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Background: Inducible laryngeal obstruction (ILO) refers to respiratory disorders caused by airflow limitation in the larynx, including vocal cord dysfunction, and may sometimes be misdiagnosed as bronchial asthma (BA). Here, we report the case of an 11-year-old boy diagnosed with BA in infancy. He was referred to our Allergy Center and was taking a high dose of inhaled corticosteroids (ICS) due to frequent coughing from the age of 10 years and persistent coughing following COVID-19 infection at the age of 11. However, the patient continued to experience frequent coughing attacks and repeated visits to the emergency department after inhalation of β 2 -stimulants failed to improve his cough. We admitted him to the allergy center for examinations to assess the BA severity. In the airway hypersensitiveness test, saline inhalation performed prior to methacholine inhalation caused expiratory stridor and respiratory distress in the larynx, which worsened with β 2 -stimulant inhalation. Based on these results, we ruled out BA and diagnosed ILO. We instructed him on breathing maneuvers, and he was able to respond appropriately when symptoms appeared. We then started reducing his ICS dose.

Nivolumab is known to cause immune-related interstitial lung diseases. A 44-year-old woman developed multiple lung metastases 5 years after breast cancer resection. She was treated with docetaxel/trastuzumab/pertuzumab and obtained a complete response. This was a case of off-label use of nivolumab as an immune checkpoint inhibitor evaluated in a private clinic. After standard therapy with T-DM1, she developed fever and hypoxemia. Drug-induced pneumonia was suspected based on a ground-glass shadow finding in chest computed tomography. Drug-induced pneumonia may develop following molecular-targeted therapy delivered after nivolumab administration, and fatal cases have been reported. The antitumor effects of nivolumab for breast cancer have not been proven, and its off-label use may have possible adverse effects on future treatments.

Although there is no remarkable change of anesthetics or anesthesia methods in recent years, several new technologies are used for safety management of cardiac, lung or thoracic surgery. Stroke volume variation (SVV) monitoring indicates SVV, a parameter to optimize fluid infusion and is used to avoid edema or congestive heart damage due to over hydration. SmartPilot View, a pharmacokinetic simulator during anesthesia, represents the measured effective site concentration of anesthetics and contributes the optimization of induction and maintenance of anesthesia. Pressure controlled ventilation-volume guarantee (PCV-VG) is a ventilation mode that can secure preset tidal volume even under PCV to avoid hypoxemia and hypercapnia, even when unexpected airway pressure raised. AutoFlow system supplies tidal volume at the lowest airway pressure and has the function of maintaining tidal volume while keeping low airway pressure according to the change of pulmonary compliance. In 2017, we modified the position of cuff air delivery lumen while maintaining the strength and elasticity of double-lumen tube (DLT) made by a company to avoid deflation failure of bronchial cuff by our team.

Intraoperative complications regarding spinal cord stimulation (SCS) are dural or arachnoidal puncture, spinal or radicular injury and bleeding. Most common complications after SCS are malposition of epidural lead and unexpected device trouble. Other severe complica- tions are infection, hematoma and post dural puncture headache. Complications associated with radiofre- quency and pulsed radiofrequency are bleeding, infec- tion, tissue damage, sensory or motor disturbance and burn injury. And there is known spinal cord infarction as a severe complication. We should explain about the therapeutic procedure and associated complications to patients. Moreover, the immediate assessing of complications and appropriate treatments are necessary.

Thermography is an imaging method using the instrument to detect infrared rays emitted from the body surface, and to plot them as a distribution diagram of the temperature information. Therefore, a thermographic instrument can be assumed to measure the skin temperature of the diseased region. Such an instrument is a useful device for noninvasive and objective assessment of various diseases. Examination using a thermographic instrument can assess the autonomic dysfunction by measuring the skin blood flow involved with the sympathetic innervation. Thermography is useful in assisting the determination of the therapeutic effect. However, autonomic dysfunction should be confirmed correctly with the assessment of thermatome that shows abnormal thermal distribution in the region of the disease. Thermography should make noticeable the difference between the body temperature of abnormal and normal sites, and show the alteration of temperature. Monitoring using thermography is useful to determine the effect of sympathetic nerve block. If a thermographic instrument is used, it is important that examiners should understand the function of the instrument, as well as its advantages and disadvantages.

