Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

The Study of Nursing NAVI

We have examined the nurses' thinking process in their professional judgment and action in the Partogram of 170 labors by 17 Midwifery students in 2 years.

Emerging ST121/agr4 community-associated methicillin-resistant Staphylococcus aureus (MRSA) with strong adhesin and cytolytic activities: trigger for MRSA pneumonia and fatal aspiration pneumonia in an influenza-infected elderly

The pathogenesis of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia in influenza-infected elderly individuals has not yet been elucidated in detail. In the present study, a 92-year-old man infected with influenza developed CA-MRSA pneumonia. His CA-MRSA was an emerging type, originated in ST121/agr4 S. aureus, with diversities of Panton–Valentine leucocidin (PVL)⁻/spat5110/SCCmecV⁺ versus PVL⁺/spat159^(etc.)/SCCmec⁻, but with common virulence potentials of strong adhesin and cytolytic activities. Resistance to erythromycin/clindamycin (inducible-type) and gentamicin was detected. Pneumonia improved with the administration of levofloxacin, but with the subsequent development of fatal aspiration pneumonia. Hence, characteristic CA-MRSA with strong adhesin and cytolytic activities triggered influenza-related sequential complications.

Safety and efficacy of oral rehydration therapy until 2 h before surgery: a multicenter randomized controlled trial

PURPOSE

In many countries, patients are generally allowed to have clear fluids until 2-3 h before surgery. In Japan, long preoperative fasting is still common practice. To shorten the preoperative fasting period in Japan, we tested the safety and efficacy of oral rehydration therapy until 2 h before surgery.

METHODS

Three hundred low-risk patients scheduled for morning surgery in six university-affiliated hospitals were randomly assigned to an oral rehydration solution (ORS) group or to a fasting group. Patients in the ORS group consumed up to 1,000 ml of ORS containing balanced glucose and electrolytes: 500 ml between 2100 the night before surgery and the time they woke up the next morning and 500 ml during the morning of surgery until 2 h before surgery. Patients in the fasting group started fasting at 2100 the night before surgery. Primary endpoints were gastric fluid volume and pH immediately after anesthesia induction. Several physiological measures of hydration and electrolytes including the fractional excretion of sodium (FENa) and the fractional excretion of urea nitrogen (FEUN) were also evaluated.

RESULTS

Mean (SD) gastric fluid volume immediately after anesthesia induction was 15.1 (14.0) ml in the ORS group and 17.5 (23.2) ml in the fasting group (P = 0.30). The mean difference between the ORS group and fasting group was -2.5 ml. The 95% confidence interval ranged from -7.1 to +2.2 ml and did not include the noninferior limit of +8 ml. Mean (SD) gastric fluid pH was 2.1 (1.9) in the ORS group and 2.2 (2.0) in the fasting group (P = 0.59). In the ORS group, mean FENa and FEUN immediately after anesthesia induction were both significantly greater than those in the fasting group (P < 0.001 for both variables). The ORS group reported they had been less thirsty and hungry before surgery (P < 0.001, 0.01).

CONCLUSIONS

Oral rehydration therapy until 2 h before surgery is safe and feasible in the low-risk Japanese surgical population. Physicians are encouraged to use this practice to maintain the amount of water in the body and electrolytes and to improve the patient's comfort.

[Nasotracheal intubation using a fiberscope with a 32Fr blue line endobroncheal tube in a patient with micrognathism]

A 61-year-old woman with pulmonary lymphangioleiomyomatosis was scheduled for video-assisted thoracoscopic surgery for partial resection of the lung. The patient had micrognathism and a recent history of difficult airway management [difficult mask ventilation and intubation (Cormak grade III)]. On induction, mask ventilation was accomplished with the use of nasal airway. We initially inserted Airtraq laryngoscope and gained a view of Cormak grade III. Therefore, a 32 Fr left-sided Blue Line endobroncheal tube was nasotracheally intubated using a fiberscope (3.1-mm diameter). Nasotracheal intubation with a 32F Blue Line endobroncheal tube can be a choice for patients with difficult airway when one lung ventilation is required.

[A phase II clinical study of once-a-day fentanyl citrate patch in patients with cancer pain--switching from once-every-three-days fentanyl patch to once-a-day fentanyl citrate patch]

We examined the efficacy and safety of a new transdermal fentanyl citrate patch (HFT-290), which was applied once daily in patients with cancer pain who were receiving a stable dose of once-every-three-day application transdermal fentanyl patch [TDF (72 hr)]. After TDF (72 hr) was applied for three days at the same dose used before starting the study, treatment was switched to HFT-290 (once daily) for 9 days. The analgesic effect was judged with a 5-point scale based on each patient's assessment of pain on a 100-mm visual analog scale (VAS). Seventy-eight patients were enrolled. The efficacy rate (95% confidence interval) of the analgesic effect at the time of final removal of HFT-290 (the primary efficacy end-point) was high at 83.9% (71.7-92.4%; 47/56 patients). Furthermore, based on the shift of the VAS, good pain control was achieved after switching. All adverse drug reactions were either mild or moderate, and the main reactions were those commonly observed with opioid analgesics. No respiratory depression was observed. HFT-290 demonstrated good tolerability after switching from TDF (72 hr) and provided stable pain control.

[Case of thyroid crisis with persistent tachycardia diagnosed postoperatively]

A 35-year-old man with multiple bone fractures underwent an emergency operation. On arriving at the operating room, his heart rate was 160 beats x min(-1), and blood pressure was 100/50 mmHg. We anesthetized him with oxygen, sevoflurane, fentanyl and remifentanil. We suspected hypovolemia, and treated him with crystalloid and transfused red cells and fresh frozen plasma so that heart rate and blood pressure could be stabilized. Tachycardia of 140 beats x min(-1) persisted, and landiolol was continuously administered at a rate of 5-10 mg x hr(-1) after a 2.5 mg bolus injection. Heart rate became controlled around 120 beats x min(-1) without hypotension during anesthesia. Finally, we noticed thyroid crisis in this case, and diagnosed it with laboratory data after operation. We should be aware that atypical tachycardia is caused by thyroid crisis.

Impact of fresh-frozen plasma from male-only donors versus mixed-sex donors on postoperative respiratory function in surgical patients: a prospective case-controlled study

BACKGROUND

To reduce the risk of transfusion-related acute lung injury (TRALI), plasma products are mainly made from male donors in some countries because of the lower possibility of alloimmunization; other countries are considering this policy. The advantage of male-only fresh-frozen plasma (FFP) should be examined in a prospective case-control study.

STUDY DESIGN AND METHODS

This study compared pulmonary function after the transfusion of FFP derived from either male donors only (FFP-male) or mixed donors (FFP-mixed) in informed surgical patients treated at a tertiary university hospital in Japan. The factors contributing to pulmonary distress (PD) after transfusion were then statistically examined.

RESULTS

Eighty-two patients participated in this study (FFP-male, n = 55; FFP-mixed, n = 27). Nineteen patients developed PD (PaO(2)/FiO(2) ratio [P/F] < 300) within 6 hours after transfusion: seven had congestive pulmonary edema (transfusion-associated circulatory overload), five had permeability pulmonary edema (possible TRALI), and seven had no apparent pulmonary edema. A multivariate logistic regression analysis revealed that the use of cardiopulmonary bypass and preoperative liver dysfunction were significantly associated with a P/F of less than 300 (odds ratios [ORs], 8.95 [p = 0.004] and 6.54 [p = 0.005], respectively), while the use of FFP-male was significantly associated with the absence of PD (OR, 0.219; p = 0.022). All the patients with possible TRALI had received either white blood cell or granulocyte antibody-positive FFP. The lysophosphatidylcholine level was not correlated with PD.

CONCLUSIONS

Our data suggests that the use of FFP derived from male donors may be advantageous for posttransfusion pulmonary function, although PD is also determined by background characteristics.

Calcium loading capacity and morphological changes in mitochondria in an ischemic preconditioned model

The concept of the mitochondrial permeability transition (mPT) has been used to explain cell death induced by calcium deregulation, which is in turn induced by a disruption in the mitochondrial loading capacity of cytosolic calcium (CLC). Whether mitochondria have specific morphologies representing the CLC and the mPT remains controversial. We examined ultrastructural changes in the mitochondria of cultured hippocampal neurons preconditioned with oxygen-glucose deprivation (OGD) for 30 min (30OGD) or 120 min (120OGD). The CLC was then evaluated using simultaneous imaging of the mitochondrial and plasma Ca++ concentrations after the induction of Ca++ influx by the application of glutamate. In the 30OGD group, the CLC increased as the mitochondria rapidly reacted to the increase in plasma Ca++, which was soon cleared. In the 120OGD group, however, the CLC was disturbed because the mitochondrial uptake of Ca was blunted, and the plasma Ca++ was not cleared after glutamate application. We classified the specific morphological changes in the mitochondria according to a previously reported classification. Rounded mitochondria with scarce interior content were observed in the 120OGD group, a model of prolonged lethal OGD, and disruptions in the mitochondrial outer membrane were frequently confirmed, suggesting mPT. The 30OGD group, a model of enhanced CLC in preconditioned neurons, was characterized by round mitochondria with condensed matrices. After glutamate application, the mitochondria became even more rounded with expanded matrices, and outer membrane disruptions were occasionally seen. Our observations suggest that subpopulations of mitochondria with specific morphologies are linked to the CLC and mPT.

Isotopic dependence of the giant monopole resonance in the even-A 112-124Sn isotopes and the asymmetry term in nuclear incompressibility

The strength distributions of the giant monopole resonance (GMR) have been measured in the even-A Sn isotopes (A=112-124) with inelastic scattering of 400-MeV alpha particles in the angular range 0 degrees -8.5 degrees . We find that the experimentally observed GMR energies of the Sn isotopes are lower than the values predicted by theoretical calculations that reproduce the GMR energies in 208Pb and 90Zr very well. From the GMR data, a value of Ktau = -550 +/- 100 MeV is obtained for the asymmetry term in the nuclear incompressibility.

A new technique for endoscopic submucosal dissection for early gastric cancer using an external grasping forceps

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has improved the success rate of en-bloc resection. We report here on a new technique using an external grasping forceps.

