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AIMS: The objective of this study was to investigate the effect of the head-first or tail-first injection of sperm into the cytoplasm by Piezo-ICSI (PICSI) on oocyte survival, fertilization, embryo development and implantation ability in humans. METHODS: We retrospectively investigated 632 mature oocytes retrieved from 152 infertile patients who attended our PICSI-ET program at the Niji Clinic between October 2010 and January 2014. Of these, 342 mature oocytes retrieved from 75 patients were injected with sperm head first, and 290 mature oocytes retrieved from 77 patients were injected with sperm tail first into the cytoplasm. The rates of oocyte survival, fertilization, good-quality day-3 embryos, pregnancy, implantation and live birth were evaluated in both groups. RESULTS: There were no differences among the two groups with respect to survival, fertilization, good-quality day-3 embryos, pregnancy, implantation and live birth rates. CONCLUSION: Sperm direction (i.e., head first or tail first) does not influence the outcome of PICSI in human oocytes, including oocyte survival, fertilization, embryo development and implantation ability. These findings contribute to an understanding of factors that influence the success of human intracytoplasmic sperm injection (ICSI) techniques.

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BACKGROUND: Three eyes of 2 cases had repeating recurrences and spontaneous closures of macular holes (MHs) after vitrectomy. CASES: A 66-year-old man had rhegmatogenous retinal detachment (RRD) in his left eye and underwent vitrectomy with successful retinal reattachment. A full-thickness MH developed 1 year after the vitrectomy and spontaneously closed 1 month later. Opening and spontaneous closure of the MH recurred an additional 4 times over 7 years. An 80-year-old man had suffered intraocular lens (IOL) dislocation and underwent vitrectomy in his left eye. An MH developed in the eye 6 years and 3 months after the vitrectomy. Repeated opening and spontaneous closure of the MH occurred twice in the left eye. The same patient also suffered IOL dislocation and underwent vitrectomy in his right eye. An MH also developed in the right eye 2 years and 9 months after the vitrectomy. Repeated opening and spontaneous closure of the MH occurred 3 times in the right eye. OBSERVATIONS: The visual acuity was maintained at the last visit in both cases. CONCLUSIONS: MHs in vitrectomized eyes can show repeated recurrence and spontaneous closure.

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Erratum to: J Assist Reprod Genet (2015) 32:1827­1833, DOI 10.1007/s10815-015-0597-9. The authors would like to apologize for accidentally making a mistake in the inner and outer diameter calculation of the Piezo-ICSI micropipettes.

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PURPOSE: The purposes of the present study are to assess the clinical efficiency of Piezo-intracytoplasmic sperm injection (ICSI) and to improve the Piezo-ICSI method for human oocytes. METHODS: We examined three ICSI methods to determine their clinical efficiency by comparing the survival, fertilization, good-quality day-3 embryo, pregnancy, and live birth rates. The three ICSI methods tested were conventional ICSI (CI) (using beveled spiked micropipettes with a wall thickness of 1 µm), conventional Piezo-ICSI (CPI) (using flat-tipped micropipettes with a wall thickness of 0.925 µm), and improved Piezo-ICSI (IPI) (using flat-tipped micropipettes with a wall thickness of 0.625 µm). We collectively investigated 2020 mature oocytes retrieved from 437 patients between October 2010 and January 2014. RESULTS: The survival rates after CI, CPI, and IPI were 90, 95, and 99 %, respectively. The fertilization rates after CI, CPI, and IPI were 68, 75, and 89 %, respectively. The good-quality day-3 embryo rates after CI, CPI, and IPI were 37, 43, and 55 %, respectively. The pregnancy rates after the transfer of good-quality day-3 embryo of CI, CPI, and IPI were 19, 21, and 31 %, respectively. The live birth rates of CI, CPI, and IPI were 15, 16, and 25 %, respectively. Significantly higher survival, fertilization, good-quality day-3 embryo, pregnancy, and live birth rates were obtained using IPI. CONCLUSIONS: When comparing the IPI to the CI and CPI, the results revealed that the Piezo-ICSI using flat-tipped micropipettes with a wall thickness of 0.625 µm significantly improves survival, fertilization, good-quality day-3 embryo, pregnancy, and live birth rates.

