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Purpose: Spinal anesthesia is a standard technique for cesarean delivery; however, it possesses a risk of hypotension. We hypothesised that the changes in the corrected flow time induced by the Trendelenburg position could predict the incidence of hypotension after spinal anesthesia for cesarean delivery., Methods: Patients undergoing elective cesarean delivery under spinal anesthesia were enrolled. Before anesthesia induction, corrected flow time was measured in the supine and Trendelenburg positions (FTc-1 and FTc-2, respectively). Additionally, a percent change in corrected flow time induced by the Trendelenburg position was defined as ΔFTc. The primary endpoint was to investigate the ability of ΔFTc to predict the incidence of spinal anesthesia-induced hypotension until delivery. The receiver operating characteristics curves to assess the ability of FTc-1, FTc-2, and ΔFTc to predict the incidence of hypotension were generated., Results: Finally, 40 patients were included, and of those, 26 (65%) developed spinal anesthesia-induced hypotension. The areas under the curve for FTc-1, FTc-2, and ΔFTc were 0.591 (95% CI: 0.424 to 0.743) (P = 0.380), 0.742 (95% CI: 0.579 to 0.867) (P = 0.004), and 0.882 (95% CI: 0.740 to 0.962) (P < 0.001) respectively, indicating ΔFTc as the best predictor among these three parameters. The best threshold for ΔFTc was 6.4% (sensitivity: 80.8% (95% CI: 53.8 to 96.2), specificity: 85.7% (95% CI: 42.9 to 100.0))., Conclusions: This study demonstrated that changes in the corrected carotid flow time induced by the Trendelenburg position could serve as a good predictor of spinal anesthesia-induced hypotension for cesarean delivery., (© 2024. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Objective: This study aimed to clarify the features and causes of dependent edema (DE) in the legs of patients in geriatrics. Patients and Methods: We retrospectively reviewed 224 patients with DE, aged ≥65 years, who visited our clinic from April 2009-March 2022. DE was defined as bilateral leg edema in patients without known systemic edemagenic conditions, venous insufficiency confirmed by duplex venous scanning, or a cancer treatment history in the pelvic/inguinal lesions. Results: The median patient age was 77 years (range: 65-94 years), where 74% were female. Overall, 198 patients (88%) had gait disturbances caused mainly by musculoskeletal disorders, but 58 (26%) walked without aid. Compared with patients with DE only (N=129), patients with DE and venous stasis-related skin lesions (N=95) included a larger number of those with obesity than did those with DE only (26% vs. 14%, p=0.02). Conclusion: The primary cause of DE in older patients was the sedentary lifestyle secondary to aging and gait disturbance, not solely because of reduced leg function. The complications of obesity are associated with increased venous stasis-related skin lesions., Competing Interests: Declaration of Conflicting InterestsThe authors declare no conflict of interest., (© 2023 The Editorial Committee of Annals of Vascular Diseases.)

Objectives: To clarify the cause of leg volume reduction during tiptoe movement in the standing position., Methods: The right legs of 20 participants were assessed. The participants performed tiptoe movement in the supine position, and then stood up and performed the tiptoe movement and ankle dorsiflexion. Leg volume changes were recorded continuously using air plethysmography., Results: Differences between leg volume changes due to tiptoe movement and the refilling volumes were not significantly different between the supine (59 mL) and standing (49 mL) positions, indicating that this amount of motion artifact was included in the downward trace recorded by tiptoe movement in the standing position., Conclusions: Leg volume reduction during tiptoe movement in the standing position included a significant amount of motion artifacts. Therefore, it may be difficult to accurately measure the ejection volume using tiptoe movement in the standing position.

Objectives: We aimed to clarify whether acute lipodermatosclerosis (LDS) progress to chronic LDS without continued compression therapy., Methods: Between April 2015 and November 2021, 30 patients with acute/subacute LDS, which was diagnosed clinically by presence of isolated, poorly demarcated, tender erythema, and induration limited to the lower leg(s), visited our clinic and were able to be followed up for longer than a year. We reviewed their treatment results and the post-treatment courses., Results: In all cases, the symptoms in the acute phase subsided with compression bandages. After the discontinuation of compression therapy, 18 legs (56%) progressed to chronic LDS, and 14 legs (44%) did not. In the legs without progression, subcutaneous tissue in the affected leg was thicker compared with that in the contralateral leg (median 19.1 mm vs. 13.4 mm, p < 0.05) on the initial visit. In the legs with progression, the difference in subcutaneous tissue thickness between the affected and unaffected legs was not significant (10.0 mm vs. 7.6 mm)., Conclusions: Our findings suggest that in legs which later progress to chronic LDS, subcutaneous tissue contraction due to panniculitis is already present during the acute phase; therefore, long-term compression therapy is unlikely to improve the prognosis.