PATIENTS AND METHODS

A total of 25 patients with suitable EGCs over 10 mm in diameter located in the gastric body were enrolled. After submucosal injection followed by circumcision of the lesion with a needle-knife, an external grasping forceps was introduced with the help of a second grasping forceps and anchored at the distal margin of the lesion. With gentle oral traction applied with this forceps, the lesion was dissected endoscopically in retroversion from the aboral side.

RESULTS

The mean lesion size was 15.0 mm (range 10 - 25 mm). Using the technique described, all lesions could be resected en bloc with free margins. The mean procedure time was 45 min (range 30 - 80 minutes). No significant bleeding requiring blood transfusion or perforation occurred.

CONCLUSIONS

This technical modification may simplify and shorten the gastric ESD procedure, except for lesions in distal locations, without compromising the efficacy.

[Questionnaire survey of anesthesiologists' opinion regarding the Japanese guidelines for transfusion]

BACKGROUND

Anesthesiologists' opinions regarding the Japanese guidelines for transfusion were surveyed.

METHODS

From December 28, 2004 to January 28, 2005 a questionnaire survey was performed in 958 hospitals registered with the Japanese Society for Anesthesiologists. Queries regarding the guidelines for packed red cells, fresh frozen plasma, platelet concentrates, autologous blood transfusions, and other miscellaneous subjects were sent to these hospitals.

RESULTS

A total of 537 hospitals (56.1%) responded to the survey. The guidelines for packed red cells were complied with and widely accepted. The trigger value of hemoglobin concentration was 7-9 g x dl(-1). Although 54.4% of the anesthesiologists used the coagulation disorder as the triggering factor for transfusion of fresh frozen plasma, only 19.6% of the hospitals monitored coagulopathy. In most hospitals, the trigger value of hemorrhage for use of fresh frozen plasma was the bleeding amount of less than 3000 ml, which is less than 70% of the recommended triggering value (bleeding exceeding 100% of circulating blood volume). The guideline for platelet concentrate transfusions for elective surgery was somewhat accepted (77.1%), but the triggering value; 3 x 10(4) x l(-1) for cardiopulmonary bypass surgery was considered too strict (41.4%).

CONCLUSIONS

These guidelines for transfusions appear to be widely accepted. The most dominant complaint was the inadequacy of the guidelines for rapid massive bleeding.

Perioperative circulating blood volume analysis in management of a 13-year-old female patient with an extraadrenal pheochromocytoma and refractory ventricular tachycardia: a case report

This report describes the use of discrete real-time monitoring of blood volume (BV) and cardiac index (CI) by a dye densitography analyzer before, during, and after removal of a pheochromocytoma. The BV expanded by about 1.1 L and CI increased by about 2.2-fold after the tumor was removed. In lieu of a rapid catecholamine determination, the hemodynamic data were used to choose a supplemental catecholamine to stabilize the patient during and after the protracted surgery. This case demonstrates the importance of hemodynamic monitoring (BV and CI) to predict or detect cardiac and other complications, particularly in young patients with catecholamine-secreting tumors.

[Randomized, multicenter study of interaction between Org 9426 (rocuronium bromide) and anesthetic agents in Japanese population]

BACKGROUND

The purpose of this randomized, multi-center phase III trial was to investigate the influence of sevoflurane and propofol on the neuromuscular blocking effects and pharmacokinetic parameters of Org 9426 (rocuronium bromide) in Japanese population.

METHODS

Thirty-nine adult Japanese patients participated in this randomized, multi-center study. Neuromuscular function was monitored continuously with TOF-Watch SX (Organon NV, Netherlands) after anesthetic induction with propofol. These subjects randomly received either 0.6 mg x kg(-1) or 0.9 mg x kg(-1) of rocuronium for endotracheal intubation. These two groups were further divided to two anesthetic regiments : sevoflurane group and propofol group. The difference in onset and recovery of rocuronium-induced neuromuscular block was statistically analyzed with two-way ANOVA.

RESULTS

Mean duration for maximal block was 76 seconds and 66 seconds, respectively. The duration between Org 9426 administration and 25% recovery of first twitch response was significantly prolonged in patients given 0.9 mg x kg(-1) of Org 9426. Sevoflurane also significantly increased this duration. However, the serum concentration of Org 9426 was not statistically different between the four study groups.

CONCLUSIONS

The duration of Org 9426-induced neuromuscular blockade was significantly increased under sevoflurane anesthesia compared to propofol anesthesia. This difference may be attributed to pharmacodynamic change.

Neuroprotective effect of propofol on necrosis and apoptosis following oxygen-glucose deprivation--relationship between mitochondrial membrane potential and mode of death

Mitochondrial membrane potential (MMP) appears to play an important role in apoptotic cascade and has been proposed as an index for apoptosis or necrosis. We examined the neuroprotective effect of propofol on mode of death, focusing on MMP. Hippocampal cell culture was divided into three groups: control, oxygen-glucose deprivation for 30 min (30OGD), 90 min (90OGD). Propofol was added to each culture group at a concentration of 0 microM (Vehicle), 0.1 microM (Pro0.1) or 1.0 microM (Pro1.0). MMP was expressed as normalized JC-1 fluorescence. ATP content was assayed using the luciferin-luciferase reaction. Neuronal viability and appearance of apoptosis were also assessed. ATP content was decreased after OGD (0.276 +/- 0.115 microM/microg (control), 0.172 +/- 0.125 microM/microg (30OGD) and 0.096 +/- 0.092 microM/microg (90OGD)). Propofol did not alter ATP content. MMP was hyperpolarized after 30OGD (1.26 +/- 0.23 (vehicle), 1.29 +/- 0.13 (Pro0.1) and 1.18 +/- 0.06 (Pro1.0)) but was depolarized after 90OGD (0.77 +/- 0.04 (vehicle), 0.89 +/- 0.04 (Pro0.1), but Pro1.0 prevented depolarization (1.03 +/- 0.15 (P < 0.05)). Viability of cells significantly decreased to 50.3 +/- 5.7% (vehicle), 46.1 +/- 7.5% (Pro0.1), but Pro1.0 significantly salvaged neurons 65.1 +/- 6.2% (higher than vehicle and Pro0.1 value, P < 0.05) after 90OGD. At 24 h after OGD, TUNEL-positive cells were increased to 34.5 +/- 6.2% (vehicle), 26.7 +/- 7.9% (Pro0.1) and 30.4 +/- 7.1% (Pro1.0) in the 30OGD group. No pharmacological effect of propofol on the incidence of apoptosis was found. Propofol inhibited acute neuronal death accompanied with the maintenance of MMP but did not prevent subsequent apoptosis. Propofol induces a moratorium on neuronal death, during which pharmacological intervention might be able to prevent cell death.

[Neuromuscular blocking effects, pharmacokinetics and safety of Org 9426 (rocuronium bromide) in Japanese patients]

BACKGROUND

The purpose of this study was to examine pharmacodynamics, pharmacokinetics and safety of Org 9426 (rocuronium bromide) in Japanese patients.

METHODS

Seventy-eight patients anesthetized with thiopental, droperidol, fentanyl and nitrous oxide, were randomized to receive either a single dose of Org 9426 0.3 mg x kg(-1), 0.6 mg x kg(-1) or 0.9 mg x kg(-1). Contraction of the adductor pollicis to the ulnar nerve stimulation (0.1 Hz) was measured by acceleromyography. Blood was sampled over 6 hr and pharmacokinetic variables were calculated by plasma concentrations of Org 9426.

RESULTS

Onset times for patients receiving 0.3 mg x kg(-1), 0.6 mg x kg(-1) or 0.9 mg x kg(-1) were 271.5 s, 140.0s and 125.4s, respectively. There was a dose-dependent increase in clinical durations until 25% recovery of twitch height (17.4 min in 0.3 mg x kg(-1) group, 37.2 min in 0.6 mg x kg(-1) and 60.4 min in 0.9 mg x kg(-1) group). Pharmacokinetic study revealed that elimination half life, steady state volume of distribution and plasma clearance of Org 9426 were 48-76 min, 146-181 ml x kg(-1), and 3.8-4.5 ml x min(-1) x kg(-1), respectively. No adverse effects were found except a case of local erythema on a forearm.

CONCLUSIONS

The efficacy of neuromuscular block, stable pharmacokinetic behavior and excellent safety of Org 9426 were also confirmed in Japanese surgical patients.

[Critical events in the operating room among 1,440,776 patients with ASA PS 1 for elective surgery]

BACKGROUND

The Japanese Society of Anesthesiologists (JSA) survey of critical incidents in the operating room has shown that preoperative complications are the leading causes of critical incidents, and affect the occurrence, severity and outcome of critical incidents which are due to causes other than preoperative complications. Causes of critical events in the operating room were examind in patients for elective surgery with American Society of Anesthesiologists physical status (ASA PS) 1.

METHODS

JSA has conducted annual surveys of critical incidents in the operating room by sending and collecting confidential questionnaires to all JSA Certified Training Hospitals. From 1999 to 2002, 3,855,384 anesthesia patients were registered. Among these, 1,440,776 patients with ASA PS 1 for elective surgery were analyzed. The causes of critical incidents were classified as follows: totally attributable to anesthetic management (AM), mainly to intraoperative pathological events (IP), to preoperative complications (PC), and to surgical management (SM). IP consists of coronary ischemia mainly due to coronary vasospasm, arrhythmias, pulmonary embolism, and other conditions.

RESULTS

The incidences of cardiac arrest, critical incidents other than cardiac arrest and subsequent death were 9.86, 59.41 and 3.12 per 100,000 anesthesia cases, respectively. IP and SM were responsible for 36.6% and 34.5% of cardiac arrest, respectively. AM and SM were responsible for 46.7% and 26.8% of critical incidents other than cardiac arrest, respectively. SM, IP and AM were responsible for 66.7%, 22.2% and 4.4% of subsequent deaths (within 7 postoperative days), respectively. Coronary ischemia and pulmonary embolism were the main causes of death due to IP. The incidences of cardiac arrest and death totally attributable to AM were 1.87 and 0.14 per 100,000 anesthesia cases, respectively. Medication problems were responsible for 48.1% of arrests, while airway/ventilation problems were for 57.2% of critical incidents other than arrest. Human factors (SM combined with AM) were responsible for 53.5%, 73.5%, and 71.1% of cardiac arrest, critical incidents other than arrest and death, respectively.

