Successful closure of intractable tracheoesophageal fistula using a combination of a modified silicon stent and metallic stents.

Although surgery is the usual management strategy for acquired benign tracheoesophageal fistula, sometimes this approach is contraindicated or the patient declines surgical management. In this report, we describe a case of a patient with tracheoesophageal fistula at the level of the carina due to bronchial arterial infusion chemotherapy. Closure could not be achieved in response to multiple treatment strategies, including airway stenting, esophageal stenting, occlusion with microcoils, or cyanoacrylate glue. We subsequently achieved closure of this fistula through the combination of a modified silicon stent and metallic stents.

Lower incidence of Bronchiolitis obliterans in allogeneic hematopoietic stem cell transplantation with reduced-intensity conditioning compared with myeloablative conditioning.

Bronchiolitis obliterans (BO) is one of the most devastating complications after allogeneic stem cell transplantation (HSCT). However, its true pathogenesis is still to be elucidated. We conducted this study to find whether tissue damage due to high-dose chemo-radiotherapy is related to its pathogenesis. In all, 144 patients who received allogeneic HSCT between May 1999 and October 2001, and survived more than 80 days after transplant, were analyzed. Clinical course, pulmonary function tests, imaging studies including CT scan, and pathology results were reviewed. The overall incidence of BO was 9.7% (14/144). The cumulative incidence of BO at 2 years after transplant was 17% with myeloablative conditioning, and 2.3% with reduced intensity conditioning (P=0.024). Multivariate analysis showed that myeloablative conditioning was the only factor which affected the incidence of BO. Development of BO did not significantly affect the overall survival of patients. However, if they developed BO earlier than 200 days post transplant, the prognosis was significantly worse than if they developed it later than 200 days post transplant (P=0.003) or if they did not develop BO (P=0.002). Our results imply that tissue damage secondary to intensive chemo-radiotherapy may contribute to the pathogenesis of BO.

A short daytime test using correlation dimension for respiratory movement in OSAHS.

In order to examine the pathology in patients with obstructive sleep apnoea/hypopnoea syndrome (OSAHS), the nonlinear properties of respiratory movement and breath-to-breath variations during resting wakefulness with eyes closed was investigated. Recording of the respiratory movement using inductive plethysmography was performed on 14 patients with OSAHS and 13 control subjects for 2 h in the supine position during daytime. To calculate the correlation dimension (D2) for respiratory movement, an algorithm proposed by Grassberger and Procaccia was applied. The indices of breath-to-breath variations were estimated. To calculate D2 and breath-to-breath variations, two different segments were selected (200 s each). The value of D2 for respiratory movement in patients with OSAHS was significantly greater than that in control subjects. In the case of > or = 2.0 of D2 for respiratory movement, the sensitivity and specificity of detecting the presence of OSAHS was 85.7% and 76.9%, respectively. On the basis of breath-to-breath variations, only the coefficient of variation of expiratory time for respiratory movement in patients with OSAHS was significantly greater than that in the control subjects. In conclusion, the measurements of correlation dimensions for respiratory movement with a brief period during wakefulness may be a useful index for identifying patients with obstructive sleep apnoea/hypopnoea syndrome.

Nonlinear behavior of human respiratory movement during different sleep stages.

To investigate the nonlinear properties of respiratory movement during different sleep stages, we applied an algorithm proposed by Grassberger and Procaccia to calculate the correlation dimension in rapid eye movement and non-rapid eye movement sleep. We also tested for nonlinearity in respiratory movement by comparing the correlation dimension for the original data with that for surrogate data. The study population included eight healthy volunteers. We recorded respiratory movement and the sleep electroencephalogram for 8 h. The correlation dimension for respiratory movement was 3.28+/-0.19 (mean +/- SD) during rapid eye movement sleep, 2.31+/-0.21 during light sleep (stage I) and 1.64+/-0.25 during deep slow-wave sleep (stage IV). Thus, the correlation dimension differed significantly by sleep stage (p < 0.001): it was least during stage IV sleep and greatest during REM. The correlation dimension for the original data also differed from that for surrogate data, confirming nonlinearity in original data. The results suggest that the nonlinear dynamics of respiratory movement in sleep changes with sleep stage, presumably due to the information processing by the cerebral cortex. The increased correlation dimension for respiratory movement in REM sleep may be related to increased cortical information processing associated with dreaming.