Objective: We aimed to determine the prevalence and risk factors for osteonecrosis of the femoral head (ONFH) in a multicentre cohort of patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV)., Methods: One hundred and eighty-six AAV patients who underwent radiographs and MRI screening of bilateral hip joints at more than 6 months after initial remission induction therapy (RIT) were retrospectively assessed for the presence of ONFH., Results: Among 186 AAV patients, 33 (18%) were diagnosed with ONFH. Among the patients with ONFH, 55% were asymptomatic and 64% had bilateral ONFH. Seventy-six per cent of ONFH joints were in precollapse stages (stage ≤2), whereas 24% of ONFH joints were in collapse stages (stage ≥3). Moreover, 56% of the precollapse stage joints were already at risk of future collapse (type ≥C-1). Even in asymptomatic ONFH patients, 39% of the precollapse stage joints were type ≥C-1. Prednisolone dose of ≥20 mg/day on day 90 of RIT was an independent risk factor for ONFH in AAV patients (OR 1.072, 95% CI 1.017 to 1.130, p=0.009). Rituximab use was a significant beneficial factor against ONFH (p=0.019), but the multivariate analysis rejected its significance (p=0.257)., Conclusion: Eighteen per cent of AAV patients developed ONFH, and two-thirds of the ONFH joints were already in collapse stages or at risk of future collapse. Prednisolone dose of ≥20 mg/day on day 90 of RIT was an independent risk factor for ONFH. A rapid reduction of glucocorticoids in RIT and early detection of precollapse ONFH by MRI may decrease and intervene ONFH development in AAV patients., Competing Interests: Competing interests: KI has received research grants from Mitsubishi-Tanabe Pharma and has received honoraria for lectures from Abbvie, Mitsubishi-Tanabe Pharma, Eli Lilly Japan, Novartis, Pfizer Japan, Janssen Pharmaceutical, Eisai, Gilead Sciences and Bristol Myers Squibb, all unrelated to the current manuscript. HN has received research grants from Chugai Pharmaceutical, Abbvie, Takeda Pharmaceutical, Astellas Pharma, Eli Lilly Japan, Asahikasei Pharma, Pfizer Japan, UCB Japan, Eizai, Mitsubishi Tanabe Pharma and Bristol Myers Squibb, and has received honoraria for lectures from Chugai Pharmaceutical, Abbvie, Takeda Pharmaceutical, Astellas Pharma, Eli Lilly Japan, Asahikasei Pharma, Janssen Pharmaceutical, Mitsubishi Tanabe Pharma, Eisai, Bristol Myers Squibb and Nippon Kayaku, all unrelated to the current manuscript., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This experimental study aimed to assess the efficacy of hydrogen gas inhalation against spinal cord ischemia-reperfusion injury and reveal its mechanism by measuring glutamate concentration in the ventral horn using an in vivo microdialysis method., Methods: Male Sprague-Dawley rats were divided into the following 6 groups: sham, only spinal ischemia, 3% hydrogen gas (spinal ischemia + 3% hydrogen gas), 2% hydrogen gas (spinal ischemia + 2% hydrogen gas), 1% hydrogen gas (spinal ischemia + 1% hydrogen gas), and hydrogen gas dihydrokainate (spinal ischemia + dihydrokainate [selective inhibitor of glutamate transporter-1] + 3% hydrogen gas). Hydrogen gas inhalation was initiated 10 minutes before the ischemia. For the hydrogen gas dihydrokainate group, glutamate transporter-1 inhibitor was administered 20 minutes before the ischemia. Immunofluorescence was performed to assess the expression of glutamate transporter-1 in the ventral horn., Results: The increase in extracellular glutamate induced by spinal ischemia was significantly suppressed by 3% hydrogen gas inhalation (P &lt; .05). This effect was produced in increasing order: 1%, 2%, and 3%. Conversely, the preadministration of glutamate transporter-1 inhibitor diminished the suppression of spinal ischemia-induced glutamate increase observed during the inhalation of 3% hydrogen gas. Immunofluorescence indicated the expression of glutamate transporter-1 in the spinal ischemia group was significantly decreased compared with the sham group, which was attenuated by 3% hydrogen gas inhalation (P &lt; .05)., Conclusions: Our study demonstrated hydrogen gas inhalation exhibits a protective and concentration-dependent effect against spinal ischemic injury, and glutamate transporter-1 has an important role in the protective effects against spinal cord injury., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Postoperative pulmonary complications (PPC) remain a main issue after cardiac surgery. The objective was to report the incidence and identify risk factors of PPC after cardiac surgery., Design: An international multicenter prospective study (42 international centers in 9 countries)., Participants: A total of 707 adult patients who underwent cardiac surgery under cardiopulmonary bypass., Interventions: None MEASUREMENTS AND MAIN RESULTS: During a study period of 2 weeks, the investigators included all patients in their respective centers and screened for PPCs. PPC was defined as the occurrence of at least 1 pulmonary complication among the following: atelectasis, pleural effusion, respiratory failure, respiratory infection, pneumothorax, bronchospasm, or aspiration pneumonitis. Among 676 analyzed patients, 373 patients presented with a PPC (55%). The presence of PPC was significantly associated with a longer intensive care length of stay and hospital length of stay. One hundred ninety (64%) patients were not intraoperatively ventilated during cardiopulmonary bypass. Ventilation settings were similar regarding tidal volume, respiratory rate, inspired oxygen. In the regression model, age, the Euroscore II, chronic obstructive pulmonary disease, preoxygenation modality, intraoperative positive end-expiratory pressure, the absence of pre- cardiopulmonary bypass ventilation, the absence of lung recruitment, and the neuromuscular blockade were associated with PPC occurrence., Conclusion: Both individual risk factors and ventilatory settings were shown to explain the high level of PPCs. These findings require further investigations to assess a bundle strategy for optimal ventilation strategy to decrease PPC incidence., Competing Interests: Conflict of Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: We aimed to clarify whether pathological changes in skin and subcutaneous tissue with lymphedema affected the skin hardness sensed by palpation. Methods and Results: In 50 patients with unilateral legs with lymphedema (LE), the skin hardness of the lower inner thigh and lower inner calf was determined using a scale ranging from 1 (softest) to 7 (hardest) based on palpation. Then, the skin hardness was correlated with the measurements of skin/subcutaneous tissue ultrasonography images obtained from the palpated parts. Multivariate logistic regression analysis demonstrated that dermal thickness was a significant factor that affected the difference in skin hardness between the LE and the contralateral asymptomatic leg for both thigh ( p  < 0.05) and calf ( p  < 0.01). When the thigh and calf in the LE were individually studied, subcutaneous echogenicity ( p  < 0.05), indicating subcutaneous inflammation/fibrosis, and subcutaneous thickness ( p  < 0.01) also seemed to affect skin hardness, respectively. Conclusions: The skin hardness sensed in the LE seemed to be affected predominantly by dermal thickening. In addition, the pathological changes in the subcutaneous tissue caused by LE seemed to have an impact on skin hardness. Clinical Trial Registration number 2020-150.

Non-invasive methods to assess patients' fluid responsiveness during lung-protective ventilation are needed. We hypothesized changes in the corrected carotid flow time induced by the recruitment maneuver predict fluid responsiveness under general anesthesia. Thirty patients undergoing general anesthesia in the supine position were prospectively enrolled. The study protocol was conducted when the patient was hemodynamically stable during surgery. Flow time was measured on Doppler images of the common carotid artery. Carotid flow time, heart rate, stroke volume, stroke volume variation, and pulse pressure variation were recorded before and after a recruitment maneuver at a continuous airway pressure of 30 cmH 2 O for 30 s, and before and after volume expansion with 250 mL for 10 min. Patients were defined as fluid responders if the increase in stroke volume was > 10% after volume expansion. Twenty patients (67%) were fluid responders. All Doppler images for carotid flow time were obtained within 30 s. Changes in the corrected flow time accurately predicted fluid responsiveness (area under the curve: 0.82, 95% confidence interval [CI] 0.64-0.94, p = 0.002). The optimal threshold for changes in the corrected flow time was - 11.7% with a sensitivity of 95.0% (95% CI 75.1-99.9%) and a specificity of 80.0% (95% CI 44.4-97.5%). The gray-zone of changes in the corrected flow time was from - 25.1 to - 12.2% and included 12 patients (40%). Changes in the corrected carotid flow time were a useful, technically easy-to-perform, and non-invasive method to predict fluid responsiveness without a need for hemodynamic monitoring or arterial cannulation., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Objective: This study aimed to investigate the accuracy and precision of continuous, non-invasive blood pressure obtained using the ClearSight system by comparing it with invasive arterial blood pressure, and to assess the hemodynamic changes using invasive methods and the ClearSight system in patients undergoing cesarean section., Methods: Arterial pressure was measured invasively with an intra-arterial catheter and non-invasively using the ClearSight system during cesarean section in patients with placenta previa or placenta accreta. Blood pressure measurements obtained using these two means were then compared., Results: Total 1,277 blood pressure measurement pairs were collected from 21 patients. Under Bland-Altman analysis, the ClearSight system demonstrated an acceptable accuracy with a bias and standard deviation of 8.8±13.4 mmHg for systolic blood pressure, -6.3±7.1 mmHg for diastolic blood pressure, and -2.7±8.0 mmHg for median blood pressure. Cardiac index levels were significantly elevated during fetal delivery and 5 minutes after placental removal, and systemic vascular resistance index levels were significantly decreased during fetal delivery and 40 minutes after placental removal., Conclusion: In patients undergoing cesarean section, the ClearSight system showed excellent accuracy and precision compared to that of the currently used invasive monitoring system.

The purpose of this study was to investigate the therapeutic effect of cryopreserved allogenic fibroblast cell sheets in a mouse model of skin ulcers. It is necessary to reduce the cost of regenerative medicine for it to be widely used. We consider that cell sheets could be applied to various diseases if cryopreservation of allogenic cell sheets was possible. In this study, fibroblasts were frozen using a three-dimensional freezer. Freeze-thawed fibroblasts had ~80% cell viability, secreted ≥ 50% vascular endothelial growth factor, hepatocyte growth factor, and stromal derived factor-1α compared with non-frozen fibroblast sheets, and secreted approximately the same amount of transforming growth factor-β1. There was no difference in wound-healing rates in the skin ulcer model between non-frozen and freeze-thawed fibroblast sheets regardless of autologous and allogenic cells. The degree of angiogenesis was comparable between autologous and allogenic cells. The number of CD3-positive cells in healed tissues was larger for allogenic fibroblast sheets compared with autologous fibroblast sheets. However, histopathological images showed that the fibrosis, microvascular density, and healing phase of the wound in allogenic freeze-thawed fibroblast sheets were more similar to autologous freeze-thawed fibroblast sheets than to allogenic non-frozen fibroblast sheets. These results suggest that allogenic freeze-thawed fibroblast sheets may be a promising therapeutic option for refractory skin ulcers., Competing Interests: None., (AJTR Copyright © 2022.)