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The measurement method of three-dimensional posture and flying trajectory of lower body during jumping motion using body-mounted wireless inertial measurement units (WIMU) is introduced. The WIMU is composed of three-dimensional (3D) accelerometer and gyroscope of two kinds with different dynamic range and one 3D geomagnetic sensor to adapt to quick movement. Three WIMUs are mounted under the chest, right thigh and right shank. Thin film pressure sensors are connected to the shank WIMU and are installed under right heel and tiptoe to distinguish the state of the body motion between grounding and jumping. Initial and final postures of trunk, thigh and shank at standing-still are obtained using gravitational acceleration and geomagnetism. The posture of body is determined using the 3D direction of each segment updated by the numerical integration of angular velocity. Flying motion is detected from pressure sensors and 3D flying trajectory is derived by the double integration of trunk acceleration applying the 3D velocity of trunk at takeoff. Standing long jump experiments are performed and experimental results show that the joint angle and flying trajectory agree with the actual motion measured by the optical motion capture system.

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OBJECTIVES: We aimed to establish optimal overnight pulse oximetric thresholds for determining the indication of tonsillectomy and adenotomy (TA) in children by revising the definition of 'desaturation'. METHODS: One hundred and thirty four children scheduled for TA (TA group, 5.3 +/- 1.4 years old) and 112 otherwise healthy children scheduled for elective minor surgery (control group, 5.4 +/- 1.5 years old) were enrolled into this prospective study. Data were recorded and stored every 10 s using Nellcor N-395. Desaturation/resaturation events were defined as x% change (x = 1-4) of SpO2 (oxyhemoglobin saturation by pulse oximetry) in 10 s. The desaturation/resaturation indices were calculated as events per hour of total sleeping time. For each index, a wide range of temporary thresholds was set. The optimal thresholds for TA were the ones that maximized the weighted average for sensitivity, specificity (based on whether the index improved or not after TA), and the percentage of the control children whose indices were below the threshold. RESULTS: For all the indices, the optimal thresholds that fulfilled the above condition were determined. Compared with the x = 3-4% results, the application of x = 1-2% approximately doubled the TA patients whose preoperative 'positive' indices improved after TA, with the weighted averages of 84.3-92.3% as described above. CONCLUSIONS: By defining desaturation/resaturation as a 1-2% change in SpO2 from the preceding value, children with adenotonsillar hypertrophy whose pulse oximetric indices are expected to improve after TA can be detected by pulse oximetry with relatively high sensitivity and specificity.

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We retrospectively reviewed 33 patients (35 cases) who underwent foreign body removal at our institution from 1995 through 2003. Male-female ratio was 21 : 12 and the most frequent age was one year. The most common foreign bodies (FBs) were nuts (n = 14) and plastics (n = 7). A repeater (3 cases) had mental retardation. Patients were referred to our institution with an average interval of 90 hours, and after 1.3 hospitals. All the patients were managed with general anesthesia. Direct laryngoscopy was performed to extract FBs in 11 cases suspected of having pharyngeal or laryngeal FBs. In 24 cases suspected of having tracheobronchial FBs, the trachea was intubated and a flexible fiberoptic bronchoscopy was performed to locate the FBs. FBs were found in the trachea in 2 cases and in the bronchus in 18 patients and were successfully extracted by rigid bronchoscopy in 10 cases. All the patients were admitted for fear of laryngotracheal edema. There were no significant postoperative complications.

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BACKGROUND: In our institution, spinal anesthesia is the first choice for cesarean section. After the introduction of bupivacaine in 2000 in Japan, the intrathecal anesthetic agent shifted from tetracaine to bupivacaine. We analyzed the anesthesia for cesarean section in recent 7 years and compared the anesthetic quality of tetracaine with that of bupivacaine. METHODS: The anesthetic records were reviewed in the patients who had received cesarean section between January 1998 and December 2004 at our institution. RESULTS: There were 10456 deliveries during the study period with a cesarean section rate of 28.2% (2947 cases). Ninety-one percent of cesarean section was performed under spinal anesthesia. Spinal anesthetic agent shifted from tetracaine to bupivacaine in 2000-2001, both of which was prepared as a hyperbaric solution and supplemented with 0.1 mg of morphine hydrocloride. Of the 2711 patients in whom a cesarean section was started under spinal anesthesia, 20 (0.7%) required conversion to general anesthesia. Three hundred eighteen patients (11.7%) required some analgesic supplementation. The incidence of intra-operative analgesic supplementation was greater in the patients anesthetized with hyperbaric tetracaine and morphine than in those anesthetized with hyperbaric bupivacaine and morphine (22.96% vs 4.20% ; P<0.01). The conversion rate from spinal to general anesthesia for cesarean section was 0.7%. CONCLUSIONS: Comparing these two intrathecal anesthetic agents, the rate of analgesic supplementation in those anesthetized with bupivacaine was lower than in those anesthetized with tetracaine. This suggests that bupivacaine provides the more profound blockade of the visceral pain than tetracaine, and is superior as a local anesthetic.