CONCLUSIONS

Even in elective patients with good physical status, non-lethal incidents were not rare, and lethal incidents were also reported. We should pay significant attention to the following findings, and take some measures to overcome these problems especially related to human factors. Firstly, SM badly harmed some operative patients. Secondly, coronary vasospasm and pulmonary embolism were the main causes of death due to IP. Thirdly, drug administration and airway/ventilation management were the major causes of critical incidents totally attributable to AM. Human factors were responsible for 70.6% of critical incidents and 71.1% of deaths.

[Critical incidents during regional anesthesia in Japanese Society of Anesthesiologists-Certified Training Hospitals: an analysis of responses to the annual survey conducted between 1999 and 2002 by the Japanese Society of Anesthesiologists]

BACKGROUND

Recently, a national survey in France including 35,439 patients who had received spinal anesthesia showed that the incidences of cardiac arrest and mortality associated with spinal anesthesia were 2.5 and 0.8 per 10,000 anesthetics, respectively. In this study, we investigated these values using data obtained from annual surveys conducted by the Japanese Society of Anesthesiologist (JSA).

METHODS

Since 1994, JSA has conducted annual surveys concerning critical incidents in the operating theater by sending confidential questionnaires to JSA-certified training hospitals, then collecting and analyzing the responses. We investigated critical incidents associated with regional anesthesia using data from annual surveys between 1999 and 2002. The questionnaire was identical in each survey conducted during these years. The total number of anesthetics available for this analysis was 3,855,384, of which spinal anesthesia, combined spinal-epidural anesthesia and epidural anesthesia were performed in 409,338, 146,282, and 69,001 patients, respectively. In patients receiving regional anesthesia, 628 critical incidents including 108 cardiac arrests, and 45 subsequent deaths were reported. The causes of critical incidents were classified as follows: totally attributable to anesthetic management, due mainly to intraoperative pathological events, preoperative complications, and surgical management. IP consists of coronary ischemia including coronary vasospasm not suspected preoperatively, arrhythmias including severe bradycardia, pulmonary thromboembolism, and other conditions. Mortality was determined by postoperative day 7. Statistical analysis was performed by chi-square test and Mann-Whitney test. A p value less than 0.05 was considered significant.

RESULTS

The incidences of cardiac arrest and mortality due to all etiologies were 1.69 and 0.76 with spinal anesthesia, 1.78 and 0.68 with combined spinal-epidural anesthesia, and 1.88 and 0.58/10,000 anesthetics with epidural anesthesia, respectively. The incidences of cardiac arrest and mortality due to anesthetic management were 0.54 and 0.02 with spinal anesthesia, 0.55 and 0.00 with combined spinal-epidural anesthesia, and 0.72 and 0.14/10,000 anesthetics with epidural anesthesia, respectively. These values did not significantly differ among regional anesthesia. Death attributable to anesthetic management was reported in 2 patients: both patients were classified as ASA-PS 3 E, and developed cardiac arrest; one due to inadvertent high spinal anesthesia with spinal anesthesia, and the other due to local anesthetic intoxication with epidural anesthesia. Anesthetic management and intraoperative pathological events comprised 33 and 43% of cardiac arrests, respectively. The distribution of causes of death was as follows: anesthetic management, 5%; intraoperative pathological events, 34%; preoperative complications, 35%; surgical management, 26%. Among the causes of anesthetic management-induced critical incidents, inadvertent high spinal anesthesia was the leading cause of cardiac arrest in spinal and combined spinalepidural anesthesia: 90% of arrests occurred in patients with ASA-PS 1+2; 88% in patients below 65 years of age; 45 and 25% in patients undergoing hip or lower extremities surgery, and cesarean section, respectively. Among the causes of intraoperative pathological event-induced critical incidents, pulmonary thromboembolism was the leading cause of cardiac arrest in spinal and combined spinal-epidural anesthesia: 59% of arrests occurred in patients with ASA-PS 1+2; 81% in patients above 66 years of age; 91% in patients undergoing hip or lower extremity surgery.

CONCLUSIONS

The incidence of cardiac arrest and mortality associated with spinal anesthesia in Japan was shown to be in the same order as in France by analyzing a larger population. In patients with good ASA-PS, critical incidents occurred more often under regional anesthesia than under general anesthesia. Inadvertent high spinal anesthesia should be carefully avoided. We should also pay much attention to subclinical deep vein thrombosis in patients who were scheduled for hip or lower extremity surgery, and tourniquet- or bone cement-associated pulmonary embolism in these patients.

Comparison of antagonizing potencies of dodecane analogues to isoflurane in goldfish

PURPOSE

We reported previously that long-chain fatty acids (carbon atoms > or =12) antagonize volatile anesthetics in goldfish. To examine the contribution of the carboxyl group to the antagonizing potency of fatty acids in vivo, we compared antagonizing potencies to isoflurane in goldfish among terminally substituted dodecane analogues.

METHODS

Dodecane (carbon atoms = 12) analogues [fatty acid (DoAC), alcohol (DoAL), alkane (DoAK), sulfate (DoSF), trimethylammonium (DoTA)] were examined. We determined the EC50 (the anesthetic concentration producing a 50% effect) values of isoflurane in the absence or presence of these chemical compounds in goldfish by observing the escape reaction of goldfish from an electrical stimulus.

RESULTS

DoAC at higher than 10 microM and DoAL at higher than 20 microM increased the EC50 values of isoflurane in a concentration-dependent manner compared with the control (P < 0.05). DoAC at 50 microM and DoAL at 100 microM increased the EC50 1.7- and 1.6 fold, respectively. DoAK, DoSF, and DoTA showed no significant differences from the control. In the comparison of DoAC and DoAL at the same concentration, DoAC was more effective than DoAL (P < 0.001).

CONCLUSION

DoAC and DoAL showed antagonizing potencies to isoflurane, whereas DoAK, DoSF, and DoTA had no effect. DoAC was more effective than DoAL. The findings suggest that polarity of the chemical compounds may be necessary to exert antagonizing potency to isoflurane. Furthermore, a highly negative charge density of the carboxyl group may be responsible for the effective antagonization of DoAC to isoflurane.

[Supplemental survey in 2003 concerning life-threatening hemorrhagic events in the operating room]

BACKGROUND

We previously showed that pre-operative hemorrhagic shock and surgical hemorrhage were the major causes of life-threatening events in the operating room and subsequent fatality. We investigated the background of these events.

METHODS

The Subcommittee on Surveillance of Anesthesia-Related Critical Incidents, Japanese Society of Anesthesiologist (JSA) sent confidential questionnaires to all JSA-certified training hospitals (n=862). The questionnaires were composed of two parts: one for examining all life-threatening events in the operating room and the other for examining the background of massive hemorrhage in the operating room. The number of patients registered between January 1, 2003 and December 31, 2003 was 1,367,790 from 782 hospitals. Life-threatening hemorrhagic events were reported in 1,011 patients, of whom 876 patients were available for further analysis of the background of the events. Fatality within 7 postoperative days following these events was 45.4%.

RESULTS

In patients who developed life-threatening events due to hemorrhage, 35.2% had blood loss of more than 12 l x 60 kg(-1) of body weight, 44.9% had a maximal hemorrhagic speed of more than 240 ml x min(-1) x 60 kg(-1) of body weight, and 39.1% had a minimal hemoglobin concentration of less than 5 g x dl(-1). The main sources of hemorrhage were as follows: the abdominal aorta, 15.4%; the thoracic aorta, 14.0%; the liver, 12.6%; intra-cranium, 8.2%; the pelvic organs, 8.0%; celiac or mesenteric artery, 7.8%; the lung, 7.1%. Of patients who developed life-threatening events due to preoperative hemorrhagic shock, 18.3% underwent cardiac massage preoperatively, 50.0% lost consciousness, 58.5% were intubated, and 16.4% were retrospectively judged to have had no operative indications. Human factors also affected the life-threatening events due to preoperative hemorrhagic shock: delayed decision making concerning indications for surgical treatment, 15.6%; delayed admission to the operating room, 16.6%; delayed supply of blood products, 25.5%; problems in surgical management, 16.3%; problems in anesthetic management, 28.1%. These problems in anesthetic management included shortage of supportive anesthesiologists. This was partly explained by the time of their admission to the operating room: 67.0% of the patients admitted during the week end or at night. Of the patients who developed life-threatening events due to surgical hemorrhage, 58.0% were predicted preoperatively to develop massive hemorrhage by anesthesiologists, and 66.7% were informed of the risks of massive hemorrhage and associated complications. The main causes of surgical hemorrhage were as follows: adhesion or invasion, 44.7%; and problems in surgical judgments or techniques, 43.7%. Anesthetic management affected the development of life-threatening events in these patients: lack of infusion prior to hemorrhage, shortage of supportive anesthesiologists, delay in ordering additional blood products, delayed judgment to start blood transfusion, and shortage of rapid infusion/transfusion apparatus. Delay for hospitals in obtaining blood supply from blood banks was reported in 13.0% of cases, and delayed supply from inhospital blood transfusion service to the operating room in 16.0%. Despite massive hemorrhage, ABO cross-matching was omitted only in 13.4% of patients, and transfusion of ABO-compatible, instead of ABO-identical red blood cells, was performed only in 1.3%.

CONCLUSIONS

To reduce life-threatening hemorrhagic events in the operating theater, reorganization of emergency medical service and blood supply, improvement of surgical techniques, improved triage of patients with hemorrhagic shock, flexible application of compatible blood products in emergency situations, and improvement of the quality and number of anesthesiologists should be considered.

[Surgical volume and mortality due to intraoperative critical incidents at Japanese Society of Anesthesiologists certified training hospitals: an analysis of the annual survey in 2002]

BACKGROUND

We have previously showed that surgical volume affects mortality due to intraoperative critical incidents among patients undergoing cardiac surgery, the surgery with the highest risk, using data obtained by the annual survey in 2001 conducted by the Japanese Society of Anesthesiologists (JSA). In this study, we investigated whether surgical volume affects mortality due to intraoperative critical incidents independent of the surgical site.