Changing the dosing schedule minimizes the disruptive effects of interferon on clock function.

The effectiveness and toxicity of many drugs vary depending on the relationship between the dosing schedule and the 24-hour rhythms of biochemical, physiological and behavioral processes. In addition, several drugs can cause alterations to the 24-hour rhythms leading to illness and altered homeostatic regulation. However, the mechanisms of this drug-based disruption of circadian 'clock' genes remain unclear. Here, we show the disruptive effect of interferon-alpha on the rhythm of locomotor activity, body temperature and clock-gene mRNA expression in the periphery and suprachiasmatic nuclei, a primary circadian pacemaker. The rhythmicity of clock genes and the photic induction of the Per gene in suprachiasmatic nuclei were disturbed by the repetitive administration of interferon-alpha. Moreover, alteration of clock function, a new concept of adverse effects, can be overcome by optimizing the dosing schedule to minimize adverse drug effects.

Theophylline chronotherapy of nocturnal asthma using bathyphase of circadian rhythm in peak expiratory flow rate.

We studied the efficacy of theophylline chronotherapy for nocturnal asthma using the changes of the circadian rhythms in peak expiratory flow rate (PEF). Eight patients with nocturnal asthma were evaluated for the periods with nocturnal symptoms and with an evening dose of theophylline administered daily. Patients recorded their PEF every 4 hours on one of the days (from 7:00 to 23:00 h) in each period. Circadian rhythms in PEF were examined using the single and group-mean cosinor method. Significant circadian rhythms in PEF were observed in the period with nocturnal symptoms. When nocturnal symptoms were present, the bathyphase of PEF was present between midnight and morning. A significant circadian rhythm disappeared or PEF amplitude decreased during theophylline chronotherapy. The circadian rhythm in PEF was altered according to the severity of the asthma. In patients with symptoms present between midnight and early morning, an evening dose of theophylline chronotherapy can be prophylactically used for nocturnal asthma attacks. Consideration of the circadian rhythm and bathyphase of PEF is useful in selecting appropriate chronotherapy for nocturnal asthma.

Human pulmonary dirofilariasis presenting as a small nodule with a cavity.

A 73-year-old woman had a 4-year history of lung fibrosis from collagen vascular disease. She presented with a complaint of dry cough. A chest radiograph showed a 2-cm solitary pulmonary nodule with a small cavity in the right lower lobe. Preoperatively, we performed computed tomography of the chest and measured tumor markers. Video-assisted thoracotomy was performed because we could not rule out lung cancer. Pathologic analysis confirmed the presence of a granuloma with Dirofilaria immitis. In Japan, the incidence of human dirofilariasis has steadily increased and must be considered in the workup of cavitary pulmonary nodules.

[Anesthetic management of an extremely low birth weight neonate for two thoracic surgeries of patent ductus arterious and coarctation of the aorta].

An extremely low birth weight (832 g) and 29 gestational week neonate underwent surgical ligation of patent ductus arterious 20 days after birth and repair of coarctation of the aorta two months after the first operation. She developed asphyxia neonatorum and was artificially ventilated because of IRDS and attack of apnea. At the first operation, anesthesia was maintained with fentanyl and sevoflurane. The only perioperative complication was severe hypothermia (34.5 degrees C). At the second operation, anesthesia maintenance was identical to the first operation. The only perioperative complication was mild hyperthermia (37.7 degrees C). The key points of anesthetic management were the use of a low inspired oxygen fraction to avoid retrolental fibroplasia at a gestational age before 32 weeks and management of the baby's temperature.

Circadian rhythm in peak expiratory flow: alteration with nocturnal asthma and theophylline chronotherapy.

