of spinal injury. The patient, his family, and the home-care physician repeatedly shared decision-making to deliver home-based treatment instead of amputation. Administration of wound dressing, AQUACEL® Ag, led to complete epithelialization. Such shared decision-making and dressing were feasible in a home-care setting and broadened its scope.

Soluble thrombomodulin and cardiovascular disease risk factors in Japanese children.

This study aimed to establish standard reference values for soluble thrombomodulin in healthy prepubertal school-aged children and elucidate the relationship between soluble thrombomodulin levels and obesity, metabolic syndrome-associated indices, and other markers of vascular endothelial damage. The participants in this study were healthy Japanese children aged 9-10 years (315 boys and 267 girls). Blood tests for soluble thrombomodulin, leptin, fibrinogen, and general biochemical markers were performed, and the mean and 10th, 50th, and 90th percentiles for each marker were determined. Participants were divided into two groups based on their waist circumference (≥75 vs. <75 cm), and each parameter was compared between the two groups. Analyses were performed to compare subgroups with different numbers of risk factors for cardiovascular disease (CVD). We found that as CVD risk factors accumulated, the levels of total cholesterol, alanine aminotransferase, uric acid, soluble thrombomodulin, fibrinogen, and leptin were significantly elevated, whereas the level of high-density lipoprotein cholesterol significantly decreased. We determined reference values for soluble thrombomodulin in prepubertal children, and our results suggest that soluble thrombomodulin levels contribute to the latent progress of arteriosclerosis from childhood.

Continuous pericapsular nerve group block for postoperative pain management in total hip arthroplasty: report of two cases.

BACKGROUND: Total hip arthroplasty (THA) is one of the surgical procedures associated with severe postoperative pain. Appropriate postoperative pain management is effective for promoting early ambulation and reducing the length of hospital stay. Effects of conventional pain management strategies, such as femoral nerve block and fascia iliaca block, are inadequate in some cases. CASE PRESENTATION: THA was planned for 2 patients with osteoarthritis. In addition to general anesthesia, continuous pericapsular nerve group (PENG) block and lateral femoral cutaneous nerve (LFCN) block were performed for postoperative pain management. Numerical rating scale (NRS) scores measured at rest and upon movement were low at 2, 12, 24, and 48 h postoperatively, suggesting that the treatments were effective for managing postoperative pain. The Bromage score at postoperative days (POD) 1 and 2 was 0. CONCLUSION: Continuous PENG block and LFCN block were effective for postoperative pain management in patients who underwent THA. PENG block did not cause postoperative motor blockade.

Effectiveness of a Walking Program Involving the Hybrid Assistive Limb Robotic Exoskeleton Suit for Improving Walking Ability in Stroke Patients: Protocol for a Randomized Controlled Trial.

BACKGROUND: Gait disturbance often occurs in stroke survivors. Recovery of walking function is challenging, as some gait disturbance due to hemiparesis often remains even after rehabilitation therapy, presenting a major obstacle towards regaining activities-of-daily-living performance and achieving social reintegration. OBJECTIVE: This study aims to clarify the effectiveness of a walking program involving the wearable Hybrid Assistive Limb (HAL-TS01) robotic exoskeleton for improving walking ability in stroke patients with hemiparesis and stagnant recovery despite ongoing rehabilitation. METHODS: This is a multicenter, randomized, parallel-group, controlled study (HAL group, n=27; control group, n=27). The study period includes preintervention observation (until stagnant recovery), intervention (HAL-based walking therapy or conventional rehabilitation; 5 weeks), and postintervention observation (2 weeks). Following provision of informed consent and primary registration, the patients undergo conventional rehabilitation for preintervention observation, during which the recovery of walking ability is monitored to identify patients with stagnant recovery (based on weekly assessments using the 10-meter maximum walking speed [MWS] test). Patients with an MWS of 30-60 m/minute and insufficient weekly improvement in MWS undergo secondary registration and are randomly assigned to undergo HAL-based walking therapy (HAL group) or conventional rehabilitation (control group). The primary outcome is the change in MWS from baseline to the end of the 5-week intervention. RESULTS: This study began in November 2016 and is being conducted at 15 participating facilities in Japan. CONCLUSIONS: Assessments of walking ability vary greatly and it is difficult to define the threshold for significant differences. To reduce such variability, our study involves conducting conventional rehabilitation to the point of saturation before starting the intervention. Stagnation in the recovery of walking ability despite conventional rehabilitation highlights the limits of current medical care. The present study may bring evidence that HAL-based therapy can overcome such limitations and induce added recovery of walking ability, which would promote the use of HAL technology in the clinical setting. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000024805; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000028545.

Two cases of compartment syndrome of the lower extremities during surgery for gynecological malignancies.