Buprenorphine is a chemically synthesized opioid characterized as the partial mu agonist and kappa antagonist, and transdermal buprenorphine patch will be considered useful as a strong analgesic with fewer psychological side effects in the treatment of chronic non-cancer pain. Use of transdermal buprenorphine should be limited for pain relief of intractable muscle skeletal pain that cannot be alleviated with other analgesics. To avoid severe complication and drug abuse or addiction, assessment of pain and medical history including drug dependence by medical team are important before administration of transdermal buprenorphine. Moreover, side effects such as nausea, vomiting, constipation, erythema and itching, loss of appetite should be treated appropriately. When transdermal buprenorphine is administered to chronic pain patients, physicians must examine the condition of patients regularly at an outpatient clinic. Moreover, decreasing and discontinuation of opioid including transdermal buprenorphine should always be considered during the treatment. Most important objective of chronic pain treatment is to improve QOL and ADL of patients.

Oncology IVR is a minimum invasive and locoregional treatment by newly developed interventional techniques consisting of transarterial chemoembolization (TACE), radiofrequency ablation, cryoablation and percutaneous bone plasty (PBP), etc. These treatment methods are considered to be effective to rapid tumor reduction and palliation. The redistributed subclavian arterial infusion chemotherapy via an implanted catheter-port system which was newly developed by authors would be effective for local recurrence of breast cancer. The combination therapy of these interventional techniques can offer new treatment strategies for an improvement of patient's quality of life and more effective palliative medicine.

A 68-year-old man was scheduled for pancreaticoduodenectomy under general anesthesia. He was suffering from Charcot-Marie-Tooth disease (CMTD) for 34 years, and complicated with liver cirrhosis. Anesthesia was induced with propofol and fentanyl, and maintained with oxygen-air-sevoflurane and remifentanil. Epidural block was not used because the patient had coagulation abnormality and thrombocytopia. Rocuronium was injected intravenously for tracheal intubation, supplemented as required using an electrical nerve stimulator. The longer duration of action of rocuronium was observed in this case because the patient was complicated with CMTD and liver cirrhosis. We suggest that monitoring neuromuscular function may be necessary to detect subtle residual neuromuscular blockade when rocuronium is used in a patient with CMTD and liver dysfunction.

A 69-year-old woman had been found to have idiopathic interstitial pneumonia (fibrotic NSIP) in 1997. Proximal muscle weakness appeared in April 2005. Chest CT revealed hilar and mediastinal lymphadenopathy. Polymyositis and Sjögren's syndrome were subsequently diagnosed. We assumed that the interstitial pneumonia had preceded polymyositis and Sjögren's syndrome. A muscle biopsy and transbronchial needle aspiration biopsy demonstrated noncaseating epithelioid cell granulomas. A diagnosis of sarcoidosis complicated with polymyositis and Sjögren's syndrome was made from these findings. Moreover, her HLA genotype contained DR8. HLA-DR8 is considered to be associated with polymyositis, Sjögren's syndrome, and sarcoidosis in Japanese patients. This case suggests the possibility that there are common immunological and genetical pathogenetic mechanisms in autoimmune diseases and sarcoidosis.