We investigated changes in the circadian rhythm of peak expiratory flow (PEF) in seven persons with nocturnal asthma for a 24h span when (1) they were symptom free and their disease was stable, (2) their asthma deteriorated and nocturnal symptoms were frequent, and (3) they were treated with theophylline chronotherapy. Subjects recorded their PEF every 4h between 07:00 and 23:00 one day each period. Circadian rhythms in PEF were assessed using the group-mean cosinor method. The circadian rhythm in PEF varied according to asthma severity. Significant circadian rhythms in PEF were detected during the period when asthma was stable and when it was unstable and nocturnal symptoms were frequent. When nocturnal symptoms were present, the bathyphase (trough time) of the PEF rhythm narrowed to around 04:00; during this time of unstable asthma, the amplitude of the PEF pattern increased 3.9-fold compared to the symptom-free peiiod. No significant group circadian rhythm was detected during theophylline chronotherapy. Evening theophylline chronotherapy proved to be prophylactic for persons whose symptoms before treatment had occurred between midnight and early morning. Changes in the characteristics of the circadian rhythm of PEF, particularly amplitude and time of bathyphase, proved useful in determining when to institute theophylline chronotherapy to avert nocturnal asthma symptoms.

Effects of pneumoperitoneum on cardiac autonomic nervous activity evaluated by heart rate variability analysis during sevoflurane, isoflurane, or propofol anesthesia.

BACKGROUND: The effects of pneumoperitoneum on the activity of the cardiac autonomic nervous system have not been completely understood. METHODS: In this study, 45 unpremedicated adult patients who underwent laparoscopic cholecystectomy were anesthetized with either 3.5% sevoflurane, 2% isoflurane, or 8 mg/kg/h propofol (15 patients in each group). The status of cardiac autonomic nervous activity was evaluated by heart rate variability analysis three times: once when the patient was awake, once after induction of general anesthesia, and once after insufflation for pneumoperitoneum. Intra-abdominal pressure was maintained automatically at 10 mm Hg by a carbon dioxide (CO(2)) insufflator. For each measurement, electrocardiogram was recorded for 256 s and played back offline to detect R-R intervals. Power spectral analysis of heart rate variability was applied, and the low-frequency (LF, 0.04-0.15 Hz) and high-frequency (HF, 0.15-0. 40 Hz) bands of the spectral density of the heart rate variability were obtained from a power spectra of R-R intervals using the fast-Fourier transform algorithm. The HF/LF ratio also was analyzed. RESULTS: Measurements of heart rate variability in the three groups showed similar change. Although the power of HF, which represents parasympathetic nervous activity, did not change, the power of LF, which represents both sympathetic and parasympathetic nervous activity, decreased during the anesthetized stage and increased during the insufflated stage. The HF/LF ratio, which represents the balance of parasympathetic and sympathetic activity, increased after induction of general anesthesia, and decreased after insufflation. CONCLUSIONS: Our results suggest that pneumoperitoneum increases sympathetic cardiac activity. The choice of general anesthetic did not seem to have a major influence on the change in the cardiac autonomic nervous system after induction of pneumoperitoneum for laparoscopic cholecystectomy.

Clinical and in vitro evaluation of membrane humidifier that does not require addition of water.

It is well known that conventional bubbling humidifiers are capable of producing micro-aerosols contaminated with bacteria. We developed a unique humidifier, named a membrane humidifier, that does not require an external water supply. This new system obtains moisture from room air. We investigated the clinical and in vitro evaluation of the membrane humidifier. Ten patients with chronic pulmonary disease participated in the study. We evaluated the partial pressure of oxygen in arterial blood (PaO2) of 10 patients who used the new device. We conducted an in vitro study to determine whether the device could prevent the bacterial contamination of humidified-oxygen. We passed compressed air contaminated with Pseudomonas aeruginosa outside the hollow fibres of the membrane humidifier, and the humidified-oxygen passed inside the hollow fibres was sampled into nutrient broth periodically for 10 days. We also compared the relative humidity of oxygen humidified by a membrane humidifier with that of oxygen humidified by a bubbling humidifier. There was no significant difference between measured PaO2 while breathing oxygen humidified using a membrane humidifier and that while breathing oxygen humidified using a bubbling humidifier. Cultures of the humidified-oxygen passed through the hollow fibres were negative for bacteria. The membrane humidifier could produce good humidification. The new device appeared to prevent bacterial contamination, and may help to reduce the risk of infection in patients at hospital and home.

