Surgical rationalization of living donor liver transplantation by abolition of hepatic artery reconstruction under a fixed microscope

The small diameter of the hepatic artery is one of the complexities of living donor liver transplantation (LDLT). We analyzed whether the direct suture technique using surgical loupes can simplify the operative process for LDLT compared with fixed microscopic reconstruction. We applied the direct technique to rationalize the operative process and abolished routine microsurgery from 2004. Two hundred and nine LDLT with a postoperative period over 34 months were carried out from 1996 to 2008. The patients were divided into two groups: the micro group (children: 20, adults: 72) and the non‐micro group (children: 12, adults: 97). Running anastomosis was undertaken in the non‐micro group. The anastomotic size of the children was significantly smaller than that of the adults, but larger than 2 mm (2.38 ± 0.4 vs. 2.7 ± 0.47 mm, p = 0.0005). By appropriate choice of the proximal artery, direct anastomosis is possible even in children. Early complications occurred in seven cases in the micro group, but none occurred in the non‐micro group (p < 0.05). Significant reductions were observed in operation time (p < 0.0001), blood loss (p < 0.05), and hospital stay (p < 0.01) in the non‐micro group. Non‐microscopic anastomosis is useful for the rationalization of LDLT.     

Combination of familial Barlow’s disease with bilateral axillary artery aneurysms in two brothers

We encountered two brothers with a combination of Barlow’s disease and bilateral axillary artery aneurysms who were operated on during their third decade of life. A symmetrical form of true bilateral axillary artery aneurysms is uncommon. Recurrent mitral regurgitation was presented in the older brother with an endocardial defect in the left atrium, suggesting connective tissue fragility. A hereditary connective tissue disorder was strongly suspected because of the similar presentation and an unusual cluster of pathologies in siblings. Careful follow-up is required to detect recurrence of mitral regurgitation or aneurysm formation in other vessels.     

Applicability of the prehospital termination of resuscitation rule in an area dense with hospitals in Tokyo: a single-center,retrospective, observational study : Is the pre hospital TOR rule applicable in Tokyo?

Background

It is unclear whether the prehospital termination of resuscitation (TOR) rule is applicable in specific situations such as in areas extremely dense with hospitals.

Objectives

The objective of the study is to assess whether the prehospital TOR rule is applicable in the emergency medical services system in Japan, specifically, in an area dense with hospitals in Tokyo.

Methods

This study was a retrospective, observational analysis of a cohort of adult out-of-hospital cardiopulmonary arrest (OHCA) patients who were transported to the University of Tokyo Hospital from April 1, 2009, to March 31, 2011.

Results

During the study period, 189 adult OHCA patients were enrolled. Of the 189 patients, 108 patients met the prehospital TOR rule. The outcomes were significantly worse in the prehospital TOR rule–positive group than in the prehospital TOR–negative group, with 0.9% vs 11.1% of patients, respectively, surviving until discharge (relative risk [RR], 1.11; 95% confidence interval [CI], 1.03-1.21; P = .0020) and 0.0% vs 7.4% of patients, respectively, discharged with a favorable neurologic outcome (RR, 1.08; 95% CI, 1.02-1.15; P = .0040). The prehospital TOR rule had a positive predictive value (PPV) of 99.1% (95% CI, 96.3-99.8) and a specificity of 90.0% (95% CI, 60.5-98.2) for death and a PPV of 100.0% (95% CI, 97.9-100.0) and a specificity of 100.0% (95% CI, 61.7-100.0) for an unfavorable neurologic outcome.

Conclusions

This study suggested that the prehospital TOR rule predicted unfavorable outcomes even in an area dense with hospitals in Tokyo and might be helpful for identifying the OHCA patients for whom resuscitation efforts would be fruitless.     

Motivations and barriers to implementing electronic health records and ED information systems in Japan

Background

Although electronic health record systems (EHRs) and emergency department information systems (EDISs) enable safe, efficient, and high-quality care, these systems have not yet been studied well. Here, we assessed (1) the prevalence of EHRs and EDISs, (2) changes in efficiency in emergency medical practices after introducing EHR and EDIS, and (3) barriers to and expectations from the EHR-EDIS transition in EDs of medical facilities with EHRs in Japan.

Materials and methods

A survey regarding EHR (basic or comprehensive) and EDIS implementation was mailed to 466 hospitals. We examined the efficiency after EHR implementation and perceived barriers and expectations regarding the use of EDIS with existing EHRs. The survey was completed anonymously.

