[Reoperation for multidrug-resistant pulmonary tuberculosis]

We have performed pulmonary resection combined with chemotherapy for multidrug-resistant tuberculosis (MDR-TB). Postoperative complications of pulmonary resection for MDR-TB include space problem, prolonged air leak, bronchopleural fistula with or without empyema, chylothorax, and relapse. Indication, surgical technique, postoperative management, and follow-up of reoperation (thoracoplasty and muscle plombage, clousure of bronchopleural fistula, resuture of bronchial stump, open window thoracostomy, and 2nd pulmonary resection) for these complications are described.

Analysis of Heat Flu from Molten Polymers to Molds in Injection Molding Processes

The inverse analysis method is applied in the evaluation of heat flux at the interface between the molten polymer and the mold during the injection molding process. In addition, the dependence of cooling behavior on both the molding conditions and the material properties of the resin are investigated. During low-velocity polymer flow in the thick regions of the mold cavity, the heat flux in the later stage of the process evaluated through experiment correlates well with the theoretical results of equations describing heat conduction at the interface of two semi-infinite objects. In contrast, in the thin region of the mold cavity, the analyzed heat flux is greater than the theoretical result for high-velocity polymer flow, and the difference expands with an increase in the shear rate at the wall of the mold. Based on these results, a simple empirical equation applicable to a wide range of molding conditions is proposed for the estimation of heat flux at the polymer-mold interface.

Adjuvant surgical treatment of nontuberculous mycobacterial lung disease

BACKGROUND

According to the 2007 American Thoracic Society/Infectious Diseases Society of America statement on nontuberculous mycobacterial diseases, more evidence for the benefits of adjuvant nontuberculous mycobacterial lung disease surgical intervention is needed before its wide application can be recommended.

METHODS

A retrospective review was conducted of 60 consecutive patients who met American Thoracic Society/Infectious Diseases Society of America diagnostic criteria and underwent pulmonary resection for localized nontuberculous mycobacterial lung disease between January 2007 and December 2011. All patients were receiving chemotherapy before resection.

RESULTS

Included were 41 women (68%) and 19 men (32%), with a median age of 50 years (range, 20 to 72 years). Of these, 55 patients (92%) had Mycobacterium avium complex disease. Bronchiectatic disease was noted in 29 patients, cavitary disease in 25, both in 4, and nodular disease in 2. The indications for resection were a poor response to drug therapy in 52 patients, hemoptysis in 6, and a secondary infection in 2. Sixty-five pulmonary resections were performed: 1 pneumonectomy, 3 bilobectomies, 39 lobectomies, 17 segmentectomies, 3 lobectomies plus segmentectomies, and 2 wedge resections. There were no operative deaths, and all patients attained sputum-negative status postoperatively. Eleven postoperative complications occurred in 8 patients (12%); relapse was observed in only 2 (3%).

CONCLUSIONS

Pulmonary resection combined with chemotherapy is safe, with favorable treatment outcomes, for patients with localized nontuberculous mycobacterial lung disease. Our results support the liberal use of operations for nontuberculous mycobacterial lung disease whenever indicated.

Examination of mitral regurgitation with a goat heart model for the development of intelligent artificial papillary muscle

Annuloplasty for functional mitral or tricuspid regurgitation has been made for surgical restoration of valvular diseases. However, these major techniques may sometimes be ineffective because of chamber dilation and valve tethering. We have been developing a sophisticated intelligent artificial papillary muscle (PM) by using an anisotropic shape memory alloy fiber for an alternative surgical reconstruction of the continuity of the mitral structural apparatus and the left ventricular myocardium. This study exhibited the mitral regurgitation with regard to the reduction in the PM tension quantitatively with an originally developed ventricular simulator using isolated goat hearts for the sophisticated artificial PM. Aortic and mitral valves with left ventricular free wall portions of isolated goat hearts (n=9) were secured on the elastic plastic membrane and statically pressurized, which led to valvular leaflet-papillary muscle positional change and central mitral regurgitation. PMs were connected to the load cell, and the relationship between the tension of regurgitation and PM tension were measured. Then we connected the left ventricular specimen model to our hydraulic ventricular simulator and achieved hemodynamic simulation with the controlled tension of PMs.