[The clinical usefulness of predicting difficult endotracheal intubation].

We conducted several tests for predicting the difficult intubation airway in 476 patients excluding those with neck disease and anatomical abnormalities. The evaluation was performed using four methods. 1. The size of the tongue in relation to the oral cavity (Mallampani test: M-T). 2. The hyomental distance (H-D). 3. The thyromental distance (T-D). 4. The atranto-occipital joint extension (AOJE). Of these four methods, M-T was the best predictor of a difficult airway. However, all of these four methods may be good predictors, employing modified criteria which include M-T = class 2, 3, 4, H-D = less than 3.0 cm, T-D = less than 6.0 cm, and AOJE = less than 35 degrees.

Poor renal accumulation of 99mTc-DMSA in idiopathic tubular proteinuria.

In Japanese patients idiopathic tubular proteinuria presents mainly as asymptomatic tubular low molecular weight proteinuria. This disease has recently been shown to resemble Dent's disease which is characterized by tubular proteinuria, hypercalciuria, rickets and eventual renal failure. We report on 4 children with idiopathic tubular proteinuria. Although they had normal renal function, as evidenced by serum creatinine or creatinine clearance, they had very poor renal accumulation of 99mTc-DMSA and the presence of large amounts of tracer in the bladder. Additionally, the patient with the largest amounts of tubular proteinuria had the poorest renal accumulation of the 4 patients. The renal accumulation of tracer decreased with time from a maximum at 10 min after injection. These findings demonstrate that the tracer, once taken to be confined to the proximal tubular cells, is immediately excreted to the tubular lumen. We suggest that poor renal accumulation of 99mTc-DMSA is very important in elucidating the mechanism of idiopathic tubular proteinuria, and that 99mTc-DMSA renoscintigraphy is useful in the evaluation of the patient's renal function over time.

Clinical efficacy of the FLUTTER device for airway mucus clearance in patients with diffuse panbronchiolitis.

Expectoration of mucus is important in preventing the development of airway inflammation in patients with diffuse panbronchiolitis (DPB). To evaluate the clinical efficacy of the FLUTTER device in clearing mucus from the airways of patients with DPB who have difficulty expectorating, we assessed pulmonary function and symptoms in patients treated with FLUTTER. Eight patients in a stable clinical condition with DPB were included in the study. The study was divided into two consecutive, 1-week periods. The initial week was an observation week. During the following week, patients used FLUTTER four times daily. Expectorated sputum was collected in a container and weighed every day during 2 weeks. Pulmonary function, partial oxygen pressure and partial carbon dioxide pressure in arterial blood were measured in all patients on the last day of the observation week and the FLUTTER treatment week. A symptom score for difficulty of expectoration was determined by questionnaire. A pneumothorax developed in one patient during using FLUTTER. The mean daily sputum weight and peak expiratory flow rate increased significantly after treatment with FLUTTER ( P< 0.04 and P< 0.02, respectively). Symptom score improved significantly after using FLUTTER ( P< 0.02). We conclude that the use of FLUTTER is effective in clearing mucus from the airways. However, the development of a pneumothorax may complicate use of the procedure in some cases.

[Primary pulmonary aspergilloma presenting as an isolated nodular shadow].

A 55-year-old man was admitted to our hospital because of an abnormal shadow at the right hilum on a chest radiograph. The chest radiograph and the chest CT scan showed a nodular showed in the right S6. There was no air-crescent sign in the shadow, but CT-guided percutaneous needle biopsy led to the diagnosis of pulmonary aspergillosis. Anti-fungal agents (miconazole, fluconazole, and itraconazole) were given but the patient's condition did not improve. Surgical resection was done and the postoperative course was uneventful. The resected lung had a bronchiectatic area with a fungus ball. Attempts to culture the fungus ball were not successful. Histologic examination revealed conidial heads characteristic of Aspergillus fumigatus. This case is interesting because the pulmonary aspergilloma appeared as an isolated nodular shadow. This might have been a case of primary pulmonary aspergilloma.

[A case of life-threatening anaphylactoid reaction caused by povidone-iodine].