A 36-year-old Philippine woman had had fever and general fatigue from September, 2006 (11th week of pregnancy). She was admitted with high fever, general fatigue and dyspnea on October 16, 2006 (13th week of pregnancy). A chest radiograph on admission showed bilateral miliary shadows and ground glass shadows. She already had severe hypoxia on admission. As acid-fast bacilli were positive in urine (Gaffky 8) and sputum (Gaffky 1), we diagnosed as miliary tuberculosis and pulmonary tuberculosis complicated with acute respiratory distress syndrome (ARDS). We treated her with antituberculosis chemotherapy, corticosteroid, sivelestat sodium hydrate, direct hemoperfusion using a polymyxin B immobilized column, and mechanical ventilation, but she died due to respiratory failure. We emphasize that in this case pregnancy has the risk of to causing disease progression of miliary tuberculosis and we should treat immediately and intensively for miliary tuberculosis complicated with ARDS.

A 58-year-old woman had a productive cough but not from bronchial asthma. A chest radiograph revealed infiltrative shadows in right middlelung field on September, 2004. Aspergillus fumigatus was detected in a sputum culture. She was treated with oral itraconazole. After the treatment, infiltrative shadows on her chest radiograph disappeared. On October 2005, her peripheral blood showed eosinophilla, a high serum level of total immunoglobulin E (IgE), and a chest radiograph revealed new infiltrative shadows in both lung fields. A chest computed tomography revealed multiple nodular shadows and central bronchiectasis. We detected a mucoid plug which showed a large number of eosinophils pathologically by bronchoscopy. Aspergillus niger was detected in a bronchial lavage fluid. We therefore made a diagnosis of allergic bronchopulmonary aspergillosis (ABPA). The decreases of peripheral blood eosinophils and a serum IgE level were recognized and multiple nodular shadows disappeared by reinstitution of itraconazole. However, a chest computed tomography revealed new infiltrative shadows. Therefore, we treated her with the concomitant administration of oral itraconazole and inhaled corticosteroid. All laboratory data and image findings were improved. It is critical to consider the both aspects of allergy and infection in the treatment for ABPA.

A 66-year-old man was admitted because of general fatigue. A chest computed tomography showed bilateral alveolar consolidation and ground glass opacities. Although we treated him with broad-spectrum antibiotics, his symptoms and chest image findings did not improve. Thoracoscopic lung biopsy (rS2, S9) was performed. The specimens showed obstructive type intraluminar organization and interstitial inflammatory thickening. Membranous organization was seen in a limited area. The etiology of the illness could not be identified. We diagnosed acute interstitial pneumonia (AIP) because the specimens showed diffuse alveolar damage pattern (DAD/P) and because of unknown etiology. The symptoms and chest image findings were improved on treatment with corticosteroid and cyclophosphamide. However, he was readmitted because of dyspnea 6 months later after the thoracoscopic lung biopsy. Chest computed tomography showed bilateral diffuse ground glass opacities and reticular opacities in both lower lobes. We employed mechanical ventilation, antibiotics, sivelestat sodium hydrate and steroid pulse therapy, but he died without any response to treatment. The findings of autopsy revealed DAD/P accompanied by a new lesion mainly composed of membranous organization and hyaline membrane. We believe this case is valuable when considering the variety of responses to treatment of AIP and prognosis.

A 68 year-old woman was admitted with fever, productive cough and sore throat. A chest radiograph and a chest computed tomography showed multiple nodules in both lungs. Thoracoscopic lung biopsy was performed. The specimens showed vasculitis and geographic basophilic necrosis with palisading histiocytes, giant cells, and neutrophils. Wegener's granulomatosis was diagnosed. On the 5th hospital day, the serum sodium level was 128 mEq/l. Since secretion of antidiuretic hormone had continued despite a low plasma osmolarity, we diagnosed the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and initiated oral prednisolone and cyclophosphamide. As a result, the symptoms and image findings were improved, and serum sodium level became normal. This case was considered to be SIADH secondary to Wegener's granulomatosis.

Recently, a customized oxygen tube is available. The circumference of a newly designed oxygen tube is larger than the original tube. In addition, new features are attached at the four sides of the connecter. As a result, a customized oxygen tube is safer than the previous original oxygen tube with minimum increase of weight. The customized oxygen tube is useful for reducing the misconnecting trouble of the tracheal tube and oxygen tube.