METHODS

We investigated this relationship using data obtained from the 2002 annual survey conducted by the Subcommittee on Surveillance of Anesthesia-related Critical Incidents, JSA. Between January 1, 2002 and December 31, 2002, 1,987,988 patients were registered from 704 training hospitals certified by the JSA. Intraoperative critical incidents occurred in 2,844 patients. Of these, 804 patients died within 7 postoperative days. The overall mortality was 4.61 per 10,000 anesthetics. Hospitals were divided into 5 groups according to their annual surgical cases: Group A, fewer than 1,000 (62 hospitals); Group B, 1,000-1,999 (204 hospitals); Group C, 2,000-3,999 (288 hospitals); Group D, 4,000-5,999 (110 hospitals); Group E, more than 6,000 (40 hospitals). Hospitals were also divided into 2 groups according to mortality: Group 1, under 20.00 per 10,000 anesthetics (672 hospitals); Group 2, equal to or higher than 20.00 per 10,000 anesthetics (32 hospitals). Total number of deaths in Group 2 was 158. Mortality was expressed as the mean (95% confidence interval). Statistical analysis was performed using chi-square test and Fisher test. A p value of <0.05 was considered significant.

RESULTS

The mortality rates in Groups A-E were 14.89 (8.48-21.3), 3.86 (3.05-4.67), 3.88 (3.19-4.57), 4.04 (3.20-4.88), and 3.12 (2.19-4.05) per 10,000 anesthetics, respectively. Average surgical cases and mortality in Group 1 were 2,789 (2,775-3,002) and 3.24 (2.90-3.58), respectively, while those in Group 2 were 1,672 (1,243-2,101) and 22.18 (30.58-45.94), respectively. If all patients in Group 2 (n=53,509) had been treated in the hospitals of Group 1, 139-143 deaths might have been avoided.

CONCLUSIONS

Surgical volume was shown to affect mortality independent of the surgical site. Hospitals with low surgical volume should pay significant attention to improving surgical outcomes. These results also suggest that centralization or regionalization should be discussed from the perspective of socio-economical problems as well as patient safety.

Clinical significance of cytomegalovirus (CMV) antigenemia in the prediction and diagnosis of CMV gastrointestinal disease after allogeneic hematopoietic stem cell transplantation

To evaluate the clinical significance of a cytomegalovirus (CMV) antigenemia assay in the prediction and diagnosis of CMV gastrointestinal (CMV-GI) disease after hematopoietic stem cell transplantation (HSCT), 19 allogeneic HSCT recipients developing CMV-GI disease were retrospectively reviewed. All patients were monitored by a CMV antigenemia assay, at least once weekly after engraftment. The median onset of CMV-GI disease occurred 31 days post transplant (range: 19-62). Only four of 19 patients (21%) developed a positive CMV antigenemia test before developing CMV-GI diseases. Although all 19 patients subsequently developed positive CMV antigenemia tests during their clinical courses, the values remained at a low-level in nine (47%) patients. Among the 14 patients in whom results of real-time polymerase chain reaction (PCR) were available, seven (50%) yielded positive results of real-time PCR before developing CMV-GI disease. In contrast to the values of CMV antigenemia, all 14 patients exclusively yielded high viral loads (median: 2.8 x 10(4) copies/ml plasma). We conclude that CMV antigenemia testing has limited value in prediction or early diagnosis of CMV-GI disease, and that real-time PCR could have a more diagnostic significance.

An increased circulating blood volume does not prevent hypotension after pheochromocytoma resection

PURPOSE

Pulse dye-densitometry, a novel monitor that measures circulating blood volume (CBV) and cardiac output (CO), was used in patients with pheochromocytoma to determine the relationship between CBV and post resection hypotension.

METHODS

Case control study. An alpha blocker was administered for approximately two weeks, and its effect on the expansion of CBV was quantified. CBV was monitored in seven patients admitted for resection of suspected pheochromocytoma before preoperative alpha-blocker therapy, after alpha-blocker therapy and three times during the operation. Relationships between the CBV and blood pressure after resection of the tumour were examined.

RESULTS

CBV increased from 72.0 +/- 10.0 mL.kg(-1) to 83.4 +/- 12.2 mL.kg(-1) after alpha blockade. (P < 0.001). We found a significant inverse relationship between the increase in CBV after alpha-blocker therapy and blood pressure after resection of the tumour.

CONCLUSIONS

Expansion of the CBV by alpha-blocker therapy was related to lower blood pressures after resection of the pheochromocytoma. Expansion of the CBV by an alpha blocker may have increased the elastance of blood vessels. Preoperative blood volume expansion does not preclude hypotension after tumour resection. Although the CBV value itself is not a predictor for hypotension after tumour resection, pulse dye-densitometry provides values of CO and CBV simultaneously, assisting in the management of volume resuscitation and/or the need for catecholamines.

Human intestinal epithelial cell-derived interleukin (IL)-18, along with IL-2, IL-7 and IL-15, is a potent synergistic factor for the proliferation of intraepithelial lymphocytes

Intestinal epithelial cell (IEC)-derived cytokines, such as stem cell factor (SCF), interleukin (IL)-7 and IL-15 are known to be required for the development of intestinal intraepithelial lymphocytes (IELs). A newly described cytokine, IL-18, has also been shown to be produced by intestinal epithelial cells. To demonstrate the functional effects of IL-18 on human IELs, we assessed IL-18/IL-18 receptor expression in IEC/IEL and proliferation following stimulation of intestinal IELs by IL-18. IL-18 transcripts were detected both in freshly isolated human colonic epithelial cells and in various colonic epithelial cell lines. IL-18 protein was also detected by ELISA and flow cytometric analysis using antihuman IL-18-specific monoclonal antibody (MoAb). Furthermore, IELs constitutively expressed the IL-18 receptor in addition to the IL-2 and IL-7 receptors. More importantly, IL-18 augmented significant proliferative responses of IEL in combination with IL-2, IL-7 and IL-15 both in the presence and in absence of anti-CD3 MoAb. These results suggest that IL-18 might play a crucial role in the proliferation and maintenance of intestinal IELs.

Antagonizing potencies of saturated and unsaturated long-chain free fatty acids to isoflurane in goldfish

PURPOSE

We have previously reported that myristate, a saturated free fatty acid (FFA) with 14 carbons (C14), antagonizes volatile anesthetics in goldfish. The hydrophobicity and molecular configuration of FFAs may play an important role in the antagonizing effect. To examine their contribution, we investigated the antagonizing potencies of saturated and unsaturated long-chain FFAs in goldfish.

METHODS

Saturated and monounsaturated FFAs of C14-18 were tested. We determined the anesthetic concentration producing a 50% effect (EC50) of isoflurane in the absence or presence of FFA by observing the escape reaction of goldfish against an electrical stimulus.

RESULTS

All FFAs increased the EC50 of isoflurane dose-dependently compared with reactions in the absence of FFA ( P < 0.05). For saturated FFAs, the relationship between chain lengths and antagonizing potencies was not linear. C18 was the most effective and C16 was the least effective antagonist ( P < 0.05). Among unsaturated FFAs, C14 was the most effective antagonist ( P < 0.05). In a comparison of saturated and unsaturated FFAs, saturated C14 and C18 were more effective antagonists than unsaturated FFAs of the same carbon numbers ( P <<0.05).

CONCLUSION

The hydrophobicity of FFAs increases as the chain length increases. Therefore, our findings suggest that the antagonizing effect of long-chain FFAs in goldfish, in terms of their capacity to perturb the lipid membrane structure, may be determined not solely by their hydrophobicity but also by their molecular configuration.

[Critical incidents due to drug administration error in the operating room: an analysis of 4,291,925 anesthetics over a 4 year period]

BACKGROUND

Wrong drugs, overdose of drugs, and incorrect administration route remain unsolved problems in anesthetic practice. We determined the incidence and outcome of drug administration error in the operating room of Japanese Society of Anesthesiologists Certified Training Hospitals.

METHODS

Data were obtained from annual surveys conducted by Japanese Society of Anesthesiologists between 1999 and 2002. There were 4,291,925 cases of anesthetic delivery for this analysis.

RESULTS

Incidence of critical incidents due to drug administration error was 18.27/100,000 anesthetics. Cardiac arrest occurred in 2.21 patients per 100,000 anesthetics. Causes of these critical incidents were as follows: overdose or selection error involving non-anesthetic drugs, 42.1%; overdose of anesthetics, 28.7%; inadvertent high spinal anesthesia, 17.9%; local anesthetic intoxication, 6.4%; ampule or syringe swap, 4.3%; blood mismatch, 0.6%. Incidence of death following these incidents was 0.44/100,000. Causes of death were as follows: overdose or selection error involving non-anesthetic drugs, 47.4%; overdose of anesthetics, 26.3%; inadvertent high spinal anesthesia, 15.8%; local anesthetic intoxication, 5.3%. Ampule or syringe swap did not lead to any fatalities. Death following inadvertent high spinal anesthesia and local anesthetic intoxication was reported only in patients who had developed cardiac arrest. It should be noted that 88 percent of ampule or syringe swap occurred in patients with American Society of Anesthesiologists-Physical Status 1 or 2, who did not seem to require complex anesthetic management.

CONCLUSIONS

We should increase awareness that drug administration is generally performed with limited objective monitoring, although "To error is human". Increased vigilance is required to avoid drug administration error in the operating room. Additional anesthesia resident education, adequate supervision, and improved organization are necessary. Bar-coding technology might be useful in preventing drug administration error.

[Incidence and characteristics of perioperative pulmonary thromboembolism in Japan]

BACKGROUND

Perioperative pulmonary thromboembolism (preoperative PTE) is widely recognized as one of the life-threatening perioperative complications in Japan. However, incidence of perioperative PTE is not well surveyed. The Japanese Society of Anesthesiologist (JSA) mailed the questionnaire about incidence of perioperative PTE and its characteristics to the institutions registered in JSA.