A new control method depending on primary phase angle of transcutaneous energy transmission system for artificial heart

A new control method for stabilizing output voltage of the transcutaneous energy transmission system for artificial heart is proposed. This method is primary side, is outside of the body, which is not depending on a signal transmission system from the implanted device. The impedance observed from primary side changes from inductive to capacitive and the output voltage decreases drastically when the output current is large and the coupling factor is higher than that of the optimal condition. In this case, the driving frequency should be changed to higher so that the phase angle of the primary impedance is zero degree. The preliminary examination showed that this control method can enhance the output voltage limit to twice and the feasibility of the primary side control.

Multidrug resistant pulmonary tuberculosis treatment regimens and patient outcomes: an individual patient data meta-analysis of 9,153 patients

BACKGROUND

Treatment of multidrug resistant tuberculosis (MDR-TB) is lengthy, toxic, expensive, and has generally poor outcomes. We undertook an individual patient data meta-analysis to assess the impact on outcomes of the type, number, and duration of drugs used to treat MDR-TB.

METHODS AND FINDINGS

Three recent systematic reviews were used to identify studies reporting treatment outcomes of microbiologically confirmed MDR-TB. Study authors were contacted to solicit individual patient data including clinical characteristics, treatment given, and outcomes. Random effects multivariable logistic meta-regression was used to estimate adjusted odds of treatment success. Adequate treatment and outcome data were provided for 9,153 patients with MDR-TB from 32 observational studies. Treatment success, compared to failure/relapse, was associated with use of: later generation quinolones, (adjusted odds ratio [aOR]: 2.5 [95% CI 1.1-6.0]), ofloxacin (aOR: 2.5 [1.6-3.9]), ethionamide or prothionamide (aOR: 1.7 [1.3-2.3]), use of four or more likely effective drugs in the initial intensive phase (aOR: 2.3 [1.3-3.9]), and three or more likely effective drugs in the continuation phase (aOR: 2.7 [1.7-4.1]). Similar results were seen for the association of treatment success compared to failure/relapse or death: later generation quinolones, (aOR: 2.7 [1.7-4.3]), ofloxacin (aOR: 2.3 [1.3-3.8]), ethionamide or prothionamide (aOR: 1.7 [1.4-2.1]), use of four or more likely effective drugs in the initial intensive phase (aOR: 2.7 [1.9-3.9]), and three or more likely effective drugs in the continuation phase (aOR: 4.5 [3.4-6.0]).

CONCLUSIONS

In this individual patient data meta-analysis of observational data, improved MDR-TB treatment success and survival were associated with use of certain fluoroquinolones, ethionamide, or prothionamide, and greater total number of effective drugs. However, randomized trials are urgently needed to optimize MDR-TB treatment. Please see later in the article for the Editors' Summary.

Elimination of Teicoplanin by Adsorption to the Filter Membrane during Haemodiafiltration: Screening Experiments for Linezolid, Teicoplanin and Vancomycin followed by in vitro Haemodiafiltration Models for Teicoplanin