Results

Totally, 215 hospitals completed the survey (response rate, 46.1%), of which, 76.3% had basic EHRs, 4.2% had comprehensive EHRs, and 1.9% had EDISs. After introducing EHRs and EDISs, a reduction in the time required to access previous patient information and share patient information was noted, but no change was observed in the time required to produce medical records and the overall time for each medical care. For hospitals with EHRs, the most commonly cited barriers to EDIS implementation were inadequate funding for adoption and maintenance and potential adverse effects on workflow. The most desired function in the EHR-EDIS transition was establishing appropriate clinical guidelines for residents within their system.

Conclusion

To attract EDs to EDIS from EHR, systems focusing on decreasing the time required to produce medical records and establishing appropriate clinical guidelines for residents are required.     

Diagnostic ability of 99mTc-HSA-DTPA scintigraphy in combination with SPECT/CT for gastrointestinal bleeding

Purpose

Gastrointestinal (GI) bleeding scintigraphy in combination with single-photon emission computed tomography/computed tomography (SPECT/CT) remains to be studied in detail. This study aimed to examine the diagnostic ability of this tool.

Methods

GI bleeding scintigraphy using ^99mTc-human serum albumin-diethylenetriaminepentaacetic acid was performed for 38 patients with suspected GI bleeding. Twenty-four patients were diagnosed using planar images alone (planar group) and 14 patients were diagnosed using planar images and additional SPECT/CT images (planar + SPECT/CT group). The diagnostic ability of each method was analyzed.

Results

GI bleeding was observed in 20 of the 38 patients. For the existence of GI bleeding, planar images alone showed a sensitivity of 70%, specificity of 93%, positive predictive value (PPV) of 88%, negative predictive value (NPV) of 81%, and an overall accuracy of 83%, whereas planar images + SPECT/CT showed a sensitivity of 100%, specificity of 75%, PPV of 91%, NPV of 100%, and an overall accuracy of 93%. The source of bleeding was accurately diagnosed in 50% in the planar group and 78% in the planar + SPECT/CT group. In the planar + SPECT/CT group, 44% of the evaluable patients showed correct localization of the source of GI bleeding by additional SPECT/CT images, although planar images only showed incorrect localization.

Conclusion

GI bleeding scintigraphy in combination with SPECT/CT is a noninvasive and useful tool for the examination of GI bleeding.     

Influence of Hip Joint Position on Muscle Activity during Prone Hip Extension with Knee Flexion

[Purpose] This study investigated the selective activation of the gluteus maximus during a prone hip extension with knee flexion exercise, with the hip joint in different positions. [Subjects] The subjects were 21 healthy, male volunteers. [Methods] Activities of the right gluteus maximus, right hamstrings, bilateral lumbar erector spinae, and bilateral lumbar multifidus were measured using surface electromyography during a prone hip extension with knee flexion exercise. Measurements were made with the hip joint in each of 3 positions: (1) a neutral hip joint position, (2) an abduction hip joint position, and (3) an abduction with external rotation hip joint position. [Results] Gluteus maximus activity was significantly higher when the hip was in the abduction with external rotation hip joint position than when it was in the neutral hip joint and abduction hip joint positions. Gluteus maximus activity was also significantly higher in the abduction hip joint position than in the neutral hip joint position. Hamstring activity was significantly lower when the hip was in the abduction with external rotation hip joint position than when it was in the neutral hip joint and abduction hip joint positions. [Conclusion] Abduction and external rotation of the hip during prone hip extension with knee flexion exercise selectively activates the gluteus maximus.Key words: Prone hip extension with knee flexion, Hip joint position, Electromyography     

Role of Interleukin-33 in Innate-Type Immune Cells in Allergy

Interleukin-33 (IL-33), a member of the IL-1 cytokine family, is preferentially and constitutively expressed in epithelial cells, and it is especially localized in the cells' nucleus. The nuclear IL-33 is released by necrotic cells after tissue injury and/or trauma, and subsequently provokes local inflammation as an alarmin, like high-mobility group box protein-1 (HMGB-1) and IL-1α. IL-33 mainly activates Th2 cells and such innate-type immune cells as mast cells, basophils, eosinophils and natural helper cells that express IL-33R (a heterodimer of IL-1 receptor-like 1 [IL-1RL1; also called ST2, T1, Der4, fit-1] and IL-1 receptor accessory protein [IL-1RAcP]). That activation causes the cells to produce Th2 cytokines, which contribute to host defense against nematodes. On the other hand, excessive and/or inappropriate production of IL-33 is also considered to be involved in the development of such disorders as allergy. In this review, we summarize current knowledge regarding the pathogenic roles of IL-33 in the development of allergic inflammation by focusing on its effects on innate-type immune cells.