Objectives: To clarify the effects of compression and active ankle motion on venous hemodynamics in healthy sitting individuals., Methods: In the sitting position, 14 participants performed plantar flexion and dorsiflexion of the ankle for 3 s each without compression. Changes in the calf volume were recorded using air plethysmography. Subsequently, the process was repeated with the application of tubular elastic bandage (TEB), followed by anti-thrombotic stocking (ATS)., Results: The median interface pressure at the calf was 16 mmHg with TEB and 21 mmHg with ATS. Without compression ( N ), the median venous volume was 76 mL. This was reduced to 58 mL with TEB and 56 mL with ATS ( p < .01 vs. N for both). On the other hand, ejection volume by plantar flexion in N (27 mL) was not significantly changed with TEB (31 mL) or ATS (31 mL). Also, ejection volume by dorsiflexion in N (53 mL, p < .001 vs. plantar flexion) was not significantly changed with TEB (53 mL, p < .01 vs. plantar flexion) or ATS (41 mL, p < .05 vs. plantar flexion)., Conclusions: The venous volume, which is defined as the change in enclosed calf volume from elevation to dependency, in the sitting position reduced similarly with TEB and ATS; however, the ejection volumes did not change significantly. Dorsiflexion exerted a larger ejection volume than plantar flexion in the sitting position.

Background: Error grid analysis was recently proposed to compare blood pressure obtained by 2 measurement methods. This study aimed to compare continuous noninvasive blood pressure (CNBP) with invasive blood pressure (IBP) using the error grid analysis and investigate the confounding risk factors attributable to the differences between CNBP and IBP., Methods: Sixty adult patients undergoing general anesthesia were prospectively enrolled. Simultaneous comparative data regarding CNBP and IBP were collected. The Bland-Altman analysis was conducted to compare CNBP and IBP for systolic blood pressure (SBP) and mean blood pressure (MBP; acceptable accuracy: mean bias <5 mm Hg; standard deviation <8 mm Hg). The clinical relevance of the discrepancies between CNBP and IBP was evaluated by the error grid analysis, which classifies the differences into 5 zones from "no risk" (A) to "dangerous risk" (E). Additionally, an ordinal logistic regression analysis was performed to evaluate the relationship between the risk zones for MBP, classified by the error grid analysis and covariates of interest., Results: A total of 10,663 pairs of CNBP/IBP were finally analyzed. The Bland-Altman analysis showed an acceptable accuracy with a bias of -3.3 ± 5.6 mm Hg for MBP but a poor accuracy with a bias of 5.4 ± 10.5 mm Hg for SBP. The error grid analysis showed the proportions of zones A to E as 96.7%, 3.2%, 0.1%, 0%, and 0% for SBP, respectively, and 72.0%, 27.9%, 0.1%, 0%, and 0% for MBP, respectively. The finger cuff missed 23.9% of epochs when SBP <90 mm Hg and 55.3% of epochs when MBP <65 mm Hg. The ordinal logistic regression analysis revealed that older age (adjusted odds ratio for decade: 1.54, 95% confidence interval [CI], 1.15-2.08; P = .004) and length of time from the initiation of finger cuff inflation (adjusted odds ratio for 60 minutes: 1.40, 95% CI, 1.13-1.73; P = .002) were significant factors of being in a more dangerous zone of the error grid., Conclusions: The error grid analysis revealed the larger clinical discrepancy between CNBP and IBP in MBP compared with that in SBP. Old age and longer finger cuff inflation time were significant factors of being in a more dangerous zone of the error grid, which could affect the hemodynamic management during surgery., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Background Saphenous vein grafts (SVGs) are broadly used in coronary artery bypass grafting despite their inferior patency compared with arterial grafts. Recently, the no-touch technique (NT), in which an SVG is harvested with a pedicle of perivascular adipose tissue (PVAT) without conduit distension, was shown to improve long-term patency compared with conventional preparation (CV), wherein outer tissue is removed with distension. The NT was also reportedly associated with reduced atherosclerosis. Although endothelial damage provoked by conventional distension may underlie poor patency when CV is performed, the precise mechanisms underlying the salutary effects of the NT have been unclear. Methods and Results Residual SVGs prepared with CV (CV-SVGs) or NT (NT-SVGs) were obtained during coronary artery bypass grafting. Nitric oxide (NO 2 - /NO 3 - (NO x )) levels after 24 hours of tissue culture were quantified. The protein expression and localization were analyzed. The isometric force of SVG strips was measured. NT-SVGs showed superior NO x production to CV-SVGs. PVAT generated the majority of NO x in NT-SVGs. PVAT highly expressed arginosuccinate synthase 1, a rate-limiting enzyme in the molecular circuit for NO synthesis, thereby continuously providing the substrate for NO. A substantial level of endothelial NO synthase was also expressed in PVAT. Pharmacological inhibition of arginosuccinate synthase 1 or endothelial NO synthase significantly suppressed the NO x production in NT-SVGs. PVAT induced vasorelaxation through NO production, even in the endothelium-denuded SVG strips. Conclusions Preserving PVAT was predominantly involved in the superior NO x production in NT-SVGs. Since NO plays crucial roles in suppressing atherosclerosis, this mechanism may greatly contribute to the excellent patency in NT-SVGs.

Objectives: We aimed to investigate the protective effect of remote ischemic preconditioning against spinal cord ischemia and find a clue to its mechanism by measuring glutamate concentrations in the spinal ventral horn., Methods: Male Sprague-Dawley rats were divided into 5 groups (n = 6 in each group) as follows: sham; SCI (only spinal cord ischemia); RIPC/SCI (perform remote ischemic preconditioning before spinal cord ischemia); MK-801/RIPC/SCI (administer MK-801, N-methyl-D-aspartate receptor antagonist, before remote ischemic preconditioning); and MK-801/SCI (administer MK-801 without remote ischemic preconditioning). Remote ischemic preconditioning was achieved by brief limb ischemia 80 minutes before spinal cord ischemia. MK-801 (1 mg/kg, intravenous) was administered 60 minutes before remote ischemic preconditioning. The glutamate concentration in the ventral horn was measured by microdialysis for 130 minutes after spinal cord ischemia. Immunofluorescence was also performed to evaluate the expression of N-methyl-D-aspartate receptor 2B subunit in the ventral horn 130 minutes after spinal cord ischemia., Results: The glutamate concentrations in the spinal cord ischemia group were significantly higher than in the sham group at all time points (P < .01). Remote ischemic preconditioning attenuated the spinal cord ischemia-induced glutamate increase. When MK-801 was preadministered before remote ischemic preconditioning, glutamate concentration was increased after spinal cord ischemia (P < .01). Immunofluorescence showed that remote ischemic preconditioning prevented the increase in the expression of N-methyl-D-aspartate receptor 2B subunit on the surface of motor neurons (P = .047)., Conclusions: Our results showed that remote ischemic preconditioning prevented spinal cord ischemia-induced extracellular glutamate increase in ventral horn and suppressed N-methyl-D-aspartate receptor 2B subunit expression., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The present study aimed to evaluate the reliability of hemodynamic changes induced by lung recruitment maneuver (LRM) in predicting stroke volume (SV) increase after fluid loading (FL) in prone position., Methods: Thirty patients undergoing spine surgery in prone position were enrolled. Lung-protective ventilation (tidal volume, 6-7 mL/kg; positive end-expiratory pressure, 5 cmH 2 O) was provided to all patients. LRM (30 cmH 2 O for 30 s) was performed. Hemodynamic variables including mean arterial pressure (MAP), heart rate, SV, SV variation (SVV), and pulse pressure variation (PPV) were simultaneously recorded before, during, and at 5 min after LRM and after FL (250 mL in 10 min). Receiver operating characteristic curves were generated to evaluate the predictability of SVV, PPV, and SV decrease by LRM (ΔSV LRM ) for SV responders (SV increase after FL > 10%). The gray zone approach was applied for ΔSV LRM ., Results: Areas under the curve (AUCs) for ΔSV LRM , SVV, and PPV to predict SV responders were 0.778 (95% confidence interval: 0.590-0.909), 0.563 (0.371-0.743), and 0.502 (0.315-0.689), respectively. The optimal threshold for ΔSV LRM was 30% (sensitivity, 92.3%; specificity, 70.6%). With the gray zone approach, the inconclusive values ranged 25 to 75% for ΔSV LRM (including 50% of enrolled patients)., Conclusion: In prone position, LRM-induced SV decrease predicted SV increase after FL with higher reliability than traditional dynamic indices. On the other hand, considering the relatively large gray zone in this study, future research is needed to further improve the clinical significance., Trial Registration: UMIN Clinical Trial Registry UMIN000027966 . Registered 28th June 2017., (© 2021. The Author(s).)