Pharmaceutical agents directed against methicillin-resistant Staphylococcus aureus can be eliminated during haemodiafiltration, not only by diffusion and ultrafiltration, but also by adsorption onto haemofilters. The latter may be affected by the binding of agents to serum albumin. The present study therefore investigated the affinity of anti-methicillin-resistant Staphylococcus aureus agents (teicoplanin, linezolid, vancomycin) for haemofilters and the pharmacokinetic properties of teicoplanin during haemodiafiltration. Linezolid, teicoplanin and vancomycin were first screened for their in vitro affinity for three different kinds of filter membranes: polysulfone, polyacrylonitrile and polymethylmethacrylate. Only teicoplanin showed significant filter-binding activity. An in vitro haemodiafiltration circulation model was then developed that incorporated a one-litre beaker containing Krebs-Ringer's bicarbonate solution with/without human albumin (0 or 3 g/dl) as an artificial plasma. Teicoplanin (initial concentration 50 μg/ml, representing the maximum plasma concentration (Cmax) resulting from a typical clinical dosage) was circulated throughout the beaker. Teicoplanin concentrations in the ‘plasma’ and ultrafiltrate were determined by high performance liquid chromatography. In the screening experiment, teicoplanin was predominantly adsorbed onto polysulfone and polymethylmethacrylate membranes. Furthermore, teicoplanin was primarily eliminated by adsorption onto these filters during in vitro haemodiafiltration. Albumin significantly reduced both haemodiafiltration clearance and the adsorption-dependent elimination, although there were complex but significant interactions between albumin and the filter membrane. Elimination of teicoplanin in an in vitro haemodiafiltration model was largely due to adsorption onto polysulfone and polymethylmethacrylate haemofilters. Future clinical studies should likely be designed to evaluate present recommendations of teicoplanin dosages in patients on haemodiafiltration.

Template for preparation of papers for IEEE sponsored conferences & Symposia

Rotary blood pumps which have contact-less suspension are small, durable and widely used for left ventricular assist devices (LVADs). In order to design a total artificial heart (TAH) with rotary blood pumps, two pumps one for each ventricle, are controlled independently. Some of the challenges for the development of a TAH includes the requirement of a small size and the anatomical fitting of inlets and outlets which should be arranged closely on the circumference in the same direction. And they should be combined into a unit. In this paper, a helical flow total artificial heart (HFTAH) combing two centrifugal pumps with helical inlet in face is proposed in order to achieve a smaller TAH. To examine the pump performance, a preliminary test model for left ventricle was built, the size of the pump was 69.0mm in diameter and 45.0mm height. The size of the impeller was 44.0mm in diameter and 23.0mm height including a 15.0mm-height hydrodynamic bearing. The pump was externally driven by a direct current motor. 5.0L/min flow rate against 100mmHg pressure difference was obtained, where the total power consumption was 5.0W, the system efficiency was 23% with a rotational speed of 2070rpm. In this system, maximum pressure head, flow rate and efficiency were 420mmHg, 15.0L/min and 26%, respectively. In acute animal experiments with three healthy adult goats, the total biventricular bypass assist system using the pumps was able to maintain the maximum aortic flow at approximately 5.0L/min, and the pulmonary arterial flow at approximately 4.6L/min, the mean aorta pressure was 105mmHg, and the mean pulmonary artery pressure was 51mmHg. The development of the control method is undergoing, and a driving system and the pump aiming at the chronic animal experiments will be developed.

Risk factors that affect the surgical outcome in the management of focal bronchiectasis in a developed country

BACKGROUND

The purpose of this study was to demonstrate our surgical experience for focal bronchiectasis in the setting of modern diagnostic modalities and state-of-the-art medical treatment in a developed country.

METHODS

Thirty-one patients undergoing 33 lung resections for the treatment of focal bronchiectasis from 1991 to 2009 were reviewed. The mean age was 54 years. Twenty-nine patients (94%) were female; 21 patients (68%) had nontuberculous mycobacterial infection; and 22 patients (71%) received preoperative multiple-drug regimens containing clarithromycin. Five patients (16%) were in an immunocompromised status. All were diagnosed by chest computed tomography scan, and either the right middle lobe or left lingula were involved in 29 (94%). The curve for relapse-free interval was estimated by Kaplan-Meier methods. The factors that affected this curve were examined using Cox's regression analysis.