A 20-year-old woman with corrected transposition of great arteries (height 163 cm, weight 69 kg) was scheduled for elective cesarean section at 36 weeks of gestation. Since her mitral insufficiency had deteriorated during pregnancy, she developed dyspnea and lower cardiac function. We decided to perform general anesthesia for her cesarean section. Under the continuous monitoring of arterial blood pressure, anesthesia induction was performed with thiamylal 150 mg, vecuronium 8 mg and fentanyl 0.2 mg, and maintained with oxygen-air-isoflurane (1-1.5%). A Swan-Ganz catheter was inserted for evaluation of her cardiac function. No cardiac events were observed during surgery. The postoperative course was uneventful, and the patient was discharged from the hospital on the 10th postoperative day. Swan-Ganz catheter was useful for the evaluation of cardiac function and for anesthetic management.

A 34-year-old man, 170 cm in height and 70 kg in weight, was scheduled for emergency operation because of gastric perforation due to gastric cancer under general anesthesia. His preoperative blood analysis showed 5.2 x 10(3) mm(-3) of red blood cell, 18 g x dl(-1) of hemoglobin and 48% of hematocrit. Based on this and other data, he was diagnosed as having polycythemia caused by stress. Anesthesia was induced with thiopental and maintained with O2-N2O-sevoflurane. The intraoperative blood loss reached approximately 7,000 ml. Although we administered only 4 units of fresh-frozen plasma (FFP) and 9,150 ml of fluid with no red cell concentrated, his hemodynamic state was stable during surgery. After the surgery, we administered the minimum amount of FFP according to his blood analysis. Although red cell concentrated was not administered in the perioperative period, his general condition remained stable.

Background: Moderate hypoxia might influence the induction of nitric oxide synthase (iNOS) messenger RNA (mRNA) expression in the rat left ventricular myocardium., Methods: Seventy-two Sprague-Dawley rats were divided into two groups as follows: 1) those with controlled ventilation with air (n = 36), and 2) those with controlled ventilation with 10% oxygen as a hypoxic group (n = 36). Heart rate (HR) and mean arterial pressure (MAP) were measured during the study. Before, and 2, 4, 6, 8, or 10 hr after, inhalation of air or 10% oxygen (6 rats for each time), thoracotomy was performed and the left ventricular myocardium was removed. Total RNA was assayed by the reverse transcription-polymerase chain reaction (RT-PCR) with gene-specific primers for iNOS and glyceraldehyde-3-phosphate dehydrogenase., Results: In the air group, there were no significant differences in HR, MAP, and the level of iNOS mRNA throughout the study. In the hypoxic group, however, HR and MAP decreased significantly from 4 and 6 hr after inducing hypoxia, respectively. The level of iNOS mRNA increased significantly from 2 through 10 hr after inducing hypoxia., Conclusions: This study demonstrated that in the rat left ventricular myocardium, iNOS mRNA expression increased from 2 hr after inducing hypoxia, and seemed to increase concomitantly with longer duration of hypoxia.

A 62-year-old male was scheduled for discectomy for lumbar disc herniation. He had bronchial asthma, and his asthma was induced by nonsteroidal anti-inflammatory drugs. We decided to use continuous epidural block for postoperative analgesia. However, he was frightened of insertion of an epidural catheter. Therefore, we planned to insert the epidural catheter before the end of surgery under general anesthesia. It was easily placed at L 5-S 1 interspace using a Tuohy needle from the surgical wound, and the contrast medium 5 ml was injected through the epidural catheter to confirm the placement. After the surgery, continuous epidural block with local anesthetics was used for two days. He did not complain of severe pain postoperatively.