METHODS

The questionnaire was mailed to 844 institutions. The items of the survey included age, sex, type of surgery and risk factors of the cases performed in 2002. Data were analyzed using chi-square test and Fisher's test, and P < 0.05 was taken as significant.

RESULTS

Four-hundred sixty-seven out of 844 institutions responded (55.3%) effectively. There were 369 cases of perioperative PTE in 208 institutions (44.5% of the institutions responded). The incidence of perioperative PTE was 4.4 per ten thousand cases. Massive PTE or cardiac arrest at the onset occurred in 57 cases (15.4%). Out of these patients, 117 patients (31.7%) had obesity, and bed-ridden rest (> 4 days) patients and cancer patients were each 105 (28.5%). Sixty-six patients died from perioperative PTE, out of which 5 patients (7.5%) died during operation, 31 patients (47.0%) died within 7 days after the operation, and 30 patients (45.5%) died 8 days after the operation. The commonest type of surgery among mortality cases was abdominal surgery (20 cases: 30.3%), and the commonest risk factor was being bedridden (34.5 cases: 51.5%). The patients who had developed PTE during surgery counted 64, among whom the major type of operation was lower limb/pelvic surgery (36 cases: 56.3%). Major risk factors were being bed-ridden in 25 cases (39.1%) and lower limb/pelvic fracture in 25 cases (39.1%). Despite having dangerous risk factors, 128 patients (57.7%) received the measures not recommended or did not receive any preventive measure for PTE.

CONCLUSIONS

This survey revealed that the incidence of perioperative PTE in Japan is considerable. On the ground that most PTE could be prevented, it is suggested that by employing preventive measures for PTE, the incidence of perioperative PTE will decrease.

[Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review]

The Japanese Society of Anesthesiologists (JSA) conducts an annual survey of life-threatening events in operating rooms (OR) in JSA Certified Training Hospitals (JSACTH) by sending and collecting confidential questionnaires. Etiologies of the incidents were divided into four categories: those totally attributable to anesthetic management (AM), those resulting from preoperative complications (PC), those resulting from intraoperative pathological events (IP) and those related to surgical procedures (SP). IP resulted from coronary ischemia not suspected preoperatively, arrhythmias, pulmonary embolism, and other conditions. Outcomes were judged on the 7th post-operative day. In the year 2002, questionnaires were sent to 844 JSACTHs, and a total of 1,461,020 cases of anesthesia were documented from 773 JSACTHs. Of these, 1,277,045 cases of anesthesia from 712 JSACTHs were available for analysis. Seven hundred thirty nine cardiac arrests (5.79 per 10,000 anesthetics) and 806 deaths (6.31 per 10,000 anesthetics) due to life-threatening events in the OR were reported. The incidence of cardiac arrest and mortality totally attributable to AM was 0.38 and 0.11 per 10,000 anesthetics. These values tended to decrease after 1994, except the mortality totally attributable to AM, which were almost at constant level during recent years. The summary of the study between 1999 and 2002 was as follows. Among 3,855,384 anesthetics, 2,443 cardiac arrests (6.34 per 10,000 anesthetics) and 2,638 deaths (6.85 per 10,000 anesthetics) due to life-threatening events in the OR were reported. PC, SP, IP and AM were responsible for 64.7, 23.9, 9.4, and 1.5% of deaths, respectively. The major cause of PC related deaths was preoperative hemorrhagic shock, followed by cardiovascular diseases such as myocardial ischemia and congestive heart failure. Excessive surgical bleeding comprised 70.2% of SP-related deaths. The major causes of IP-related death were myocardial ischemia, pulmonary embolism, and severe arrhythmias. The incidence of cardiac arrest and death totally attributable to AM was 0.47 and 0.10/10,000 anesthetics, respectively. Among patients with ASA-PS 1(E) and 2(E), AM-related deaths occurred at a rate of 0.04/10,000 anesthetics. Half of AM-induced deaths were caused by airway or ventilatory problems. Other causes of AM-related death were medication accidents and infusion/transfusion accidents. Considerable effort is required to reduce intraoperative life-threatening events caused by human error, hemorrhage, and cardiovascular diseases.

Mitochondrial hyperpolarization after transient oxygen-glucose deprivation and subsequent apoptosis in cultured rat hippocampal neurons

Mitochondrial membrane potential (MMP) regulates the production of high-energy phosphate and apoptotic cascade, both occurring after ischemic impact. The timed profile of MMP differing from grading ischemic impact has to be determined. Primary rat hippocampal cultures were exposed to oxygen-glucose deprivation (OGD) for 30, 60, and 90 min and then were reoxygenated. MMP was expressed as a voltage-dependent dye, JC-1 fluorescence, under confocal microscopy. Cell viability was assessed by calcein AM and ethidium homodimer, each at 3 hours and 24 hours after 30, 60, and 90 min of OGD. The appearance of apoptosis was also evaluated by the TUNEL method at 24 hours. Hyperpolarization of MMP (2.31+/-0.94 normalized JC-1 fluorescence ratio between red and green) was observed during reoxygenation after 30 min OGD, while 60 min OGD induced depolarization (0.66+/-0.22, Valinomycin (potassium ionophore)-induced depolarization: 0.53+/-0.19). The fluorescence of mitochondria became weak after 90 min OGD. Most of the neurons were shrunken after 90 min and neurons were TUNEL-positive 24 hours after 30 min OGD, although most neurons were viable at 3 hours. A longer period of OGD induced necrosis, and most neurons remained viable after only 3 hours. Our data present that the short (30 min) OGD induced hyperpolarization of MMP during reoxygenation, while a longer OGD (60 or 90 min) induced depolarization and acute necrosis. Neurons were still viable even during hyperpolarization of mitochondria, but this hyperpolarization appears to be linked to subsequent apoptotic change.

[The relationship between the yearly number of operations and mortality due to intraoperative critical incidents in patients for cardiac surgery: an analysis of annual survey 2001 conducted by the Japanese Society of Anesthesiologists]

BACKGROUND

The number of surgical operations performed has been reported to have a relation with surgical morbidity and mortality. In Japan, however, the relationship between surgical load and outcome has not been elucidated.

METHODS

We investigated this relationship in patients for cardiac surgery using data from the 2001 annual survey concerning anesthesia-related critical incidents, conducted by the Committee on Operating Room Safety, Japanese Society of Anesthesiologists. Between January 1, 2001 and December 31, 2001, 43,411 patients for cardiac surgery patients were registered from 486 training hospitals certified by the Japanese Society of Anesthesiologists. Intraoperative critical incidents occurred in 632 of the patients. Of these, 289 patients died within 7 postoperative days. The overall mortality was 66.57 per 10,000 anesthetics. Hospitals were divided into 4 groups according to their annual numbers of cardiac operations: Group A, fewer than 50; Group B, 50-99; Group C, 100-199; Group D, more than 200. Mortality rate was expressed as a mean +/- SD (95% confidence interval).

RESULTS

The mortality rates in Group A-D were 107.64 +/- 327.33 (63.47-151.81), 114.42 +/- 168.76 (83.02-145.87), 63.53 +/- 84.35 (48.04-79.01), and 36.97 +/- 52.83 (22.32-51.61) per 10,000 anesthetics, respectively.

CONCLUSIONS

The yearly number of operations has been shown to affect mortality rate due to intraoperative critical incidents among patients for cardiac surgery in Japan. Hospitals with a small number operations should pay significant attention to improving surgical outcome. These results also suggest that centralization or regionalization of cardiac surgery should be discussed from the socio-economical points as well as patient safety.

Contrasting action of IL-12 and IL-18 in the development of dextran sodium sulphate colitis in mice

BACKGROUND

Interleukin (IL)-12 and IL-18 are major interferon (IFN)-gamma-inducing factors that collaborate with each other. The present study was conducted to determine the distinct roles of IL-12 and IL-18 in the development of dextran sulphate sodium (DSS) colitis in mice.

METHODS

Colitis was induced in IL-12p35(-/-), IL-18(-/-), IL-18 receptor(-/-) and control mice with DSS. Clinical and histopathological analysis was conducted using survival rate, weight loss score, diarrhoea score, bloody stool score and histological score. In addition, cytokine production by lamina propria mononuclear cells (LPMCs) was examined using the specific enzyme-linked immunoassay.

RESULTS

IL-12p35(-/-) mice developed only a mild disease associated with no lethality and few histopathological abnormalities. In contrast, IL-18(-/-) and IL-18R(-/-) mice developed more severe colitis associated with high lethality and more histopathological abnormalities compared with control mice. LPMCs from DSS-fed IL-18(-/-) mice produced significantly higher amounts of IFN-gamma, while LPMCs from DSS-fed IL-12(-/-) mice produced lower amounts of IFN-gamma and tumour necrosis factor (TNF)-alpha compared with control mice.

CONCLUSION

These results suggest that IL-18 might function with manners different from IL-12 at some pathological conditions in the development of colitis.

Mitochondrial membrane potential and intracellular ATP content after transient experimental ischemia in the cultured hippocampal neuron

Ischemia limits the delivery of oxygen and glucose to cells and disturbs the maintenance of mitochondrial membrane potential (MMP). MMP regulates the production of high-energy phosphate and apoptotic cascading. Thus, MMP is an important parameter determining the fate of neurons. Differences in the time course of MMP according to the grading of the ischemic impact have not been clarified. MMP and intracellular ATP contents were monitored before and after short-term oxygen-glucose deprivation. A primary hippocampal culture seeded in a 35 mm fenestrated dish for fluorescence microscopy was mounted in a sealed chamber for an anaerobic incubation. A continuous flow of 100% nitrogen into the chamber and a replacement of glucose-free medium allowed the condition of oxygen-glucose deprivation (OGD), thereby extrapolating ischemia. MMP was evaluated by the fluorescence of a voltage-dependent dye, JC-1, under fluorescence microscopy. The intracellular ATP content was evaluated in a hippocampal culture seeded in a 96-well plate by the luciferin-luciferase reaction after a designated period of OGD. During OGD, MMP decreased to 0.72+/-0.03 (normalized JC-1 fluorescence), then increased to the hyperpolarized level 1.99+/-0.12 during 60 min reoxygenation after 30 min OGD. MMP after 60 min OGD decreased and recovered occasionally during reoxygenation. After 90 min OGD and reoxygenation, MMP was reduced and never recovered. The intracellular ATP content was 8.1+/-6.6 and 3.2+/-1.9% after 30 min OGD and 30 min reoxygenation following 30 min OGD, respectively; 60 min OGD did not significantly change these levels (7.1+/-5.8, 2.6+/-0.5%). Hyperpolarization after OGD did not accompany ATP production. This observation suggests the inhibition of electron reentry into an inner membrane during reoxygenation and the disturbance of FoF1-ATP synthase. This pathological finding of an energy-producing system after OGD may provide a clue to explain post-ischemic energy failure.

