Anatomical bases for paravertebral anesthetic block: fluid communication between the thoracic and lumbar paravertebral regions

An injection of a local anesthetics in the paravertebral region produces an analgesic field on the same side of the body, a paravertebral block. One point in question about this block is whether the local anesthetic spreads from the thoracic to the lumbar level of the paravertebral region. The purpose of this study was to find how the anesthetic fluid traveled to the lumbar paravertebral region, if at all. Twelve cadavers were used in this study. 15 ml of crimson dye was injected into the paravertebral region at the 11th thoracic level. The viscerae were removed so that we could examine the dye spread. While the crimson dye spread in the endothoracic fascia posterior to the parietal pleura, it also spread downward in the fascia mostly along the splanchnic nerves. At the upper surface of the diaphragm the dye spread laterally in the fascia, and entered the abdominal cavity through the medial and lateral arcuate ligaments. In the abdominal cavity, the dye was found to have spread so widely in the transversalis fascia that the subcostal, iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous and femoral nerves were involved. We concluded that the dye in the thoracic paravertebral region can enter the abdominal cavity through the medial and lateral arcuate ligaments. This study explained possible fluid communication between the thoracic and lumbar paravertebral regions and confirmed our former clinical observations. The result is important for the future clinical application of paravertebral anesthesia.

A single-injection, multi-segmental paravertebral block-extension of somatosensory and sympathetic block in volunteers

BACKGROUND

It is our experience that a deposition of an anesthetic solution in the ventral area of the paravertebral space near the parietal pleura and the sympathetic trunk produces extended unilateral block. Because sympathetic block effects in this extended paravertebral block are not reported yet, we undertook this singly blinded, controlled study on the sympathetic change in volunteers.

METHODS

A total of 22 ml 1% lidocaine was injected at the T11 level into the ventral area of the right-sided paravertebral space in 16 volunteers. The distribution of analgesia, heart rate, blood pressure and body temperature (measured by 12 skin sensors) was monitored. On a later occasion the volunteers underwent a control injection of saline.

RESULTS

Unilateral analgesia (with no contralateral element) was induced in every subject injected with lidocaine, contrasted with no block induction with saline. Loss of pin-prick sensation was observed within 10 min after injection and involved a mean of 12 (range 8-13) dermatomes. A sympathetic block was indicated by cutaneous temperature increase within at least 6 dermatomes. Increase of arterial blood pressure was obtained in all volunteers with no change in pulse rate. No side effects or complications occurred. Epidural spread of the local anesthetic was unlikely because of the absence of contralateral cutaneous analgesia and temperature increase.

CONCLUSION

One-sided extended analgesia (sensory loss) follows the paravertebral injection of lidocaine. A large ipsilateral sympathetic block is observed without change in pulse rate and with no hypotension. These are all characteristics of an optimal regional block.

Highly parallelized human embryonic stem cell differentiation to cardiac mesoderm in nanoliter chambers on a microfluidic chip

Human stem cell-derived cells and tissues hold considerable potential for applications in regenerative medicine, disease modeling and drug discovery. The generation, culture and differentiation of stem cells in low-volume, automated and parallelized microfluidic chips hold great promise to accelerate the research in this domain. Here, we show that we can differentiate human embryonic stem cells (hESCs) to early cardiac mesodermal cells in microfluidic chambers that have a volume of only 30 nanoliters, using discontinuous medium perfusion. 64 of these chambers were parallelized on a chip which contained integrated valves to spatiotemporally isolate the chambers and automate cell culture medium exchanges. To confirm cell pluripotency, we tracked hESC proliferation and immunostained the cells for pluripotency markers SOX2 and OCT3/4. During differentiation, we investigated the effect of different medium perfusion frequencies on cell reorganization and the expression of the early cardiac mesoderm reporter MESP1mCherry by live-cell imaging. Our study demonstrates that microfluidic technology can be used to automatically culture, differentiate and study hESC in very low-volume culture chambers even without continuous medium perfusion. This result is an important step towards further automation and parallelization in stem cell technology.

Difficult tracheal intubation in patients with retinoblastoma caused by 13q deficiency

Anesthetic management of retinoblastoma patients is unremarkable in most cases. Patients are most often babies and laryngoscopic procedures for intubation are usually easy. However, we recently experienced two cases with retinoblastoma with whom tracheal intubation was accomplished with difficulty. We report the two cases with a review of all 5-year records of retinoblastoma (rbl) in our institution. The cases we experienced recently were all patients with rbl with deletion of the long arm of thirteenth chromosome (13q-). In the 5-year review, the incidence of the difficult intubation was significantly higher (P < 0.05) in rbl with 13q- (4/11) than in rbl without 13q- (0/147). In our experience macroglossia was noted for the difficulty in the intubation. We assume that some patients with rbl will be cases of difficult intubation even to cannot ventilate-cannot intubate level when the results of their chromosomal analysis show a deletion on the thirteenth chromosome.