We present a case of a terminally ill child with cancer pain which was treated with intrathecal phenol block. A 13-year-old boy felt severe pain in the right buttock and leg due to osteosarcoma. Despite treatment with nonsteroidal anti-inflammatory drugs, intravenous injection of morphine, continuous infusion of ketamine or continuous lumbar epidural block, his pain increased progressively. Therefore, we performed intrathecal block with 10% phenol glycerine 0.2 ml. After the block, his pain was markedly relieved. He sometimes came back home and joined school events. He did not complain of the pain until his death. We suggest that intrathecal phenol block should be performed in terminally ill children with cancer pain if they do not respond to the usual therapeutic modalities including administration of morphine and continuous epidural block.

A 68-year-old male with primary aldosteronism who was scheduled for electroconvulsive therapy (ECT). We used propofol and suxamethonium to induce anesthesia, and measured plasma levels of aldosterone to evaluate the influence of ECT during anesthesia. Although plasma levels of aldosterone increased gradually after ECT, there were no complications including severe hypertension or arrhythmia perioperatively.

Background: The aim of this study is to examine the duration and magnitude of vasodilating effect induced by sympathetic block with the addition of different concentrations of clonidine to mepivacaine., Methods: In dogs, mean arterial pressure (MAP), heart rate (HR), and right as well as left brachial artery blood flow (BABF) were measured before and after stellate ganglion block (SGB) used as sympathetic block. The experimental protocol was designed as follows: 1) Group 1: left SGB using 0.5% mepivacaine 1 ml (n = 6), 2) Group 2: left SGB using the addition of clonidine 0.5 microgram to 0.5% mepivacaine 1 ml (n = 6), 3) Group 3: left SGB using the addition of clonidine 5 micrograms to 0.5% mepivacaine 1 ml (n = 6)., Results: MAP showed no significant change throughout the study in the groups 1 and 2. In the group 3, MAP was lower than that of the group 1. HR showed no significant change throughout the study in the three groups. Left BABF increased significantly after left SGB in the three groups. The duration of increased BABF in the group 2 was the longest, and that in the group 3 was the shortest among them. Right BABF after left SGB decreased significantly throughout the study in the three groups, and the magnitude of the decrease in BABF in the group 3 was the highest among them., Conclusion: Sympathetic block with the addition of clonidine to local anesthetics increases both duration and magnitude of its vasodilating effect. However, sympathetic block with the addition of higher doses of clonidine to local anesthetics may induce shorter duration and lower magnitude of vasodilating effect compared with local anesthetics alone.

A 76-year-old woman with acute myocardial infarction underwent an emergency coronary artery bypass graft operation. She developed cardiac failure and sick sinus syndrome before the surgery because she was with cardioamyloidosis. Therefore, intra-aortic balloon pumping and the pacemaker were used to maintain the hemodynamics prior to the operation. Anesthesia was induced with midazolam 5 mg, morphine 30 mg and pancuronium 5 mg, and maintained with 0.3-0.5% isoflurane in 50% nitrous oxide and 50% oxygen. Morphine 10 mg was also injected during the surgery, and the total dose of morphine 40 mg was administered. The pacemaker at 80 bpm was inserted and mexiletine 0.5 mg.kg-1.h-1 was given to prevent ventricular arrhythmias at weaning from cardio-pulmonary bypass. The surgical operation was successfully performed and the postoperative course was uneventful. A combination of light inhalation anesthesia with narcotics may be a choice for anesthetic management of patients with cardioamyloidosis as this method has less influence on hemodynamics.

A 55-year-old man with pulmonary alveolar proteinosis underwent lung lavage under general anesthesia using sevoflurane three years ago. Although transient hypoxia occurred postoperatively, there were no complications. Because of the recent deterioration of his symptoms, he was rescheduled for lung lavage. Anesthesia was induced with propofol 120 mg and fetanyl 0.2 mg. Vecuronium 7 mg was administered to facilitate tracheal intubation using a double-lumen tube. Anesthesia was maintained with propofol 4 mg.kg-1.h-1. Electrocardiogram, blood pressure, SPO2, EtCO2 and rectal temperature were monitored intraoperatively. We also checked PaO2 when necessary. Although transient hypoxia occurred after the procedure, it receded spontaneously. Since inhalation anesthetics inhibit hypoxic pulmonary vasoconstriction, intravenous anesthetics may be more useful for patients with severe pulmonary alveolar proteinosis.