Two cases of compartment syndrome of the lower extremities occurring during surgery for gynecological malignancies are reported. In addition to the risk from being in the lithotomy position for over 4 h, these two cases were believed to have been caused by the combined use of a disposable wound retractor and abdominal retractors to secure the operative field. This conclusion is based on the fact that an abrupt increase in partial pressure of end-tidal CO2 (ETCO2) was observed when wound drapes and abdominal retractors were removed approximately 4 h after the start of surgery. Prolonged compression of the external iliac vein by a disposable wound retractor and abdominal retractors is believed to have induced congestion of the lower extremities, eventually resulting in compartment syndrome. To verify this, during subsequent surgeries of the same type, changes in the diameters of femoral arteries and veins when a disposable wound retractor and abdominal retractors were used were monitored using an ultrasound device, and the findings confirmed that changes in vascular diameter do occur.

Significant associations between hemostatic/fibrinolytic systems and accumulation of cardiovascular risk factors in Japanese elementary schoolchildren.

The aim of this study was to establish the reference values of hemostatic/fibrinolytic markers and investigate their relationship with physical constitution and cardiovascular risk factors in a normal schoolchildren population. This study comprised 148 healthy Japanese children aged 9-10 years (males 73; females 75). We performed laboratory tests including blood levels of leptin, high-sensitive C-reactive protein (hs-CRP), hemostatic and fibrinolytic markers [plasminogen activator inhibitor 1 (PAI-1), coagulation factor VII (FVII), coagulation factor X (FX), fibrinogen (Fbg), protein C, protein S], as well as common biochemical markers in the morning after an overnight fast. We investigated the mean, 10th, 50th and 90th percentile values of these markers. All parameters were compared between two groups, that is those with body mass index (BMI) 90th percentile or higher and BMI less than 90th percentile, and between subgroups based on the number of cardiovascular risk factors. Multiple-linear regression was used to assess associations between these hematological parameters and the components related to metabolic syndrome (MetS). Alanine aminotransferase (ALT), uric acid, leptin, hs-CRP, and all hemostatic/fibrinolytic markers (PAI-1, FVII, FX, Fbg, protein C, protein S) tested were significantly higher in the group with BMI 90th percentile or higher, and increased with accumulation of cardiovascular risk factors. Multiple-linear regression analysis showed that these values were associated with one or more components related to MetS. Reference values of hemostatic/fibrinolytic markers in Japanese schoolchildren were obtained. Many hemostatic/fibrinolytic markers showed significant association with BMI and accumulation of cardiovascular risk factors in normal Japanese schoolchildren.

Effects of nitrous oxide on the production of cytokines and chemokines by the airway epithelium during anesthesia with sevoflurane and propofol.

The aim of this study was to evaluate the effects of nitrous oxide (a gaseous anesthetic) on the in vivo production of inflammatory cytokines and chemokines by the airway epithelium, when combined with sevoflurane or propofol. Subjects undergoing simple or segmental mastectomy were randomly assigned to the sevoflurane and nitrous oxide, sevoflurane and air, propofol and nitrous oxide, or propofol and air group (all n=13). Epithelial lining fluid (ELF) was obtained using the bronchoscopic microsampling method prior to and following the mastectomy to enable measurement of the pre- and post-operative levels of certain inflammatory cytokines and chemokines using a cytometric bead array system. Notably, the levels of interleukin (IL)-1ß, IL-8 and monocyte chemotactic protein-1 (MCP-1) in the ELF were significantly increased following the operations which involved the inhalation of sevoflurane and nitrous oxide, although the levels of these molecules were not significantly changed by the inhalation of sevoflurane and air. Furthermore, the IL-12p70 levels were significantly reduced in the ELF following the operations that involved the inhalation of sevoflurane and air, although the IL-12p70 levels were not significantly changed by the inhalation of nitrous oxide and sevoflurane. These observations suggest that the combination of sevoflurane and nitrous oxide induces an inflammatory response (increased production of IL-1ß, IL-8 and MCP-1) and suppresses the anti-inflammatory response (reduced production of IL-12p70) in the local milieu of the airway. Thus, the combination of these compounds should be carefully administered for anesthesia.

Perioperative management for a patient with hypermagnesemia-induced shock with perforative peritonitis.

We present a case of hypermagnesemia accompanied by perforative peritonitis. A 79-year-old woman took magnesium citrate as part of the pretreatment on the day before a scheduled colonoscopy. She developed nausea and muscle weakness, and she was complaining of left abdominal pain. Consciousness gradually worsened and she developed shock. Intestinal obstruction was recognized on abdominal X-ray and computed tomography (CT), and peritonitis was suspected. An exploratory laparotomy was scheduled for diagnosis and treatment. In the operating room, arterial blood gas analysis showed metabolic acidosis and hypermagnesemia (Mg: 2.75 mmol/l, normal range: 0.1-1.5 mmol/l). On laparotomy, adhesion around the sigmoid colon and turbid ascites were recognized. But we could not detect the apparent region of perforation. Based on these findings and the presence of hypermagnesemia, we diagnosed that the shock was caused by peritonitis due to intestinal micro-perforation, and by hypermagnesemia due to absorption of laxative. We started to treat for metabolic acidosis, and to manage the hypermagnesemia by calcium hydrochloride administration and by continuous hemodiafiltration after the operation. On day 4 of the illness, the plasma Mg level was normalized. She was extubated on day 12, and discharged on day 84. This case with complicated clinical symptoms reaffirms the difficulty and importance of making a diagnosis quickly by collecting various data.