Anesthesia-related mortality and morbidity over a 5-year period in 2,363,038 patients in Japan

BACKGROUND

Statistical data of mortality and morbidity related to anesthesia have not been reported in Japan since World War II. The need to comprehensively examine the events of cardiac arrest as well as mortality prompted the first national study in Japan.

METHODS

Confidential questionnaires were sent to all Japan Society of Anesthesiologists Certified Training Hospitals every year from 1994 through 1998. Collected data were analyzed for incidence of cardiac arrest and other critical events during anesthesia and surgery, and their outcomes within 7 postoperative days. The principal causes of the critical incidents were also analyzed.

RESULTS

With an average response rate of 39.9%, a total of 2,363,038 cases were documented over 5 years. The average incidence per year of cardiac arrest during surgery due to all etiologies and that totally attributable to anesthesia was 7.12 [95%CI: 6.30,7.94] and 1.00 [0.88, 1.12]) per 10,000 cases, respectively. The average mortality per year in the operating room or within 7 postoperative days due to all etiologies and that totally attributable to anesthesia was 7.18 [6.22, 8.13] and 0.21 [0.15, 0.27] per 10,000 cases, respectively. The two principal causes of cardiac arrest during anesthesia and surgery due to all etiologies were massive hemorrhage (31.9%) and surgery (30.2%), and those totally attributable to anesthesia were drug overdose or selection error (15.3%) and serious arrhythmia (13.9%). Preventable human errors caused 53.2% of cardiac arrest and 22.2% of deaths in the operating room totally attributable to anesthesia.

CONCLUSIONS

The rates in Japan of cardiac arrest and death during anesthesia and surgery due to all etiologies as well as those totally attributable to anesthesia are comparable to those of other developed countries.

Validity of simple mucosal biopsy criteria combined with endoscopy predicting patients with ulcerative colitis ultimately requiring surgery: a multicenter study

BACKGROUND

Recent mucosal biopsy criteria combined with endoscopy effectively differentiate patients with ulcerative colitis ultimately requiring surgery (UC-S) from those receiving medication alone (UC-M). However, the criteria were inconvenient in practical use because of the need for complicated calculations, and the validity has not been verified in other institutes where the indications for surgery may differ. The aims of this multicenter study were to propose simple criteria in which calculation can be performed by mental arithmetic and to measure their validity.

METHODS

Based on the above original criteria, we constructed simple criteria in which coefficients and constant were simplified to integral numbers. The criteria consisted of the diagnostic categories, highest-risk, high-risk, unpredictable, low-risk, and lowest-risk of surgery. The validity of these proposed criteria was evaluated in 121 patients with UC-S and 186 with UC-M from 11 institutes.

RESULTS

The categories of high-risk and low-risk had sensitivities exceeding 86.0% and specificities exceeding 95.2%, and the validities were maintained at high levels in most individual institutes. There was little difference in validity between the proposed and original criteria when testing using the same patients.

CONCLUSIONS

Despite simplified coefficients and constant, the proposed criteria reliably predicted the eventual clinical outcome of patients with ulcerative colitis and would be helpful in determining the necessity of surgery.

[Annual study of anesthesia-related mortality and morbidity in the year 2001 in Japan: the outlines--report of Japanese Society of Anesthesiologists Committee on Operating Room Safety]

We reported anesthesia-related mortality and morbidity in Japanese Society of Anesthesiologists Certified Training Hospitals (JSACTH) in the year 2001, as a part of the second series of annual studies in the identical questionnaires form started in 1999. JSA Committee on Operating Room Safety sent confidential questionnaires to 813 JSACTH and received effective answers from 87.9% of the hospitals. A total number of 1,284,957 anesthetics were documented. The respondents were asked to report all cases of cardiac arrests and other critical incidents (serious hypotension, serious hypoxemia and others) during anesthesia and surgery, and their outcomes (death in operating room, death within 7 days, transfer to vegetative state and rescue without sequelae) as well as one principal cause for each incident from the list of 52 items. Definition of serious hypotension, serious hypoxemia and others was those events suggesting the possibility of impending cardiac arrest or permanent disability of the central nervous system or myocardium. The respondents were also requested to submit the tabulation of patients by ASA physical status, age distribution, surgery sites and anesthetic methods. Analysis was made by total incidents under anesthesia/surgery, and also by incidents totally attributable to anesthetic management (AM), due to preoperative complications (PC), due to intraoperative pathological events (IP) and due to surgery (SG). This paper focused on analysis of entire patients, as other later papers will report analyses with special reference to ASA physical status, age distribution, surgery sites and anesthetic methods. Total incidence of cardiac arrest under anesthesia/surgery was 6.12 per 10,000 anesthetics. PC, IP and SG occupied 47.2%, 21.1% and 24.2% of principal causes of total cardiac arrest, respectively. AM occupied only 6.4% of the principal causes and the incidence was 0.39 per 10,000. The most frequent cause of cardiac arrest in 52 more detailed classifications of principal causes was preoperative hemorrhagic shock that occupied 19.2% of all cardiac arrests. The second was massive hemorrhage due to surgical procedures (12.3%), and the third was surgery itself (9.7%). Prognosis of the cardiac arrest was worst in that due to PC, i.e. 86.1% of cardiac arrests died in the operating room or within 7 days after surgery and only 5.3% survived without sequelae. Very low survival rate of preoperative hemorrhagic shock (5.3%) and preoperative multiple organ failure/sepsis (7.1%) aggravated the prognosis. Pulmonary embolism was the worst single cause in prognosis of cardiac arrest due to IP. The best prognosis was found in cardiac arrest due to AM, 82.0% survived without sequelae and 10.0% died. The mortality rate after cardiac arrest was 3.04 per 10,000 anesthetics, of them 0.04 was due to AM, 0.43 due to IP, 1.89 due to PC and 0.67 due to SG. The mortality rate after critical incidents other than cardiac arrest such as severe hypotension and severe hypoxemia was 3.37, and of them 0.06 was due to AM, 0.23 due to IP, 2.25 due to PC and 0.82 due to SG. The final mortality rate attributable to anesthesia/surgery including deaths after cardiac arrest and after other critical incidents was 6.41 per 10,000 anesthetics. The final mortality rate totally attributable to AM was 0.10 per 10,000 anesthetics, which was significantly improved from 0.21 [0.15, 0.27], that of mean [95%C.I.] in 1994-1998. IP, PC and SG showed the final mortality rate of 0.65, 4.14 and 1.49, respectively. Three major causes of all critical incidents in 52 detailed classification of principal causes were preoperative hemorrhagic shock (31.4%), massive hemorrhage due to surgical procedures (16.9%), and preoperative multiple organ failure/sepsis (9.0%). In conclusion, the obtained incidences as to cardiac arrest and death, either in total number during anesthesia/surgery or in that due to anesthetic management, kept decreasing lineally through 8 years study in 1994-2001. We expect that this second series of annual studies for five-years should reveal precise and definite direction for us to reduce anesthesia-related mortality and morbidity by analyzing further detail with special reference to ASA physical status, age distribution, surgery sites and anesthetic methods.

[Life-threatening coronary ischemia in the operating room: analysis of annual survey from 1999 to 2001 conducted by Japanese Society of Anesthesiologists]

In Japan, the incidence of cardiac morbidity among patients with ischemic heart diseases has been reported to be 13.2-16.4%, and that of perioperative myocardial infarction in these patients about 1%. We investigated the perioperative morbidity and mortality due to coronary ischemia by using data from an annual survey concerning anesthesia-related critical incidents, conducted by the Committee on Operating Room Safety, Japanese Society of Anesthesiologists. In this survey, coronary ischemia was divided into intraoperative pathological events (coronary ischemia as intraoperative event) and preoperative complication (coronary ischemia as preoperative complication). The former consists of coronary ischemia which developed in patients without preoperative diagnosis of ischemic heart diseases or which was induced by surgical and/or anesthetic procedures. The latter was coronary ischemia developed in patients with preoperative diagnosis of ischemic heart diseases. From January 1, 1999, to December 31, 2001, 3,020,021 patients were registered from certified training hospitals of Japanese Society of the Anesthesiologists in the survey. Among them 1,918 episodes of intraoperative cardiac arrest and 2,054 deaths (within 7th postoperative days) were reported. Of these 7.5% and 6.3% of cardiac arrests were due to coronary ischemia as intraoperative event and as preoperative complication, respectively. Death was due to coronary ischemia as intraoperative event in 4.0% and as preoperative complication in 5.1%. The occurrence of critical incidents (cardiac arrest and the other life-threatening events) due to both types of coronary ischemia depended on ASA-PS. The percentage of coronary ischemia as preoperative complication was higher in emergency patients than in elective patients. The percentage of coronary ischemia as intraoperative event was almost the same between emergency and elective patients. Both types of coronary ischemia developed most frequently in cardiac/aortic surgeries, followed by thoracotomy with or without laparotomy. The number of critical incidents due to coronary ischemia as preoperative complication was the largest in emergency cardiac/aortic surgeries, followed by elective non-cardiac surgeries. The number of critical incidents due to coronary ischemia as intraoperative event was the largest in elective non-cardiac, especially open abdominal, surgeries in patients with ASA-PS 1(E) + 2(E). Among the patients with ASA-PS 1(E) + 2(E) who underwent non-cardiac surgeries 13.9% of deaths were due to coronary ischemia as preoperative complication and 12.5% as intraoperative event. It should be noted that many critical incidents due to coronary ischemia as intraoperative event during laparotomy developed in patients anesthetized by inhalation anesthesia combined with epidural, spinal or conduction block. Prognosis of cardiac arrest due to coronary ischemia as preoperative complication was the worst: 47.1% of these patients died. The best prognosis was found in critical incidents other than cardiac arrest due to coronary ischemia as intraoperative event with mortality of 12.3%. The results show that quality improvement from the standpoint of intraoperative coronary ischemia is required.