Aims: This study investigated the relationship between the analgesic efficacy of acetaminophen and the descending noradrenergic systems using rodent models of inflammatory pain., Main Methods: Inflammatory pain models were established by carrageenan injection into rats' paws. The models were defined as acute (4 h after carrageenan injection), subacute (24 h after carrageenan injection), and late (1 week after carrageenan injection) phase. To evaluate intravenous acetaminophen treatment, the withdrawal threshold to mechanical stimuli was assessed simultaneously with in vivo microdialysis assay of noradrenaline levels in the locus coeruleus (LC). Further analyses were performed to observe the effect of yohimbine on the treatment and the impact of AM404 treatment, a metabolite of acetaminophen, on noradrenaline levels in the LC., Key Findings: In all phases, intravenous acetaminophen had a significant anti-hyperalgesic effect (p < 0.05). There was a significant time-dependent increase in the noradrenaline concentration within the LC (acetaminophen versus saline treatment; at 30 min, p < 0.001; 60 min, p < 0.01) in the subacute pain model, but not in the acute and late phase pain models. Intrathecal pre-injection of yohimbine attenuated the anti-hyperalgesic effect after acetaminophen injection only in the subacute model (p < 0.05). In the subacute pain model, intracerebroventricular administration of AM404 showed the same trend in noradrenaline levels as acetaminophen administration (AM404 versus vehicle group at 30 min, p < 0.001)., Significance: We found the descending noradrenergic inhibitory system is involved in the antinociceptive action of acetaminophen in the subacute phase of inflammatory pain., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We report five cases of venous leg ulcers (VLU) that were resistant to conservative therapy for 22-119 months and were eventually healed via hyperbaric oxygen therapy (HBOT). In one patient, VLU recurred four times and was managed using HBOT, each time. The VLU sizes ranged from 18 to 68 cm 2 before HBOT. HBOT was administered at 2.0 atmospheres absolute with 100% oxygen for 60 min per session, five sessions a week during hospitalization. All VLUs healed after 17-66 sessions of HBOT., Competing Interests: Disclosure StatementThe authors declare that there is no conflict of interest., (© 2021 The Editorial Committee of Annals of Vascular Diseases.)

Background/aims: We invented a cell-mixed sheet consisting of autologous fibroblast cells and peripheral blood mononuclear cells (PBMNCs) to treat refractory cutaneous ulcers. These sheets secrete the growth factors needed throughout the wound healing process in animal models., Methods: We performed this study as a pilot phase I clinical trial (UMIN-CTR: UMIN000031645). Fibroblast cells were isolated and cultured from the oral tissue, and PBMNCs were collected by apheresis. A cell-mixed sheet was prepared by co-culturing these collected cells for 3 days. The primary observation index was safety, including all adverse events. Additional observation indices were wound healing over 1, 3, and 6 months; wound healing rate at 7 days and 1, 3, and 6 months., Results: Six patients with venous leg ulcers (VLUs) were enrolled in the study, including three patients who were treated with the cell-mixed sheet transplantation. One patient was excluded because no fibroblast cells grew from the oral tissue culture, and other two were excluded because the growth factor secreted from mixed-cell sheets did not reach the reference value. The VLUs of two patients who received the cell-mixed sheet transplantation healed, and the VLU in one patient decreased in size., Conclusions: This pilot study demonstrated that cell-mixed sheets might be a new topical intervention to treat VLUs. However, it was also suggested that this treatment might be limited when using autologous cells collected from patients with VLUs. Therefore, it may be necessary to use high-quality allogeneic cells instead of autologous cells to improve the feasibility of this treatment., Competing Interests: None., (AJTR Copyright © 2021.)

Background: We aimed to evaluate the ability of lung recruitment maneuver-induced hemodynamic changes to predict fluid responsiveness in patients undergoing lung-protective ventilation during one-lung ventilation (OLV)., Methods: Thirty patients undergoing thoracic surgery with OLV (tidal volume: 6 mL/kg of ideal body weight and positive end-expiratory pressure: 5 cm H2O) were enrolled. The study protocol began 30 minutes after starting OLV. Simultaneous recordings were performed for hemodynamic variables of heart rate, mean arterial pressure (MAP), stroke volume (SV), pulse pressure variation (PPV), and stroke volume variation (SVV) were recorded at 4 time points: before recruitment maneuver (continuous airway pressure: 30 cm H2O for 30 seconds), at the end of recruitment maneuver, and before and after volume loading (250 mL over 10 minutes). Patients were recognized as fluid responders if the increase in SV or MAP was >10%. Receiver operating characteristic curves for percent decrease in SV and MAP by recruitment maneuver (ΔSVRM and ΔMAPRM, respectively) were generated to evaluate the ability to discriminate fluid responders from nonresponders. The gray-zone approach was applied for ΔSVRM and ΔMAPRM., Results: Of 30 patients, there were 17 SV-responders (57%) and 12 blood pressure (BP)-responders (40%). Area under the curve (AUC) for ΔSVRM to discriminate SV-responders from nonresponders was 0.84 (95% confidence interval [CI], 0.67-0.95; P < .001). The best threshold for ΔSVRM to discriminate the SV-responders was -23.7% (95% CI, -41.2 to -17.8; sensitivity, 76.5% [95% CI, 50.1-93.2]; specificity, 84.6% [95% CI, 54.6-98.1]). For BP-responders, AUC for ΔMAPRM was 0.80 (95% CI, 0.61-0.92, P < .001). The best threshold for ΔMAPRM was -17.3% (95% CI, -23.9 to -5.1; sensitivity, 75.0% [95% CI, 42.8-94.5]; specificity, 77.8% [95% CI, 52.4-93.6]). With the gray-zone approach, the inconclusive range of ΔSVRM for SV-responders was -40.1% to -13.8% including 13 (43%) patients, and that of ΔMAPRM was -23.9% to -5.1%, which included 16 (53%) patients., Conclusions: ΔSVRM and ΔMAPRM could predict hemodynamic responses after volume expansion during OLV., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Objective: To assess the effect of systemic vascular resistance (SVR) on the reliability of the ClearSight system (Edwards Lifesciences, Irvine, CA) for measuring blood pressure (BP) and cardiac output (CO)., Design: Observational study., Setting: University hospital., Participants: Twenty-five patients undergoing cardiac surgery., Interventions: None., Measurements and Main Results: BP, measured using ClearSight and an arterial line, and CO, measured using ClearSight and a pulmonary artery catheter, were recorded before (T1) and two minutes after phenylephrine or ephedrine administration. Bland-Altman analysis was used to compare BP and CO measurements at T1. A polar plot was used to assess trending abilities. Patients were divided into the following three groups according to the SVR index (SVRI) at T1: low (<1,200 dyne s/cm 5 /m 2 ), normal (1,200-25,00 dyne s/cm 5 /m 2 ), and high (>2,500 dyne s/cm 5 /m 2 ). The bias in BP and CO was -4.8 ± 8.9 mmHg and 0.10 ± 0.81 L/min, respectively, which was correlated significantly with SVRI (p < 0.05). The percentage error in CO was 40.6%, which was lower in the normal SVRI group (33.3%) than the low and high groups (46.3% and 47.7%, respectively). The angular concordance rate was 96.3% and 95.4% for BP and 87.0% and 92.5% for CO after phenylephrine and ephedrine administration, respectively. There was a low tracking ability for CO changes after phenylephrine administration in the low-SVRI group (angular concordance rate 33.3%)., Conclusion: The ClearSight system showed an acceptable accuracy in measuring BP and tracking BP changes in various SVR states; however, the accuracy of CO measurement and its trending ability in various SVR states was poor., Competing Interests: Conflict of Interest Koichi Suehiro has received speaker fees from Edwards Lifesciences., (Copyright © 2020 Elsevier Inc. All rights reserved.)