The difference between delayed extubation and tracheostomy in post-operative sleep apnea after glossectomy or laryngectomy

BACKGROUND

Patients with cancer of the tongue or larynx require glossectomies or laryngectomies and subsequent reconstruction. These procedures remove part of the patient's upper airway. In cancer of the tongue, the removed part of the airway is substituted by a flap of their skin. Post-operatively, it is possible that the patients have problems respiring comfortably. In addition to this, long surgical procedures may simply interfere with their circadian rhythm. To elucidate the possible change in their post-operative respiration, we monitored the patient's respiratory pattern with an apnea monitor.

METHODS

We attached an apnea monitor to the patients and recorded their respiratory pattern and arterial oxygen saturation. The patients were monitored for a total of five days: three days prior to the operation, one day before the operation, the day of operation, two days after, and on the fourth day after the operation. The period of monitoring was from 8:00 p.m. to 6:00 a.m. the next morning.

RESULTS

Sixteen patients completed this study. The patients whose tube was extubated after glossectomy showed frequent apnea, low mean oxygen saturation and low comfort score as compared to the patients with tracheostomy after laryngectomy. Because two failed cases of free skin flap were among the former, it is possible that the frequent apnea is a factor of failed free skin graft after glossectomy and laryngectomy.

CONCLUSION

Further studies are required to improve the patient's respiration during their sleep after tracheal extubation in glossectomy.

[A case report of granulomatous orchitis--review of 20 cases in Japan]

We report a case of granulomatous orchitis. A 31-year-old male complained of right lumbago and scrotal pain. The ultrasonographic finding was multiple hypo-echoic areas in the right testis as highly suggestive of testicular cancer. The diagnosis was made after orchiectomy. Granuromatous orchitis is a rare disease which true etiology remains obscure. Only 20 cases have been reported in Japan. The clinical, radiological and pathological features of 20 cases are presented and discussed. Patients' age ranged from 29 to 79 years, an average of 55 years. The left testis was involved in 7 patients, the right in 9 and 4 cases were bilateral. Ultrasonographic examination of the affected testis revealed hypoechoic mass, so little value in differentiating granulomatous orchitis from neoplasm. The correct diagnosis of granulomatous orchitis has never been made prior to surgery, because it clinically bears a lot of resemblance to testicular cancer. The diagnosis usually is made on histological examination. Orchiectomy is the main form of treatment to date, because antibiotics have little effect on the course of the disease and at the time of diagnosis, the testis is already destroyed and there is hardly any viable testicular tissue in the removed specimens.

Mass production of lumenogenic human embryoid bodies and functional cardiospheres using in-air-generated microcapsules

Organoids are engineered 3D miniature tissues that are defined by their organ-like structures, which drive a fundamental understanding of human development. However, current organoid generation methods are associated with low production throughputs and poor control over size and function including due to organoid merging, which limits their clinical and industrial translation. Here, we present a microfluidic platform for the mass production of lumenogenic embryoid bodies and functional cardiospheres. Specifically, we apply triple-jet in-air microfluidics for the ultra-high-throughput generation of hollow, thin-shelled, hydrogel microcapsules that can act as spheroid-forming bioreactors in a cytocompatible, oil-free, surfactant-free, and size-controlled manner. Uniquely, we show that microcapsules generated by in-air microfluidics provide a lumenogenic microenvironment with near 100% efficient cavitation of spheroids. We demonstrate that upon chemical stimulation, human pluripotent stem cell-derived spheroids undergo cardiomyogenic differentiation, effectively resulting in the mass production of homogeneous and functional cardiospheres that are responsive to external electrical stimulation. These findings drive clinical and industrial adaption of stem cell technology in tissue engineering and drug testing.

[Studies on recent clinically isolated Staphylococcus aureus--drug susceptibility and incidence of MRSA in clinical isolates]

Susceptibility of various antimicrobial agents against clinically isolated Staphylococcus aureus was evaluated by Kirby Bauer methods. The incidence of MRSA (Methicillin cephem resistant Staphylococcus aureus) was also investigated. When S. aureus was isolated from urine, the clinical background of the case was further studied. The results are listed below; 1) M1N0 showed the highest susceptibility rate (83.1%) against 537 strains of S. aureus tested, followed by CMZ (63.7%) and CET (63.5%). The susceptibility rate of DMPPC was 41.9%. The incidence of MRSA was 31.3%. 2) In effusion, MRSA was most highly isolated (72.2%). 3) S. aureus isolated from blood and sputa was relatively more resistant to beta-lactams. 4) Strains from urine showed relatively high susceptibility rates. No MRSA was isolated from urine. 5) Thirteen out of twenty-four cases, whose urines were proven to be S. aureus positive, were polymicrobial infection patients.

[Adenocarcinoma of the ileal segment with transitional cell carcinoma of the bladder following ileocytoplasty: a case report]

A 67 year-old woman visited our hospital complaining of pollakisuria. She had undergone left nephrectomy and augmentation ileocystoplasty for tuberculous bladder atrophy 40 years previously. She underwent a total cystectomy and tubeless ureterocutaneostomy with a preoperative diagnosis of muscle-invading transitional cell carcinoma of the bladder. The pathological diagnosis was adenocarcinoma of the ileal segment and transitional cell carcinoma of the original bladder. This is the first case report of adenocarcinoma of the ileal segment and transitional cell carcinoma of the original bladder among 22 patients suffering from bladder cancer after ileocystoplasty.