A 56-year-old male who had received total thymectomy for treatment of myasthenia gravis was scheduled for sigmoidectomy under general anesthesia. Since his symptoms had become worse after the thymectomy along with increased anti-acetylcholine receptor antibody titer, preoperatively we could not estimate his sensitivity to non-depolarizing muscle relaxants. We initially tried tracheal intubation without using a non-depolarizing muscle relaxant immediately after intravenous injection of propofol 2 mg.kg-1 and fentanyl 4 micrograms.kg-1. Since the intubation was unsuccessful, however, vecuronium 0.01 mg.kg-1 was repeatedly administered until TOF ratio reached 0%. Successful intubation was performed with 3.5 mg of vecuronium. We conclude that the initial trial of tracheal intubation should be performed without a non-depolarizing muscle relaxant in patients with myasthenia gravis whose symptoms have become worse after thymectomy. If first attempt is unsuccessful, the tracheal intubation should be performed with a smaller dose of vecuronium using an electrical nerve stimulator.

This experiment was performed to investigate whether hypertonic saline has a preventive effect on delayed neuronal death in the CA1 subfield of the hippocampus. Twenty gerbils were used, and after being anesthetized by inhalation of 1% halothane, both common carotid arteries were occluded for 2.5 min. The animals were injected intravenously with 2 ml/kg of 10% NaCl immediately after reperfusion, and 2 ml/kg of physiological saline solution was used in the same manner in a control group. Five days later, histopathological changes in the CA1 subfield were observed by staining with hematoxylin-eosin and examining sections of the brain under a light microscope. Degenerative or necrotic pyramidal cells exhibited cell shrinkage, nuclear pyknosis, dark staining of the cytoplasm vacuolation and disappearance of the radial striated zone. The pyramidal cell degeneration rate in a 1 mm length of CA1 subfield was 95.6 +/- 1.6% in the ischemia-reperfusion-saline group and 7.1 +/- 3.0% in ischemia-reperfusion-hypertonic saline group, and the difference was statistically significant. This study verified that hypertonic saline prevented delayed neuronal death in the CA1 subfield of hippocampal area after ischemia-reperfusion.

Periodontal probing is the most important examination to determine the presence and severity of periodontal lesions. In the interproximal contact areas, probing depth is not accurate because there are some errors in angulating the probe. The purpose of this study was to establish the correct probing method in these areas. Therefore a new interproximal periodontal probe was developed. It eliminated the errors which arise from angulating a probe. The effectiveness of the 8-point method which uses both a conventional probe and the new type interproximal one was determined. The results were as follows: 1. 20 human dry skulls were selected to indicate the necessary angle at which a probe could reach the center of the interproximal contact area. Approximately 30 degrees was needed in molars. This was the most popular angle for measurement in these places. 2. 12 periodontal patients were selected to determine the errors in probing depth between a conventional probe and the new type interproximal one when a probe angulated 30 degrees. The average error was 0.56 mm, indicating that the new type interproximal probe must be used when a probe was angulates 30 degrees. 3. 19 periodontal patients who received a flap operation were selected to determine the effective probing method which could predict the alveolar bone defects in the interproximal contact areas. Measurement of 3 points (bucco-mesial or distal line-angle, linguo-mesial or distal line-angle and center of mesial or distal) could estimate the form of interproximal bone defects. 4. 45 periodontal patients were selected to determine the condition of interproximal periodontal pockets. Marked periodontal damage was present not only at the center of interproximal contact areas but also in the other sites. These results suggest that the new interproximal periodontal probe is a reasonable instrument for angled probing in the interproximal contact areas, and the 8-point method is the most effective one to reveal the periodontal condition in detail.