On Mar 11, 2020, the World Health Organization declared coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a pandemic. Because COVID-19 has a pre-symptomatic period of up to 2 weeks, SARS-CoV-2 infection has continued to spread. Some individuals with SARS-CoV-2 infection have a severe clinical course, while most individuals have mild or moderate symptoms. Because SARS-CoV-2 is transmitted via droplets and secretions, anesthesiologists have higher risks of infection, especially during airway management. Therefore, general anesthesia requiring airway management can be a challenging procedure for anesthesiologists. During the pandemic, many elective surgeries have been postponed or cancelled in most affected countries. Recently, the number of elective surgeries is gradually recovering from the effect of the COVID-19 pandemic, and hence, safe clinical practice and protocols to prevent SARS-CoV-2 transmission to medical staff should be established. This mini-review focuses on the preoperative assessment and decision with regard to scheduling surgery in elective and emergency cases during the COVID-19 pandemic. A standardized questionnaire and algorithm regarding COVID-19 should be used to assess surgical patients preoperatively as it increases the reproducibility and accuracy of the decision whether to proceed with surgery.

Purpose: Invasive arterial blood pressure (IAP) and noninvasive blood pressure (NIBP) measurements are both common methods. Recently, a new method of error grid analysis was proposed to compare blood pressure obtained using two measurement methods. This study aimed to compare IAP and NIBP measurements using the error grid analysis and investigate potential confounding factors affecting the discrepancies between IAP and NIBP., Methods: Adult patients who underwent general anesthesia in the supine position with both IAP and NIBP measurements were retrospectively investigated. The error grid analyses were performed to compare IAP and NIBP. In the error grid analysis, the clinical relevance of the discrepancies between IAP and NIBP was evaluated and classified into five zones from no risk (A) to dangerous risk (E)., Results: Overall, data of 1934 IAP/NIBP measurement pairs from 100 patients were collected. The error grid analysis revealed that the proportions of zones A-E for systolic blood pressure were 96.4%, 3.5%, 0.05%, 0%, and 0%, respectively. In contrast, the proportions for mean blood pressure were 82.5%, 16.7%, 0.8%, 0%, and 0%, respectively. The multiple regression analysis revealed that continuous phenylephrine administration (p = 0.016) and age (p = 0.044) were the significant factors of an increased clinical risk of the differences in mean blood pressure., Conclusions: The error grid analysis indicated that the differences between IAP and NIBP for mean blood pressure were not clinically acceptable and had the risk of leading to unnecessary treatments. Continuous phenylephrine administration and age were the significant factors of an increased clinical risk of the discrepancies between IAP and NIBP.

Background: This study aimed to determine the factors that affect the extracellular fluid (ECF) content in the legs of patients with chronic venous disease (CVD)., Methods: Bioimpedance analysis and air plethysmography (APG) were performed in 79 patients with CVD who visited our clinic between September 2016 and March 2019. The normal right legs (N) of 14 healthy volunteers were also reviewed for comparison. The ratio of ECF resistance (Re) of the leg to that of the arm (ReL/ReA) was used to express the ECF content in the tested leg. The severity of CVD was expressed using the clinical, etiological, anatomical, and pathophysiological (CEAP) classification., Results: The ReL/ReA decreased as the CEAP class increased (N: median; 0.81 [range 0.66-0.95], C0-1: 0.79 [0.60-0.98], C2: 0.77 [0.56-1.08], C3: 0.67 [0.57-0.85], C4: 0.64 [0.44-0.89]). Older age, female sex, and CEAP class affected the ReL/ReA, but body mass index did not. The ReL/ReA did not correlate with the parameters that were derived from APG, including the venous filling index., Conclusions: We found that the ECF content in legs of patients with CVD might be primarily affected by patient-related factors and CEAP class, as opposed to venous hemodynamics., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Endovascular aneurysm repair (EVAR) using a bifurcated stent graft may involve technical challenges when aortic disease (aneurysm or dissection) consists of a length <70 mm between the inferior renal artery and aortic bifurcation or narrow aortic bifurcation that is common in asymmetric distal abdominal aortic aneurysms (AAAs) or iliac artery aneurysms (IAAs). We use EVAR with the double D technique (DDT-EVAR) for such cases, which involves straight type of stent grafts with same diameter in left and right that are deployed parallel to an aortic cuff that has been previously placed. In addition, DDT-EVAR can preserve the inferior mesenteric artery (IMA) for IAA., Methods: DDT-EVAR was performed for 21 of 910 (2%) cases from April 2007 to April 2019 at our institution. The median patient age was 74 years (range, 52-85). Nineteen patients (90%) were men. Six patients (all saccular; 1 rupture) had AAAs, 12 had IAAs, and 3 had chronic type B aortic dissociation (TBAD) for re-entry closure. AAA and IAA had diameters of 45 mm (range, 34-71) and 34 mm (range, 25-58), respectively. An aortic cuff was used for 19 (90%) cases. Endurant II (Medtronic, Santa Rosa, CA) was used for 12 cases. The Excluder (W.L. Gore & Associates, Inc, Flagstaff, AZ) was used for 7 cases. Endurant II was used for 20 cases, and the VBX (W.L. Gore & Associates, Inc) was used for 1 case as stent-graft limbs., Results: The procedural success rate was 100%. The median operative time was 146 min (range, 88-324). IMA planned for preservation was successful for all 12 cases. Type I and type III endoleaks were not observed. With TBAD, flow to the false lumen decreased or disappeared, and no complications during the hospital stay were associated with the procedure. For 2 patients whose procedure involved Endurant II stent-graft limb, limb occlusions were observed postoperatively, and reintervention was required. No other patients required additional treatment at a median follow-up of 18 months (range, 4-50)., Conclusions: DDT-EVAR is a safe and straightforward technique for the treatment of distal AAA, common iliac artery aneurysm, and TBAD. It may help preserve the IMA and internal iliac artery, even when it is impossible to preserve them with a bifurcated stent graft., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: We sought to clarify the interface pressure (IP) when using a tubular elastic bandage (TEB) and examine the possibility for TEBs to provide IPs comparable to those provided by anti-thrombotic stockings. Materials and Methods: In 40 healthy patients, IPs were measured at the level of calf at its maximum diameter (C) and transition of the medial gastrocnemius muscle into the Achilles tendon (B1) while a single or double layer of TEBs (17.5 cm in circumference) were applied with the patient in a supine position. Results: Including both the C and B1 levels, circumferences and IPs showed a good correlation (single layer; r=0.72, double layer; r=0.75). The IP obtained with a single layer of TEB at the C level (median, 17 mmHg [range, 12-23 mmHg]) was higher than that at the B1 level (14 mmHg [11-18 mmHg], p<0.001). When double-layer TEB was used, the IP at B1 level increased to 18 (14-23) mmHg (p<0.001 vs. single layer). Conclusion: Considering the characteristics of TEBs and using a single or double layer appropriately, creating a pressure profile mimicking that of an anti-thrombotic stocking seemed to be feasible when using a TEB., Competing Interests: Disclosure StatementThe authors declare that there is no conflict of interest., (© 2020 The Editorial Committee of Annals of Vascular Diseases.)