[Clinical statistics of the patients admitted to the Department of Urology, Kobe University Hospital, 1985-1987]

Between 1985 and 1987, a total number of 791 inpatients were treated at our department and 683 operations were performed. Urogenital malignant tumors (42.0%) were most frequently treated. Male infertility (14.8%) and urolithiasis (8.5%) followed. Bladder tumor was the most frequent disease in our hospital and transurethral resection of bladder tumor was the most frequent operation. Clearly endourological procedures have replaced so-called open surgeries.

[A study of the use of methotrexate, vincristine, cis-platinum, cyclophosphamide, adriamycin, bleomycin (MVP-CAB) in metastatic transitional cell carcinoma]

Eight patients with metastatic transitional cell carcinoma of the urinary tract were treated with the MVP-CAB regimen. All of them had bidimensionally measurable lesions. The MVP-CAB regimen consisted of cyclophosphamide 500 mg/m2, methotrexate 20 mg/m2, adriamycin 20 mg/m2, bleomycin 30 mg/body, and vincristine 1 mg/body on day 1, cis-platinum 50 mg/m2 on day 2, and prednisolone 20 mg/body on days 1-3, given every 3-4 weeks. A partial response was seen in five patients, minor response in one patient and no change in two patients. The response rate was 63% (5/8). The main toxic effect of the MVP-CAB regimen was leucopenia. In 75% of the patients there was a decrease in white blood cell count by not more than 2,000/mm3, but no severe complication was noted. In addition, mild nausea, vomiting, mild anorexia, alopecia and fever were found. However, these symptoms were transient. One patient died of pulmonary fibrosis induced by bleomycin after 3 cycles.

[The processing of Gekko gecko and the pharmacological action of its different parts]

Both pharmacologic and toxic experiments are made on different parts of Gekko gecko Linnaeus. The results show that Gekko gecko Linnaeus' heads and its feet have obvious pharmacological action without any toxic or side effects, which provides a sound basis for the increase in its clinical utilization and the expansion of its medicinal parts as well as guarantee of safety and effectiveness after taking the medicine.

[A case report of septicemia caused by methicillin cephem resistant Staphylococcus aureus (MRSA)]

The frequency of MRSA (Methicillin cephem resistant Staphylococcus aureus) infection has increased recently. A case of septicemia caused by MRSA is reported with discussion on its prophylaxis.

[A case of bilateral renal metastases from non Hodgkin's malignant lymphoma]

A patient with bilateral renal metastases from non Hodgkin's malignant lymphoma originating in the aortocaval abdominal lymph nodes was treated with chemotherapy. Initially, methotrexate (20 mg/m2), vincristine (0.6 mg/m2), cyclophosphamide (500 mg/m2), adriamycin (20 mg/m2), and bleomycin (30 mg/m2) were given on day 1, cisplatinum (50 mg/m2) was given on day 2, and prednisolone (20 mg/body) was given from day 1 to 3 (MVP-CAB regimen). Since the patient was 74 years old and had slight renal dysfunction, for the first and second courses of this therapy, methotrexate and cisplatinum were administered at 60% of the usual dose and the other 4 anticancer agents at 70% of the usual dose. Only prednisolone was given at the full dose. From the third course the 6 anticancer agents were used at 70% of the normal dose. Administration was performed every 4 weeks until the third course, and every 8 weeks after the fourth course (total number of cycles of MVP-CAB: 8 cycles). A marked improvement of the general state and a reduction of the tumor size were noted following treatment. Since regrowth of the residual tumor occurred, as second line chemotherapy cytosine arabinoside (100 mg/m2) on day 1, ifosfamide (1 g/m2) on day 1 to 2, etoposide (100 mg/m2) plus prednisolone (20 mg/body) on day 1 to 3 were administered (AraC-VIP regimen). The timing of administration was similar to that of the MVP-CAB regimen. More than 50% tumor reduction was obtained with this regimen. The total survival time since the beginning of chemotherapy is 2 years to date.

[A case of ganglioneuroma of the adrenal gland]

Computerized tomography accidentally revealed a huge retroperitoneal mass in a 53-year-old male. The mass was located between the liver and the right kidney. Laboratory tests including endocrinological studies were done but the diagnosis was not clearly confirmed before operation. The specimen weighed 410 g, was 12.5 X 8 X 5 cm and did not show any evidence of malignant degeneration histologically. Fourteen cases of the ganglioneuroma of the adrenal gland including our were accumulated from the Japanese literature. A review of the literature showed that cases of this tumor widely ranged from 1 to 65 years of ages, and its incidence was over twice higher in females than in males. Mainly the abdominal mass was the only symptom in these cases. The tumors were generally so well encapsulated that they could be removed completely.

[A case of ectopia testis transversa]

A case of ectopia testis transversa was reported. A patient, 35-year-old male, was admitted to our hospital with swelling of left scrotal contents. At operation, two testes were situated in the left scrotal half, but the right half was empty. Including our case, 66 cases of ectopia testis transversa have been reported in Japan.