[Perioperative mortality and morbidity in the year 2000 in 520 certified training hospitals of Japanese Society of Anesthesiologists: with a special reference to age--report of Japanese Society of Anesthesiologists Committee on Operating Room Safety]

Perioperative mortality and morbidity in Japan for the year 2000 were studied retrospectively. Committee on Operating Room Safety of Japanese Society of Anesthesiologists (JSA) sent confidential questionnaires to 794 Certified Training Hospitals of JSA and received answers from 67.6% of the hospitals. We analyzed their answers with a special reference to the age group. The total number of anesthetics available for this analysis was 910,757. All cases were divided into 7 age groups; group A (< 1 months), group B (< 12 months), group C (< 5 years), group D (< 18 years), group E (< 65 years), group F (< 85 years), and group G (> 85 years). The incidences of all critical events including cardiac arrest, severe hypotension, and severe hypoxemia were 70.04, 42.06, 17.79, 15.57, 21.14, 39.66, and 44.65 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The overall mortality rates (death during anesthesia and within 7th postoperative day) were 26.94, 5.91, 1.88, 2.57, 5.23, 11.98, and 17.50 per 10,000 anesthetics in patients with group A, B, C, D, E, F, and G, respectively. The incidences of cardiac arrest were 28.29, 8.54, 3.56, 2.57, 5.08, 10.27, and 11.47 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The mortality rates after cardiac arrest were 18.86, 4.60, 1.26, 1.57, 2.77, 5.50, and 6.64 in patients with group A, B, C, D, E, F, and G, respectively. The incidence of all critical events, the incidence of cardiac arrest, and the overall mortality rate were much higher in group A than in other groups, but much lower than those in 1999. The incidences of all critical events and the mortality rate after cardiac arrest were lowest in group C. Mortality and morbidity due to all kinds of causes including anesthetic management, intraoperative events, co-existing diseases, and operation were as follows. The incidences of all critical events attributable to co-existing disease were the highest in these four groups, and 32.33, 13.80, 5.86, 4.43, 7.50, 15.34, and 21.72 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The incidences of all critical events attributable to anesthetic management were 13.47, 16.43, 6.28, 3.86, 4.08, 6.87, and 6.64 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The incidence of cardiac arrest in group A was much more attributable to co-existing disease and operation than other causes. The incidences of cardiac arrest attributable to anesthetic management were 0.00, 1.97, 0.63, 0.29, 0.38, 0.74, and 1.81 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. Its mortality rate in each group was 0.00, 0.00, 0.21, 0.14, 0.06, 0.04, or 0.00. There were eleven cases of death or vegetative state due to anesthetic management, like improper management of airway and overdose of anesthetics. Some of them were preventable with the anesthesiologists' effort in protocol development and skilled assistance.

[Annual study of anesthesia-related mortality and morbidity in the year 2000 in Japan: the outlines--report of Japanese Society of Anesthesiologists Committee on Operating Room Safety]

This report contains anesthesia-related mortality and morbidity in Japanese Society of Anesthesiologists Certified Training Hospitals (JSACTH) in the year 2000, as a part of the second series of annual studies started in 1999. JSA Committee on Operating Room Safety (CORS) sent confidential questionnaires to 794 JSACTH and received effective answers from 65.5% of hospitals. A total number of 941,217 anesthetics were documented. The respondents were asked to report all cases of cardiac arrests and other critical incidents (serious hypotension, serious hypoxemia and others), and their outcomes (death in operating room, death within 7 days, transfer to vegetative state and rescue without sequelae) as well as one principal cause for each incident from the list of 52 items. They were also requested to submit the tabulation of patients by ASA physical status, age distribution, surgery sites and anesthetic methods. Analysis was made by total incidents under anesthesia/surgery, and also by incidents totally attributable to anesthetic management (AM), due to preoperative complications (PC), due to intraoperative pathological events (IP) and due to surgery (SG). This paper focused analysis on entire patients, since analyses with special reference to ASA physical status, age distribution, surgery sites and anesthetic methods were reported previously. Total incidence of cardiac arrest under anesthesia/surgery was 6.52 per 10,000 anesthetics. PC, IP and SG occupied 46.4%, 19.1% and 23.0% of principal causes of total cardiac arrest, respectively. AM occupied only 8.1% of the principal causes and the incidence was 0.53 per 10,000. The most frequent cause of cardiac arrest in 52 more detailed classification of principal causes was preoperative hemorrhagic shock that occupied 23.3% of all cardiac arrests. The second was massive hemorrhage and/or hypovolemia due to surgical procedures (10.6%), and the third was surgery itself (9.5%). Prognosis of the cardiac arrest was worst in that due to PC, 73.7% of cardiac arrests died in the operating room or within 7 days after surgery and only 20.4% survived without sequelae. The best prognosis was found in cardiac arrest due to AM, 76.0% survived without sequelae and 12.0% died. The mortality rate after cardiac arrest was 3.52 per 10,000 anesthetics, of them 0.06 was due to AM, 0.39 due to IP, 2.23 due to PC and 0.76 due to SG. The mortality rate after critical incidents other than cardiac arrest such as severe hypotension and severe hypoxemia was 3.48, and of them 0.03 was due to AM, 0.18 due to IP, 2.45 due to PC and 0.81 due to SG. The final mortality rate attributable to anesthesia/surgery including deaths after cardiac arrest and after other critical incidents was 7.00 per 10,000 anesthetics and very close to 7.18 [6.22, 8.13], that of mean [95%C.I.] in 1994-1998, and 7.19 in 1999. The final mortality rate totally attributable to AM was 0.10 per 10,000 anesthetics, which was significantly improved from 0.21 [0.15, 0.27], that of mean [95%C.I.] in 1994-1998, but not different from 0.13 in 1999. IP, PC and SG showed the final mortality rate of 0.56, 4.69 and 1.57, respectively. Five major causes of all critical incidents were massive hemorrhage due to surgical procedures (13.8%), preoperative hemorrhagic shock (13.1%), surgical technique (8.6%), inappropriate airway management (6.2%) and preoperative respiratory complication (5.7%). Drug overdose or wrong choice (2.7%) as a human error occupied the 10th. In conclusion, the obtained incidences as to death, other critical incidents and their outcomes as well as the occurrence of principal causes in 2000 study were remarkably close to those in 1999 study. We expect that this second series of annual studies for five-years should reveal precise and definite direction for us to reduce anesthesia-related mortality and morbidity.

[Perioperative mortality and morbidity for the year 2000 in 532 Japanese Society of Anesthesiologists certified training hospitals: with a special reference to surgical sites--report of the Japan Society of Anesthesiologists Committee on Operating Room Safety]

Perioperative mortality and morbidity in Japan for the year 2000 were analyzed with special reference to operative regions. The total number of analyzed cases was 903,086. The percentages for each operative region were as follows, CRANIOTOMY 4.5%, THORACOTOMY 3.5%, HEART and GREAT-VESSELS 3.7%, THORACOTOMY with LAPAROTOMY 0.7%, LAPAROTOMY 30.4%, CESARIAN SECTION 3.3%, HEAD-NECK-ENT 14.7%, CHEST-ABDOMEN-PERINEUM 14.0%, SUPINE 3.6%, EXTREMITY including PERIPHERAL-VESSEL 17.2%, OTHERS 4.4%. The incidence of serious events, including cardiac arrest and severe hypotension and hypoxemia developing to cardiac arrest, was 26.74 per 10,000 anesthetics in all operative regions. The events were observed more frequently in HEART and GREAT-VESSELS 170.39, THORACOTOMY with LAPAROTOMY 85.84 and THORACOTOMY 63.63, and less frequently in CHEST-ABDOMEN-PERINEUM 10.49, CESARIAN SECTION 10.95 and EXTREMITY including PERIPHERAL-VESSEL 13.42. Regarding the prognosis of events, the cases with no sequelae were 63.4% in all operative regions. While there were fewer cases with no sequelae in CRANIOTOMY 49.0%, THORACOTOMY with LAPAROTOMY 43.4% and HEART and GREAT-VESSELS 44.4%, there were more cases in HEAD-NECK-ENT 86.9% and CHEST-ABDOMEN-PERINEUM 89.5%. The incidence of serious events totally attributable to anesthetic management was 5.24 per 10,000 anesthetics in all operative regions. The events were observed more frequently in THORACOTOMY 12.91 and SPINE 8.02, and less frequently in LAPAROTOMY except CESARIAN SECTION 4.11 and EXTREMITY including PERIPHERAL-VESSEL 4.65. The main cause of events in THORACOTOMY was inadequate airway management and in SPINE was inadequate airway management and the overdose or miss selection for drugs. Regarding the prognosis of events totally attributable to anesthetic management, the cases with no sequelae were 91.8% in all operative regions. There were fewer cases with no sequelae in HEART and GREAT-VESSELS 82.6%. The incidence of serious events totally attributable to anesthetic management was one fifth of all serious events in all operative regions. While the total deaths from 903,086 cases, including deaths in the operating room or within 7 postoperative days, were 641 cases (7.10 per 10,000 cases), the deaths totally attributable to anesthesia were 9 cases (0.10 per 10,000 cases).

Relationship between oxidation of glutathione and reactive nitrogen species during the early-reperfusion phase of cerebral ischemia

A timed profile of glutathione oxidation and reactive nitrogen species during reperfusion after cerebral ischemia in rat was obtained. Dialysate was collected every 25 min from a microdialysis probe inserted into the cerebral cortex before and after cerebral ischemia. NO2-, NO3-, and reduced and oxidized glutathione (GSH, GSSG) were detected by high-performance liquid chromatography. GSH and GSSG increased and reached a peak: 3408 +/- 1710% (mean +/- SE) at 25 min of reperfusion (P < 0.0001) and 329 +/- 104% at 50 min of reperfusion (P = 0.06), respectively. Oxidation ratio decreased from 0.82 +/- 0.04 to 0.42 +/- 0.07 (P < 0.0001) at 25 min of reperfusion. NO3- levels significantly decreased (68.3 +/- 9.1%) (P < 0.01) during ischemia and remained lower than the control value during reperfusion. NO2- levels did not significantly change. These data suggest that GSH releases during early phase of reperfusion and that its rapid oxidation contributes to prevent an increase in reactive nitrogen species.