RESULTS

Operative morbidity and mortality were 18% and 0%, respectively. All patients became asymptomatic postoperatively. During the median follow-up of 48 months (11 to 216), 8 patients (26%) experienced recurrence, and the mean relapse-free interval was 34 months (3 to 216). By univariate analysis, an immunocompromised status (p=0.017), Pseudomonas aeruginosa infection (p=0.040), the preoperative extent of bronchiectatic lesion (p=0.013), and the extent of residual bronchiectasis after surgery (p=0.003) were significantly associated with the shorter relapse-free interval. By multivariate analysis, an immunocompromised status (p=0.039), Pseudomonas aeruginosa infection (p=0.033), and the extent of residual bronchiectasis (p=0.009) were independent and significant factors.

CONCLUSIONS

Complete resection of bronchiectasis while the disease is localized and is free from Pseudomonas aeruginosa infection is the key for a success. Also, immunocompromised status was suggested to be a risk factor.

[Surgical treatment of Mycobacterium avium complex lung disease]

Mycobacterium avium complex (MAC) lung disease is the most common nontuberculous mycobacterial lung disease in Japan and is difficult to treat. Multidrug regimen employing clarithromycin, rifampicin, and ethambutol is not a panacea. Pulmonary resection may be beneficial to patients whose disease is predominantly localized to one lung and who can tolerate resectional surgery under the following circumstances: poor response to drug therapy, the development of macrolide-resistant MAC disease, or the presence of hemoptysis. Resectional surgery for MAC lung disease can achieve favorable treatment outcome. However, this type of surgery is associated with a relatively high morbidity and should be performed by experienced hands.

Does postoperative serum interleukin-6 influence early recurrence after curative pulmonary resection of lung cancer?

PURPOSE

We examined the influence of inflammatory cytokine levels on postoperative early recurrence in patients who underwent curative lung cancer surgery.

METHODS

In 107 patients who underwent curative pulmonary resections for non-small cell lung cancer (NSCLC) from November 2007 to June 2008, we measured serum interleukin-6 (IL-6) levels preoperatively, and on postoperative day (POD) 0, 1, and 2. Between July 2009 and August 2009, 1 year after the date of enrollment of the last patient, we investigated survival status of each patient and identified a group with recurrence.

RESULTS

Among 107 patients, 29 patients developed recurrence with a mean follow-up of 18.1 months (range 14 to 21). P-stage was significantly more advanced in the recurrence group than in the non-recurrence group (p = 0.005). Serum IL-6 levels on POD 1 were significantly higher in the recurrence group than in the non-recurrence group (p = 0.007). In Cox's proportional hazards regression, P-stage and serum IL-6 levels on POD 1 were significant independent predicting factors for postoperative early recurrence (p = 0.006, p = 0.003).

CONCLUSIONS

The higher the serum IL-6 levels on POD 1, the higher the risk of early postoperative recurrence, even when curative pulmonary resection can be accomplished in lung cancer patients.

[Nontuberculous mycobacteria]

Mycobacterium avium complex (MAC) is the most common nontuberculous mycobacterial pathogen in Japan. There are 2 major types of clinical manifestations of MAC disease, including fibrocavitary disease and nodular bronchiectatic disease. Primary treatment of MAC disease is medical treatment. Standard multidrug regimens employ clarithromycin, rifampicin, and ethambutol. Aminoglycoside (streptomycin or kanamycin) is added if necessary. Patients whose disease is predominantly localized to 1 lung and who can tolerate resectional surgery may be considered for surgery under the following circumstances; poor response to drug therapy, the development of macrolide-resistant MAC disease, or the presence of hemoptysis. Surgery for MAC lung disease can achieve favorable treatment outcome. However, surgery is associated with significant morbidity, especially when pneumonectomy is performed. When surgical intervention is considered necessary for MAC patients, pulmonary resection should be performed before MAC lung disease has progressed too extensively to avoid pneumonectomy.