Background: Transthoracic oesophagectomy is associated with major morbidity and mortality, which may be reduced by goal-directed therapy (GDT). The aim of this multicentre, RCT was to evaluate the impact of intraoperative GDT on major morbidity and mortality in patients undergoing transthoracic oesophagectomy., Methods: Adult patients undergoing transthoracic oesophagectomy were randomised to receive either minimally invasive intraoperative GDT (stroke volume variation <8%, plus systolic BP maintained >90 mm Hg by pressors as necessary) or haemodynamic management left to the discretion of attending senior anaesthetists (control group; systolic BP >90 mm Hg alone). The primary outcome was the incidence of death or major complications (reoperation for bleeding, anastomotic leakage, pneumonia, reintubation, >48 h ventilation). A Cox proportional hazard model was used to examine whether the effects of GDT on morbidity and mortality were independent of other potential confounders., Results: A total of 232 patients (80.6% male; age range: 36-83 yr) were randomised to either GDT (n=115) or to the control group (n=117). After surgery, major morbidity and mortality were less frequent in 22/115 (19.1%) subjects randomised to GDT, compared with 41/117 (35.0%) subjects assigned to the control group {absolute risk reduction: 15.9% (95% confidence interval [CI]: 4.7-27.2%); P=0.006}. GDT was also associated with fewer episodes of atrial fibrillation (odds ratio [OR]: 0.18 [95% CI: 0.05-0.65]), respiratory failure (OR: 0.27 [95% CI: 0.09-0.83]), use of mini-tracheotomy (OR: 0.29 [95% CI: 0.10-0.81]), and readmission to ICU (OR: 0.09 [95% CI: 0.01-0.67]). GDT was independently associated with morbidity and mortality (hazard ratio: 0.51 [95% CI: 0.30-0.87]; P=0.013)., Conclusions: Intraoperative GDT may reduce major morbidity and mortality, and shorten hospital stay, after transthoracic oesophagectomy., Clinical Trial Registration: UMIN000018705., (Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Competing interests: The authors have no conflicts of interest to disclose.

We aimed to elucidate the dermoscopic vasculature of patients with Bowen Disease (BD) that was misdiagnosed as chronic eczema and had branched and/or reticular vessels after topical steroid application. The medical records of 19 patients with BD on the upper trunk were retrospectively reviewed for steroid use history, vascular structure observed in dermoscopy, and corresponding histological findings. Four patients treated with strong topical steroids showed remarkable branched and/or reticular vessels on dermoscopy. Histopathology showed partial epidermal atrophy with irregular thin elongation of the rete ridges, atypical keratinocyte proliferation in the epidermis, and vasodilation in the superficial dermis. We considered that vasodilation and partial epidermal atrophy may be induced by topical steroid application in BD-affected areas. In cases of suspected BD with reddish-brown plaque showing branched and/or reticulated vessels in dermoscopy, confirming a history of topical steroid use is helpful., Competing Interests: Conflict of interest: The authors declare no potential conflict of interests., (©Copyright: the Author(s).)

Background/aims: This study sought to confirm the difference of the wound-healing effect, cell survival, and immune response between autologous fibroblast sheets and allogeneic fibroblast sheets., Methods: Regarding wound healing, autologous or allogeneic fibroblast sheets were transplanted onto a mouse cutaneous wound healing model and the wound contraction rate was evaluated. The luciferase-expressing fibroblast sheet was prepared and the survival of the cell sheet was evaluated by IVIS ® after autologous or allogeneic transplantation. Histological evaluation was performed at five and 14 days after transplantation., Results: Allogeneic fibroblast-sheet transplantation showed significant wound contraction at the early phase of wound healing, which was equivalent to that seen with the autologous fibroblast sheets. Luminescence of the autologous and allogeneic luciferase-expressing fibroblast sheets peaked on Day 5, and no luminescence was observed on Day 13. In the allogeneic fibroblast-sheet transplant group, a significant accumulation of immune cells was observed in the healed tissue but not in the early stage of wound healing., Conclusion: The allogeneic fibroblast sheets showed comparable rates of cell survival and wound-healing effects to those of the autologous fibroblast sheets, despite the subsequent immunogenic response. This result supports the potential practical clinical application of scaffold-free allogeneic fibroblast sheets based on the paracrine effect., Competing Interests: None., (AJTR Copyright © 2020.)

Background: This study investigated the ability of stroke volume variation (SVV) during deep breathing to discriminate fluid responders among spontaneously breathing patients., Methods: Thirty patients undergoing general anaesthesia were enrolled and assessed before anaesthetic induction. Haemodynamic variables, including stroke volume (SV) and SVV, were measured using the ClearSight system during normal breathing. After these measurements, each patient was required to maintain deep breathing (6 breaths min -1 ) and haemodynamic variables were recorded. Then, the table was adjusted to the Trendelenburg position (15°) for 2 minutes, and haemodynamic variables were measured. Receiver operating characteristic curves were created for SVV during normal and deep breathing, and the difference in SVV between normal and deep breathing (ΔSVV) to discriminate fluid responders (SV increase >10% after changing position). The correlation between SV increase and ΔSVV was examined using Pearson's correlation coefficient. The grey zone approach was used to assess the inconclusive range of the haemodynamic variables., Results: Receiver operating characteristic curve analysis indicated that ΔSVV showed good reliability in predicting fluid responsiveness (AUC: 0.850; 95% CI: 0.672-0.953; threshold: 4%, sensitivity: 75.0%, specificity: 88.9%], while SVV during normal breathing did not (AUC: 0.579; 95% CI: 0.386-0.756)]. Although SVV during deep breathing exhibited acceptable predictability (AUC: 0.778; 95% CI: 0.589-0.908), the sensitivity was not good (58.3%). With the grey zone approach, the inconclusive range of ΔSVV was small with the range of 1.4%-4.2% (23% of patients)., Conclusion: Deep breathing could improve the reliability of dynamic indices in spontaneously breathing patients., Trial Registration: UMIN-CTR, identifer: UMIN000027970. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr&#95;view.cgi?recptno=R000032040., (© 2019 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Objective: Musculoskeletal ultrasound (US) is more sensitive than physical examination in detecting synovitis and helps physicians to understand its pathophysiology. In this study, we aimed to determine if the experience in musculoskeletal US scanning is independently associated with improved physical examination skills to detect synovitis., Method: Seventy patients with rheumatoid arthritis and twenty-three physicians were enrolled. Patients were first assessed by multiple physicians with a range of clinical/sonographic experience for the swelling of the wrist, metacarpophalangeal and proximal interphalangeal (PIP) joints and next underwent US assessment performed by another physician experienced in musculoskeletal US. We then calculated the positive/negative predictive values (PPV/NPV) of joint swelling to identify US-detected synovial hypertrophy. Finally, the factors independently associated with the accuracy of clinical assessment were identified by using multivariate analyses., Results: One thousand five hundred forty joints were assessed 6116 times in total for swelling. Overall, PPV and NPV of joint swelling were 51.7% and 88.3%, respectively. Multivariate analyses identified wrist joint, tenderness, male and greater patients' age as the factors significantly associated with higher PPV. In addition, there was a trend that longer experience in rheumatology clinical practice was associated with higher PPV (p = 0.058). On the other hand, longer experience in musculoskeletal US, PIP joint and positive rheumatoid factor were identified as the significant factors for higher NPV, while wrist joint, tenderness, presence of osteophyte and obesity as those for lower NPV., Conclusion: Our data suggest that the experience in musculoskeletal US improves physical examination skills particularly to avoid overestimation.Key Points• Physicians with longer US experience are less likely to overestimate synovitis by physical examination.• Musculoskeletal US is a useful tool for rheumatologists to improve their physical examination skill.• Presence of osteophytes, joint tenderness and obesity influence the accuracy of physical examination of joints.