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BACKGROUND: Laparoscopic surgery has been applied even to neonates. To examine the safety and efficacy of laparoscopic repair of neonatal congenital duodenal atresia, we compared the 5 laparoscopic cases with the 5 conventional surgical cases. METHODS: The charts were retrospectively reviewed to investigate the anesthetic management, perioperative status and complications in the most recent 5 cases each of laparoscopic and conventional surgeries. RESULTS: There was a tendency to avoid laparoscopic repair in the patients with congenital heart disease. There were no intraoperative complications in both groups. Laparoscopic group exhibited less blood loss but longer operation time. In the two out of five laparoscopic cases re-operation was required due to technical issues, and the group needed a longer period before starting enteral feeding and longer hospitalization. CONCLUSIONS: Up to this time, laparoscopic repair of congenital duodenal atresia exhibited few advantages over conventional open repair.

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We report successful anesthetic management of a 1.7-kg premature infant who underwent thoracoscopic thoracic duct ligation under general anesthesia. She was born at 30 weeks gestation with birth weight of 1,546 g and was suffering from respiratory distress due to persistent right chylothorax for two months after birth. Chest tube drainage, fasting and intrapleural fibrin glue did not reduce her right chylothorax. Thoracoscopic thoracic duct ligation was scheduled on her day 64 under general anesthesia. The tracheal tube end was placed in the midtrachea and carbon dioxide was insufflated into the operative side of the thorax. During thoracoscopy her left lung was ventilated with the right lung pressed with spatulaes, but her respiratory status did not deteriorate so much despite of unilateral ventilation. We speculate that, due to massive right chylothorax, her pulmonary blood flow had already shifted to the left lung, therefore intraoperative substantial left unilateral lung ventilation exerted minimal effect on her respiratory status. The operation was successful and she was weaned from the ventilator on the following day.

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BACKGROUND: We performed this prospective study to determine the proper amount of hyperbaric bupivacaine hydrochloride as a spinal anesthetic agent for cesarean section. METHODS: The parturients were randomly allocated to receive one of four spinal agents in a blind manner; tetracaine 10 mg (control), bupivacaine 10, 12.5 and 15 mg. Morphine HCl 0.1 mg was added to each agent and the total volume was adjusted to 3.1 ml with 10% glucose solution. RESULTS: All the four spinal agents provided an adequate analgesic level (T 5) without serious complications. Among the three dosages of bupivacaine, the time interval requiring for anesthetic level to reach T 5 tended to be shorter with a larger amount of bupivacaine. The incidence of intraoperative supplemental analgesic and hypotension and the dosage of ephedrine used to treat hypotension were greater in the patients anesthetized with tetracaine 10 mg than in those anesthetized with bupivacaine 10 mg, which is equipotent to tetracaine 10 mg. CONCLUSIONS: 1. As a spinal anesthetic agent for cesarean section, hyperbaric bupivacaine is superior to tetracaine. 2. Hyperbaric bupivacaine 10 mg, 12.5 mg or 15 mg can be used safely and effectively as a spinal agent for cesarean section. 3. High dose bupivacaine is recommended in an urgent case, and low dose bupivacaine is recommended when maternal hypotension must be strictly avoided.

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We report a case of primipara with triplet pregnancy who underwent combined spinal and epidural anesthesia 10 weeks after epidural blood patch. At 15 weeks of gestation, a woman with triplet gestation underwent Shirodkar operation under spinal anesthesia and subsequent epidural blood patch as a treatment of post-dural puncture headache. At 26 weeks she presented with acute abdomen and laparotomy was scheduled. Spinal anesthesia was selected with an epidural catheter inserted in case of prolonged operation and for postoperative pain control. The placement of an epidural catheter was without problem. Laparotomy revealed right paraovarian cyst torsion and the right salpingo-paraoophocystectomy was performed. Patient-controlled analgesia with epidural bupivacaine and fentanyl was effectively continued for two days. Postoperative course was uneventful and the triplets were delivered by cesarean section at 35 weeks.