A 64 year-old man developed life-threatening anaphylactoid reaction caused by povidone-iodine during induction of anesthesia for elective coronary artery bypass graft surgery. While he had a history of cardiac arrest caused by iodine, he could tolerate contrast material and povidone-iodine for pre-operative coronary angiography with pretreatment of H1 and H2 receptor blockades and methylprednisolone. During the operation and postoperative care we could manage cardiac failure by continuous monitoring of cardiac output (CCO) using pulsed-thermodilution method. We recommend prophylactic use of H1 and H2 receptor blockades for surgical patients who may be at risk for anaphylaxis or anaphylactoid reaction.

Clinical utility of a newly developed pressure swing adsorption-type oxygen concentrator with a membrane humidifier.

The clinical utility of the newly developed pressure swing adsorption (PSA)-type oxygen concentrator with a membrane humidifier that does not require added water for humidification was evaluated in 13 patients with chronic pulmonary disease who were receiving long-term oxygen therapy. PaO2 and the relative humidity were measured when the patient breathed air and oxygen from the new device via a nasal cannula. After using the new concentrator for 5 h, the patients were asked whether they experienced dry nasal passages or a dry throat. A significant difference between the PaO2 measured while the patients breathed room air and while they breathed oxygen from the new device was observed. A significant difference was observed between the relative humidity of room air (44.7 +/- 18.6%) and that of the oxygen flow (72.7 +/- 14.8%) from the new device. None of the patients experienced dry nasal passages, dry throat, or any other adverse effects. Since this new PSA-type oxygen concentrator with a membrane humidifier supplies well-humidified nasal oxygen without water, laborious cleaning of the container and changing of the water are not necessary, and may help to improve the patient's quality of life.

Efficacy of newly developed pressure swing adsorption type oxygen concentrator with membrane humidifier: comparison with conventional oxygen concentrator with bubble water humidifier.

To examine the clinical efficacy of a newly developed pressure swing adsorption (PSA) type oxygen concentrator with a membrane humidifier without added water for humidification, the new machine was compared with the conventional PSA type oxygen concentrator with bubble water humidifier in 10 patients with chronic pulmonary disease. Relative humidity, partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) in arterial blood were measured when the patient breathed air and oxygen from the oxygen concentrators. No significant difference between PaO2 while breathing oxygen flow from the new machine and that while breathing oxygen from the conventional oxygen concentrator was observed. All patients answered that there was no difference on subjective impression between breathing oxygen from the new machine and from the conventional oxygen concentrator. Sufficient relative humidity (above 50%) of oxygen flow was obtained by using membrane humidifier. Since this machine saves the troublesome procedures of cleaning the container and changing the water, it will be beneficial to the patients who use a PSA-type oxygen concentrator in their home.

[Evaluation of area at risk by 123I-BMIPP in patients with acute myocardial infarction].

The purpose of this study was to investigate the detection of area at risk of acute myocardial infarction (AMI) by 123I-BMIPP (BMIPP). 99mTc-tetrofosmin (TF) scintigraphy was performed on 13 patients with AMI with total coronary occlusion. BMIPP scintigraphy was done on the same patients within 1 week after successful reperfusion by direct PTCA. Activity of both tracers was scored in 8 basal, 8 midventricular and 2 apical segments, using a four-point grading system as defect score: 3 = defect, 2 = severely low uptake, 1 = slightly low uptake, 0 = normal. Extent score (ES) was defined as a total number of segment which deteriorated of uptake, and severity score (SS) was defined as a total score of defect score. ES of BMIPP was 6.5 +/- 2.4 and that of TF was 7.5 +/- 2.4. ES of BMIPP was smaller than that of TF. A ratio of BMIPP/TF was 0.86 +/- 0.18. SS of BMIPP was 16.2 +/- 6.0 and that of TF was 19.2 +/- 5.6. SS of TF was larger than that of BMIPP. A ratio of BMIPP/TF was 0.83 +/- 0.18. A correlation of ES and SS between TF and BMIPP was excellent. BMIPP showed ischemic area by culprit lesion and infarct area clearly. We concluded that BMIPP could indicate area at risk.