Objective: This study aimed to evaluate the effect of inferior mesenteric artery (IMA) embolization during endovascular aneurysm repair (EVAR) in patients at high risk of type II endoleak (T2EL) in randomized controlled trial (RCT)., Summary Background Data: Several studies have demonstrated a reduction of T2EL by IMA embolization before EVAR. However, there have been no RCT confirming the efficacy of IMA embolization., Methods: Patients scheduled for elective EVAR between April 2014 and March 2018 were eligible. Patients at high risk of T2EL (IMA patency with IMA ≥3 mm, LAs ≥2 mm, or an aortoiliac-type aneurysm) were prospectively randomized to receive EVAR with or without IMA embolization. The primary endpoint was occurrence of T2EL during follow-up. Secondary endpoints included aneurysmal sac changes, adverse events from IMA embolization, and reintervention rate due to T2EL. This trial is registered with the University Hospital Medical Information Network, number UMIN000022147., Results: One hundred thirteen patients had high risk and 106 were randomized. In the intention-to-treat analysis, the incidence of T2EL was significantly lower in the embolization group [24.5% vs 49.1%; P = 0.009, absolute risk reduction = 24.5%; 95% confidence interval (CI), 6.2-40.5, number needed to treat = 4.1; 95% CI, 2.5-16.1]. The aneurysmal sac shrunk significantly more in the embolization group (-5.7 ± 7.3 mm vs -2.8 ± 6.6 mm; P = 0.037), and the incidence of aneurysmal sac growth related to T2EL was significantly lower in the embolization group (3.8% vs 17.0%; P = 0.030). There were no complications related to IMA embolization or reinterventions associated with T2EL., Conclusions: Our results demonstrated the effectiveness of IMA embolization during EVAR in high-risk patients for the prevention of T2EL, which is suggested for avoiding aneurysmal sac enlargement related to T2EL.

This study aimed to compare the prognostic performance of the ratio of mixed and central venous-arterial CO 2 tension difference to arterial-venous O 2 content difference (Pv-aCO 2 /Ca-vO 2 and Pcv-aCO 2 /Ca-cvO 2 , respectively) with that of the mixed and central venous-to-arterial carbon dioxide gradient (Pv-aCO 2 and Pcv-aCO 2 , respectively) for adverse events after cardiac surgery. One hundred and ten patients undergoing cardiac surgery with cardiopulmonary bypass were enrolled. After catheter insertion, three blood samples were withdrawn simultaneously through arterial pressure, central venous, and pulmonary artery catheters, before and at the end of the operation, and preoperative and postoperative values were determined. The primary end-point was set as the incidence of postoperative major organ morbidity and mortality (MOMM). Receiver operating characteristic (ROC) curve and multivariate logistic regression analyses were performed to evaluate the prognostic reliability of Pv-aCO 2 , Pcv-aCO 2 , Pv-aCO 2 /Ca-vO 2 , and Pcv-aCO 2 /Ca-cvO 2 for MOMM. MOMM events occurred in 25 patients (22.7%). ROC curve analysis revealed that both postoperative Pv-aCO 2 /Ca-vO 2 and Pcv-aCO 2 /Ca-cvO 2 were significant predictors of MOMM. However, postoperative Pv-aCO 2 was the best predictor of MOMM (area under the curve [AUC]: 0.804; 95% confidence interval [CI] 0.688-0.921), at a 5.1-mmHg cut-off, sensitivity was 76.0%, and specificity was 74.1%. Multivariate analysis revealed that postoperative Pv-aCO 2 was an independent predictor of MOMM (odds ratio [OR]: 1.42, 95% CI 1.01-2.00, p = 0.046) and prolonged ICU stay (OR: 1.45, 95% CI 1.05-2.01, p = 0.024). Pv-aCO 2 at the end of cardiac surgery was a better predictor of postoperative complications than Pv-aCO 2 /Ca-vO 2 and Pcv-aCO 2 /Ca-cvO 2 .

Background: To study the effect of prolonged complex decongestive therapy (CDT) on lymphedema in arms without a subcutaneous echo-free space (SEFS) on subcutaneous tissue ultrasonography., Methods: Fifty-one patients with arm lymphedema treated for longer than 1 year using CDT in our clinic were retrospectively evaluated. Before starting CDT, subcutaneous tissue ultrasonography was performed to examine for the presence of an SEFS. Two-stage CDT was performed as recommended by the International Society of Lymphology. Limb circumference was measured, and limb volume was calculated at the initial and latest visits., Results: In patients with lymphedema in which SEFS was observed anywhere in the arm on the initial visit (n = 25), the edema ratio was significantly reduced by a median of -15% (range, -106% to 17%; P < 0.001). On the other hand, in the arms with lymphedema in which SEFS was not observed (SEFS[-], n = 26), the edema ratio was not changed significantly by CDT (median, 1% [range, -30% to 23%]). In arms without an SEFS that were not treated using arm sleeves regularly (n = 15), no increase in edema ratio was observed (median, 1% [range, -29% to 16%])., Conclusions: In arms with lymphedema without SEFS, the effect of CDT on the reduction of arm volume is limited., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: This study aimed to clarify the variations in indices derived from noninvasive assessments for the early detection of postmastectomy lymphedema (LE) from 1 month preoperatively until 2 years postoperatively., Methods: In total, 120 patients who underwent surgery for breast cancer in our institution were prospectively followed up with a questionnaire for arm swelling as well as with tape measurements, bioimpedance analysis (BIA), and skin and subcutaneous tissue ultrasound at 1 month before and 3, 6, 12, 18, and 24 months after surgery., Results: Ninety-seven patients completed the study. Among 93 patients who did not present with LE, 9% complained of arm swelling even before surgery, and the incidence peaked at 17% at 6 months after surgery. There were no differences in the circumferences of the upper arm, forearm, and hand between sides throughout the study period. However, the postoperative circumference values of the upper arm only on the operation side were slightly increased compared with the preoperative values. The mean excess fluid in the arm on the operation side compared with the contralateral side, as assessed by BIA, was nearly zero throughout the study period. There were no differences in subcutaneous echogenicity or skin and subcutaneous thicknesses between the sides throughout the study period. However, time-dependent increases in subcutaneous thicknesses were noticed on both sides. Four patients (4.1%) developed LE. In three of these patients, abnormality in the BIA was recorded 6 to 12 months before presentation. Immediately after presentation, the common findings included BIA abnormality and increased subcutaneous echogenicity and skin thickness in the medial forearm., Conclusions: In this study, a complaint of arm swelling was not sensitive enough for detection of the early onset of LE because a certain number of patients constantly complained of this symptom. Measurements of circumference might help in the diagnosis of LE onset, but this method is not specific enough because these measurements are also affected by various factors. However, BIA and skin and subcutaneous ultrasound were identified as potential tools for the early detection of LE., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Concurrent abdominal aortic aneurysm (AAA) and unilateral iliac occlusion is a challenge in the implantation of bifurcated stent grafts (BFGs). The endovascular approach is less invasive than open surgery; the aortouni-iliac (AUI) graft with crossover femorofemoral bypass (CFFB) has many problems associated with extra-anatomic reconstruction. We attempted endovascular aneurysm repair (EVAR) using BFGs in such cases and evaluated the outcomes., Methods: This was a retrospective study. Between October 2012 and December 2017, there were 649 patients who underwent surgery for AAA, of whom 32 patients underwent open reconstruction and 617 patients underwent endovascular aneurysm repair; 15 patients with unilateral occluded iliac arteries and AAA were included. The analysis included patients with unilateral iliac chronic total occlusion (CTO). The intraoperative, postoperative, and follow-up variables were reviewed., Results: The occluded lesions were the common iliac artery in 5 patients, the common iliac artery-external iliac artery (EIA) in 2 patients, the EIA in 7 patients, and the EIA-common femoral artery in 1 patient. The mean occlusive length was 89.7 ± 43.6 mm, and the mean AAA size was 54.6 ± 5.6 mm. Technical success was achieved in 13 patients (87%). All patients underwent recanalization through the true lumen and stent placement. The only procedure-related complication was distal embolism, which was treated with intraoperative thrombectomy. Recanalization of CTO lesions was not possible in two patients (13%), who underwent AUI graft placement with CFFB. The 30-day mortality and morbidity rates were 0%. The mean follow-up periods were 12 and 32 months for patients who underwent BFG placement and AUI graft placement with CFFB, respectively. During follow-up, the primary patency rate of successfully recanalized arteries was 100%. Aneurysm size decreased in four patients who underwent BFG placement; no change was seen in the other 11 patients. Freedom from aneurysm-related events was 100%; no patient needed secondary interventions. All patients with claudication pain preoperatively reported improvement in their symptoms during follow-up. In addition, the ankle-brachial index improved significantly from 0.51 ± 0.25 preoperatively to 0.88 ± 0.20 postoperatively (P < .001) in patients who underwent BFG placement., Conclusions: Recanalization of unilateral iliac CTO lesions and placement of BFG in cases with concomitant aneurysmal disease and unilateral iliac occlusive disease demonstrated a significant primary patency rate with improvements in claudication and ankle-brachial index., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the advantages of chimney endovascular aneurysm repair (chEVAR) using an Endurant stent-graft with uncovered balloon-expandable stents (BES) for patients with juxtarenal aortic aneurysms., Materials and Methods: Twenty-two patients (mean age 78.5±9.0 years; 13 men) who underwent chEVAR using Endurant and uncovered BES between January 2014 and December 2017 were analyzed retrospectively. The maximum aneurysm diameter was 59.1±11.9 mm, and the proximal neck length was 5.2±2.9 mm. Of the 22 cases, 9 (40%) involved proximal neck angulation and 9 (40%) had a conical neck. Single and double chimneys were performed using BES in 19 and 3 cases, respectively. In 2 cases, an additional self-expanding covered stent was used inside the uncovered BES., Results: The technical success was 91% (20/22) as 2 (9%) cases showed minor type Ia endoleak. No postoperative systemic complications or acute renal dysfunction (Acute Kidney Injury Network classification stage 2 or higher) were observed. The mean radiologic observation period was 16.1±9.6 months, and no aneurysm expansion (>5 mm) was observed during this time. The mean maximum aneurysm diameter decreased to 52.9±10.2 mm (p<0.001 vs preoperative), with an individual mean sac regression of 6.2±5.9 mm. Overall primary chimney stent patency was 100%. One of the 2 cases of intraoperative type Ia endoleak resolved at the 6-month imaging, and no new type Ia endoleaks developed in any cases at follow-up. No additional treatment- or aneurysm-related events were observed., Conclusion: Short-term outcomes of chEVAR using Endurant with uncovered BES have been favorable when covered stents were unavailable, and it can be useful for high-risk patients with juxtarenal aortic aneurysms.