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We report the anesthetic management of Freeman-Sheldon (whistling face) syndrome in a two-month-old boy scheduled for lateral canthoplasty. He had features of the syndrome including blepharophimosis, hypertelorism, a flat nose, microstomia with a limited opening, micrognathia, a very short webbed neck, scoliosis and multiple arthrogryposis. He was fed with a naso-gastric tube and suffered from several episodes of aspiration and oxygen desaturation. Difficult airway and intubation were anticipated. Anesthesia was induced via a mask with sevoflurane, although mask ventilation was difficult. Direct laryngoscopy and the insertion of a laryngeal mask airway were impossible due to microstomia with the limited opening as anticipated. A naso-tracheal intubation was achieved using a fiberoptic bronchoscope via a fiberoptic mask while ventilating the lungs. The operation and anesthesia afterwards were uneventful. In the ward, he was given supplemental oxygen but with occasional desaturation episodes. Thirteen days after the operation he was found cyanotic and resuscitation was attempted but failed. Autopsy demonstrated the hypoplasia of the lungs and thorax, atelectasis and bronchitis.

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A 3-year-old girl, who presented with dilated cardiomyopathy in conjunction with congenital fiber-type disproportion, underwent open reduction for congenital dislocation of the hip. Preoperative echocardiography demonstrated left ventricular dilatation with an ejection fraction (EF) of 0.33. Anesthesia was induced with intravenous ketamine and fentanyl, and maintained with fentanyl administered incrementally to a total dose of 10 micrograms.kg-1 and 1-1.5% isoflurane. During operation, we continuously monitored left ventricular wall motion and measured left ventricular diastolic dimension (LVDd), systolic dimension (LVDs), cardiac output (CO), EF, and fractional shortening (FS) with transesophageal echocardiography (TEE). At the end of surgery, preload (LVDd) and LV contractility (CO, EF, FS) decreased, but LV wall motion remained almost stable throughout the procedure. In conclusion, TEE was useful for intraoperative management of a child with dilated cardiomyopathy.

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A 16-year-old girl had suffered from chronic graft versus host disease (GVHD) caused by peripheral blood stem cell transplantation (PBSCT) after chemotherapy for neuroblastoma and pulmonary aspergillosis of the right upper lobe. She presented with hematemesis and underwent upper gastrointestinal endoscopy under general anesthesia. At the end of the examination, massive pulmonary hemorrhage occurred suddenly. A double lumen endobronchial tube was inserted for unilateral ventilation in order to control hemorrhage, and right pulmonary hemorrhage was found. Pulmonary scintigram and angiography could not demonstrate the bleeding site, and we suspected that pulmonary hemorrhage had been caused by pulmonary aspergillosis because aspergillus is known to have pathologically invasive character to the adjacent tissue and blood vessels. Despite right pneumonectomy was performed to control pulmonary hemorrhage, she died five days later from multiple organ failure. This case suggests that immediate unilateral ventilation is useful for the isolation of the bleeding lung when pulmonary hemorrhage is massive and we should know the risk of pulmonary hemorrhage in patients with pulmonary aspergillosis.

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We investigated the effect of ketamine on reducing postoperative agitation after sevoflurane anesthesia in children undergoing elective strabismus surgery. Fifty-five children, 3-9 years of age, were randomly assigned to the following three groups; ketamine (group K, n = 18), pentazocine (group P, n = 19), and flurbiprofen axetil(group F, n = 18). Group K received ketamine 1 mg.kg-1 intravenously, followed by infusion of ketamine 1 mg.kg-1.hr-1 during surgery, group P received pentazocine 0.2 mg.kg-1 intravenously after induction of anesthesia, and Group F received intravenous flurbiprofen axetil, 1 mg.kg-1 5 minutes before the end of surgery. Agitation (evaluated by Aono's four-point scale; AFPS) and awareness (evaluated by Steward score) were assessed just before tracheal extubation(T 1), 5 minutes after tracheal extubation(T 2), arrival at the ward(T 3), and 60 minutes after arrival at the ward(T 4). We considered AFPS > or = 3 patients as "agitated" and APFS < or = 2 patients as "not agitated". At T 1 and T 2, the incidence of agitation(AFPS > or = 3) in group K was less than that of group F and group P. However, in group K, more patients needed oxygen supplement after extubation. We concluded that coadministration of ketamine could be beneficial for reducing postoperative agitation after sevoflurane anesthesia in pediatric strabismus surgery.

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