[Exposure to nitrous oxide may increase airway inflammation during sevoflurane anesthesia].

BACKGROUND: The purpose of this study was to examine whether nitrous oxide increases the inflammatory reaction in the airway in patients undergoing minor surgery. METHODS: Twenty patients were divided into two groups at random. The patients were anesthetized by either sevoflurane with air (Group A: n=10) or sevoflurane with nitrous oxide (Group G: n=10). In addition, all patients were mechanically ventilated. Epithelial lining fluid (ELF) specimens were obtained by bronchoscopic microsampling method at both the beginning and end of surgery. The concentrations of interleukin (IL)-6 and IL-8 in the ELF were measured by enzyme immunometric assay(ELISA). RESULTS: Significant differences were observed in the IL-8 concentrations in the ELF of the G group at the end of surgery in comparison with those seen at the beginning of surgery in the G group (P < 0.05), and at the end of surgery in the A group (P < 0.05). The IL-6 levels were not measured in either group. CONCLUSIONS: The pulmonary immunologic function changed progressively during anesthesia, surgery and positive pressure mechanical ventilation. The data from this study suggest that the immune ability of the lung may possibly change due to the administration of nitrous oxide. As a result, our findings suggest that the postoperative inflammatory reaction in the lung may increase when sevoflurane plus nitrous oxide are used during general anesthesia.

Nicorandil decreases cardiac events during and after noncardiac surgery.

STUDY OBJECTIVE: To assess whether nicorandil reduces the likelihood of cardiac events during and after intermediate risk surgery. DESIGN: Multicenter study. SETTING: 13 hospitals in Japan. PATIENTS: Intermediate-risk patients were identified by the presence of risk factors such as angina, a history of myocardial infarction, heart failure, diabetes mellitus, and abnormal electrocardiography (ECG). INTERVENTIONS: Nicorandil was given to these patients during the operation. MEASUREMENTS AND MAIN RESULTS: Cardiac events during the operation and the following 5 days were monitored. The frequency of cardiac events in nicorandil-treated patients was compared with those in nontreated patients. Eighty-four patients received nicorandil during surgery and 237 patients received standard care. Cardiac events in the nicorandil-treated group occurred less frequently both during the operation (odds ratio, 0.15; 95% confidence interval, 0.03-0.76; P=0.02) and after it (odds ratio, 0.24; 95% confidence interval, 0.06-0.90; P=0.04). CONCLUSIONS: Nicorandil reduces the frequency of cardiac events in patients undergoing noncardiac surgery, both during and after the operation.

[A case of latex allergy caused by hypersensitivity to the latex-containing facemask].

We experienced anesthetic management of a 2 year-old girl with Pierre-Robin syndrome. She had received respiratory support for 6 months from the birth. As soon as we induced general anesthesia, she had a skin rash. We suspected that this rash was caused by hypersensitivity to the latex-containing facemask. We stopped anesthesia and postponed operation. After a month, operation was performed under general anesthesia using latex-free anesthetic circuit and equipments. Perioperative course was uneventful. Since the first report in 1979, the number of patients with latex allergy has progressively been increasing. It has been reported that latex allergy occurs in persons considered at high risk for latex allergy including patients with spina bifida, urogenital abnormalities and atopic dermatitis, and in health care workers and rubber industry workers. If patients suspected of having latex allergy undergo surgical procedures, anesthesiologists must check patients' past history and possibility of chronic exposure to latex products. In these cases, preoperative preparation is essential and thorough precaution should also be taken to avoid life-threatening allergic reaction.

[Clinical effects of steroid in the perioperative management of patients undergoing extensive esophagectomy].

We investigated clinical effects of steroid during perioperative management of 40 patients undergoing extensive radical surgery for esophageal cancer. Methylprednisolone 500 mg was administered in 20 patients preoperatively (the steroid group). The non-steroid group received no steroid. Clinical parameters checked were pre- and postoperative changes of P/F ratio, fluid balance and postoperative epidural analgesia in the two groups. The steroid group had significantly more optimal P/F ratio postoperatively. Fluid balance was significantly more favorable, and postoperative period was significantly less painful in the steroid group. We assumed that steroid had prevented enhancement of vascular permeability and also had suppressed secretion of inflammatory mediators. We conclude that preoperative administration of steroid is beneficial for the perioperative management of patients undergoing extensive surgery.