We report nine cases with acute or subacute lipodermatosclerosis treated successfully using multilayer bandages. All patients were women aged 52-90 years. Before presenting to our clinic, all patients had been treated for a tentative diagnosis of cellulitis caused by bacterial infection or inflammation of unknown cause for 3-19 weeks without improvement. Initially, we instructed all patients or their caregivers regarding the bandaging technique to achieve an interface pressure of >40 mmHg. Subsequently, this technique was continued by patients/caregivers. Symptoms subsided within 2-7 weeks in all patients except one who had been noncompliant with the compression therapy.

Objectives: To assess whether a tissue Doppler imaging (TDI)-based parameter consisting of the sum of early diastolic velocities of the mitral annulus (Me') and tricuspid annulus (Te') can serve as a predictor of adverse outcomes after cardiac surgery., Design: Prospective, observational study., Setting: University hospital., Participants: The study comprised 100 patients undergoing cardiac surgery., Interventions: None., Measurements and Main Results: After anesthetic induction, transesophageal echocardiography was performed to obtain the values of the early transmitral flow velocity (E), Me', and Te'. The primary endpoint was the incidence of postoperative major organ morbidity and mortality (MOMM) events, including death, redo surgery, prolonged ventilation, stroke, sternal infection, and dialysis. Receiver operating characteristic and multivariate logistic analyses were used to examine the prognostic performance of TDI-based parameters for predicting MOMM incidence. The secondary endpoint was the incidence of death or rehospitalization for cardiovascular disease within 1 year post-discharge. TDI-based parameters were measured in 87 of the 100 patients enrolled. Me' plus Te' had better prognostic ability (area under the curve 0.771; threshold 13 cm/s; sensitivity 86.7%; specificity 64.9%) than that of Me' or E to Me' (E/Me')% and was an independent predictor of MOMM (odds ratio 0.45; 95% confidence interval 0.28-0.74, p = 0.001), whereas Me' was not. Lower Me' plus Te' (≤13 cm/s) was associated with a significantly higher incidence and earlier onset of cardiovascular events within 1 year post-discharge (p = 0.012)., Conclusions: Compared with Me' and E/Me', which traditionally are used for assessing diastolic function, Me' plus Te' showed better prognostic ability for both short- and long-term outcomes of cardiac surgery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: This study aimed to investigate the efficacy of the ClearSight™ system (Edwards Lifesciences, Irvine, CA) for reducing the incidence of hypotension compared with the traditional oscillometric blood pressure monitoring in cesarean delivery under spinal anesthesia., Methods: Forty patients undergoing cesarean delivery under spinal anesthesia were enrolled. The patients were randomly divided into two groups (Control and ClearSight groups). All patients received spinal anesthesia using 0.5% hyperbaric bupivacaine (11.5 mg) and fentanyl (10 µg). Blood pressure was managed with the same protocol using the ClearSight™ system (ClearSight group) and oscillometric blood pressure monitoring (Control group). Furthermore, we compared the accuracy of the ClearSight™ system with the traditional oscillometric monitoring for blood pressure measurement using Bland-Altman, four-quadrant plot, and polar plot analyses., Results: The incidence of hypotension was significantly lower in the ClearSight group from induction to delivery (45% vs. 0%, p < 0.001) and to the end of surgery (50% vs. 20%, p = 0.049). Intraoperative nausea occurred more frequently in the Control group (45% vs. 10%, p = 0.012). The ClearSight™ system demonstrated acceptable accuracy with a bias of - 4.3 ± 11.7 mmHg throughout the procedure. Four-quadrant analysis revealed an excellent trending ability of the ClearSight™ system with a concordance rate of approximately 95%. In the polar plot analysis, the angular bias and concordance rate were - 13.5° ± 19.0° and 76.9%, respectively., Conclusions: The accuracy and trending ability of the ClearSight™ system for blood pressure measurement was clinically acceptable in cesarean delivery under spinal anesthesia, leading to reductions in maternal hypotension and nausea.

This study assessed the ability of a continuous non-invasive blood pressure (BP) monitoring system to reduce intra-anesthetic hemodynamic fluctuation compared with intermittent BP cuff measurement. Forty patients undergoing total knee arthroplasty under general anesthesia were enrolled and randomly divided into two groups (Control and CS group). BP management was performed using the same protocol with BP measured by intermittent BP cuff in the Control and that by continuous non-invasive BP monitoring in the CS group. We assessed the accuracy and precision of the continuous non-invasive BP monitoring compared with BP cuff measurement using Bland-Altman, four-quadrant plot, and polar-plot analyses. Additionally, the occurrence of hypotension and hypertention during general anesthesia was compared between the two groups. The continuous non-invasive BP monitoring showed excellent accuracy of - 1.1 ± 8.1 mmHg during surgery and an acceptable trending ability with a concordance rate of 95.1% according to the four-quadrant plot analysis and an angular concordance rate of 86.7% by polar-plot analysis. Hypotension was less common in the CS group during induction of anesthesia (p = 0.002) and surgery (p = 0.008). Hypertension occurred more frequently in the Control group during emergence from anesthesia (p = 0.037). The duration of hemodynamic stability (systolic BP 80-110% of baseline) intraoperatively was longer in the CS group than in the Control group (87.7 vs. 61.9%; p < 0.001). Accuracy and trending ability of the continuous non-invasive BP monitoring was clinically acceptable, and lead to hemodynamic stability and reduction of intra-anesthetic hypotension and hypertension intraoperatively.