Dose-adjusted preemptive therapy for cytomegalovirus disease based on real-time polymerase chain reaction after allogeneic hematopoietic stem cell transplantation

We have prospectively evaluated the efficacy of real-time PCR-guided preemptive therapy for CMV diseases in allogeneic hematopoietic stem cell transplant recipients with grades II-IV acute GVHD. The dose of ganciclovir was adjusted according to the viral load determined by real-time polymerase chain reaction (PCR). On detecting CMV reactivation in the plasma, ganciclovir was initiated at a dose of 5 mg/kg body weight once daily, and the dose was increased to twice daily if viral load continued to increase after initiating ganciclovir. In 39 evaluable patients, CMV reactivation assessed by real-time PCR became positive in 30 (77%). One developed CMV gastroenteritis before PCR became positive. Thus the remaining 29 patients were treated preemptively with ganciclovir. The dose of ganciclovir was increased in 12 patients (41%) of preemptively treated patients for increasing viral load. CMV diseases were diagnosed in two patients (one gastroenteritis and one retinitis), and late CMV disease was diagnosed in one patient (gastritis). The treatment was generally well-tolerated, but three patients (10%) developed neutropenia (neutrophil count less than 1.0 x 10(9)/l). In conclusion, real-time PCR-guided preemptive therapy with decreased dose of ganciclovir is feasible and does not increase the frequency of CMV diseases if the dose is adjusted according to the viral load.

[Annual report of perioperative mortality and morbidity for the year 2000 at certified training hospitals of Japanese Society of Anesthesiologists: with a special reference to anesthetic methods--report of the Japanese Society of Anesthesiologists Committee on Operating Room Safety]

The Committee on Operating Room Safety of Japan Society of Anesthesiologists (JSA) sends annually confidential questionnaires of perioperative mortality and morbidity (cardiac arrest, severe hypotension, severe hypoxia) to Certified Training Hospitals of JSA. This report is a special reference to anesthetic methods in perioperative mortality and morbidity in 2000. Five hundreds and twenty hospitals reported perioperative mortality and morbidity referred to anesthetic methods and total numbers of reported cases were 910,007. The percentage of cases reported by each anesthetic method was as follows; inhalation anesthesia 45.47%, total intravenous anesthesia (TIVA) 6.15%, inhalation anesthesia + epidural or spinal or conduction block 24.48%, TIVA + epidural or spinal or conduction block 6.33%, spinal with continuous epidural block (CSEA) 3.67%, epidural anesthesia 1.92%, spinal anesthesia 10%, conduction block 0.47% and others 1.49%. The incidence of cardiac arrest per 10,000 cases due to all etiology (anesthetic management, preoperative complications, intraoperative complications, surgery, others) is estimated to be 6.55 cases in average; 5.36 cases in inhalation anesthesia, 30.72 cases in total intravenous anesthesia (TIVA), 4.62 cases in inhalation anesthesia + epidural or spinal or conduction block, 2.6 cases in TIVA + epidural or spinal or conduction block, 1.2 cases in spinal with continuous epidural block (CSEA), 0.57 cases in epidural anesthesia, 1.65 cases in spinal anesthesia, 2.36 cases in conduction block and 46.38 cases in other methods. However, the incidence of cardiac arrest per 10,000 cases totally attributable to anesthetic management is estimated to be 0.54 cases in average; 0.34 cases in inhalation anesthesia, 1.07 cases in TIVA, 0.58 cases in inhalation anesthesia + epidural or spinal or conduction block, 0.17 cases in TIVA + epidural or spinal or conduction block, 0.9 cases in CSEA, 0.57 cases in epidural anesthesia, 0.99 cases in spinal anesthesia, zero case in conduction block and 1.47 cases in other methods. The incidence of severe hypotension per 10,000 cases due to all etiology is estimated to be 11.14 cases in average; 11.31 cases in inhalation anesthesia, 36.61 cases in TIVA, 9.29 cases in inhalation anesthesia + epidural or spinal or conduction block, 6.59 cases in TIVA + epidural or spinal or conduction block, 3.59 cases in CSEA, 6.3 cases in epidural anesthesia, 4.39 cases in spinal anesthesia, 2.36 cases in conduction block and 23.56 cases in other methods. On the other hand, the incidence of severe hypotension per 10,000 cases totally attributable to anesthetic management is estimated to be 1.25 cases in average; 0.97 cases in inhalation anesthesia, 0.89 cases in TIVA, 1.39 cases in inhalation anesthesia + epidural or spinal or conduction block, 1.39 cases in TIVA + epidural or spinal or conduction block, 2.09 cases in CSEA, 3.44 cases in epidural anesthesia, 1.87 cases in spinal anesthesia, zero case in conduction block and zero case in other methods. The incidence of severe hypoxia per 10,000 cases due to all etiology is estimated to be 4.8 cases in average; 6.35 cases in inhalation anesthesia, 9.64 cases in TIVA, 3.82 cases in inhalation anesthesia + epidural or spinal or conduction block, 2.26 cases in TIVA + epidural or spinal or conduction block, 0.3 cases in CSEA, 1.15 case in epidural anesthesia, 1.21 cases in spinal anesthesia, zero case in conduction block and 5.89 cases in other methods. On the other hands, the incidence of severe hypoxia per 10,000 cases totally attributable to anesthetic management is estimated to be 1.98 cases in average; 3.09 cases in inhalation anesthesia, 2.32 cases in TIVA, 1.3 cases in inhalation anesthesia + epidural or spinal or conduction block, 0.87 cases in TIVA + epidural or spinal or conduction block, zero case in CSEA, zero case in epidural anesthesia, 0.55 cases in spinal anesthesia, zero case in conduction block and zero case in other methods. The mortality rate of cardiac arrest within 7 postoperative days per 10,000 cases due to all etiology is estimated to be 3.55 (54.2%) cases in average; 3.12 (58.1%) cases in inhalation anesthesia, 19.29 (62.8%) cases in TIVA, 1.17 (25.2%) cases in inhalation anesthesia + epidural or spinal or conduction block, 0.52 (20%) cases in TIVA + epidural or spinal or conduction block, zero cases in CSEA, zero case in epidural anesthesia, 0.33 (20%) cases in spinal anesthesia, zero case in conduction block and 39.76 (85.7%) cases in other methods. On the other hands, the mortality rate of cardiac arrest per 10,000 cases totally attributable to anesthesia is estimated to be 0.07 (12.2%) case in average, 0.07 (21.4%) case in inhalation anesthesia, 0.18 (16.8%) case in TIVA, zero case in inhalation anesthesia + epidural or spinal or conduction block, zero case in TIVA + epidural or spinal or conduction block, zero case in CSEA, zero case in epidural anesthesia, 0.11 (11.1%) case in spinal anesthesia, zero case in conduction block and 0.74 (50%) case in other methods. Five major combinations of listed critical incidents, causes and anesthetic methods were as follows: 18.93 cases in TIVA, preoperative complications and severe hypotension; 18.75 cases in TIVA, preoperative complications and cardiac arrest; 11.07 cases in TIVA, surgery and severe hypotension; 6.79 cases in TIVA, surgery and cardiac arrest; 5.24 cases in inhalation anesthesia, preoperative complications and severe hypotension. In summary: 1. There was no significant difference with regard to perioperative mortality and morbidity due to anesthetic management among anesthetic methods. 2. The percentage of each anesthetic method in 2000 was not different significantly from that in 1999 in spite of increased cases reported. 3. Incidence of severe hypotension due to all etiology of TIVA in 2000 decreased significantly compared with that in 1999 (P < 0.05). This may be attributed to the decreased incidence in preoperative complication (shock) and massive bleeding due to surgery.

[A comment on five reports concerning perioperative mortality and morbidity of the year 1999 in Japanese Society of Anesthesiologists certified training hospitals]

Japanese Society of Anesthesiologists (JSA) has conducted an annual survey concerning anesthesia-related morbidity and mortality in JSA certified training hospitals. This survey was conducted through confidential questionnaires sent by mail to the hospitals. In 'Survey 1999', 60.3% of the hospitals responded to the questionnaire. The results were published in five separate reports: with special reference to ASA-physical status, age, anesthetic methods, operative regions, and 'outline'. However, overall morbidity and mortality differed among the reports. For example, overall anesthesia-related morbidity in the report with special reference to ASA-PS was 0.08 (5/655,644) per 10,000 cases, although it was 0.13 (11/793,847) in a report 'outline'. This difference was caused by imperfect answers from some hospitals. Some hospitals only reported the total number of patients in 1999 and total cases with cardiac arrest or other critical events, without details of distribution as to ASA-physical status, age, anesthetic methods, and/or operative regions. As a result, a part of critical incidents was reflected in the calculation of overall mortality and morbidity in the 'outlines', but not in that of ASA-physical status, age, anesthetic methods, and/or operative regions. In 'Survey 2000', however this type of confusion was reduced, because increasing number of hospitals had answered the questionnaire completely.

A case of systemic lupus erythematosus presenting with rectal ulcers as the initial clinical manifestation of disease

Gastrointestinal involvement is often seen in patients with systemic lupus erythematosus (SLE). All parts of the gastrointestinal tract may be affected. However, rectal involvement at onset is rare. We describe here a case of SLE in which rectal ulcers due to vasculitis occurred as the initial manifestation of the disease without involvement of any other organ. The ulcers worsened, along with the appearance of lupus nephritis 5 years later When steroid therapy was initiated, there was rapid clinical and radiographic improvement. Our case suggests that rectal ulcer is a rare but important complication of SLE and can represent the initial and sole clinical manifestation of the disease.