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OBJECTIVE: Anesthetic management of patients with giant mediastinal tumors is challenging from the perspective of both cardiovascular and respiratory management, and airway assessment is important for both concerns. We report the successful induction of general anesthesia and double-lumen tube intubation in the right lateral position for a patient with a giant mediastinal tumor with tracheal compression, using pre-operative chest radiograph imaging to minimize tracheal compression during induction. METHODS: A 41-year-old man required thoracoscopic giant superior mediastinal tumor resection. His trachea was compressed and displaced because of the tumor. Because preoperative chest radiography revealed that the tracheal diameter increased in the right lateral position, we chose this position for induction. RESULTS: Prompt and smooth intubation with a 35-Fr double-lumen tube (DLT) was achieved, and no adverse events associated with intubation were encountered. CONCLUSION: Safe and smooth induction with a DLT was performed owing to the perioperative chest radiograph imaging examination, which revealed the most advantageous position regarding minimal tracheal compression.

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OBJECTIVE: Because of the shape of a double-lumen tube (DLT), it is more difficult to use for intubation than an ordinary endotracheal tube. We prospectively investigated the usefulness of the Airtraq DL® attached to the Universal Adapter for Smartphones® for DLT intubation. METHOD: At Tokai University Hachioji Hospital, anesthesiologists with ≥ 5 years' clinical experience intubated a tracheal intubation training mannequin with DLTs using the Airtraq DL® (Airtraq-alone phase) and the Airtraq DL® attached to the Universal Adapter for Smartphones® (adapter phase), and the time required was measured. RESULT: The mean time required for intubation was shorter in the adapter phase than in the Airtraq-alone phase for all anesthesiologists (adapter phase, 9.05±2.48 seconds; Airtraq-alone phase, 10.67±2.19 seconds). CONCLUSION: The use of Airtraq DL® a ttached to t he Universal Adapter for Smartphones® significantly reduced the time required for DLT intubation. Furthermore, the combination of these devices was found to be useful and safe for DLT intubation because they provide a significant amount of information on the area from the oral cavity to the opening of the trachea and have high educational value because their combined use allows several physicians to share imaging information.

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OBJECTIVE: The Universal Adapter for Smartphones® c an record s till images and movies during intubation using the monitor display and recording functions of a smartphone. Here, we describe the successful use of the Airtraq Double Lumen® with the Universal Adapter for Smartphones® for airway management during anesthesia in a patient with intubation difficulty. METHODS: A 78-year-old man required thoracoscopic upper lobectomy for a pulmonary tumor. Preoperative examination revealed micrognathia, mouth opening equivalent to a three-finger width, Mallampati Class II, mentum-hyoid bone distance equal to a 2.5-finger width, hyoid bone-thyroid cartilage distance equal to a two-finger width, and Class I findings in the Upper Lip Bite Test. After inducing anesthesia and confirming the feasibility of mask ventilation, we administered 70 mg of rocuronium and inserted the Airtraq Double Lumen®. The Universal Adapter for Smartphones® connected to a 4-inch iPod Touch® was attached to its eye cup, through which the iPod Touch displayed images for easy visualization of the glottal area. RESULTS: Prompt and smooth intubation with a 35-Fr double-lumen tube (DLT) was achieved. There were no adverse events associated with intubation. CONCLUSION: Combination of the Universal Adapter for Smartphones® and the Airtraq Double Lumen® can facilitate smooth tracheal intubation with a DLT in cases of difficult intubation.

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OBJECTIVE: This prospective randomized study aimed to assess the usefulness of two videolaryngoscopes with a side channel, the Airtraq DLTM and the AWS-200TM, for intubation with a double-lumen tube (DLT). METHODS: In 60 patients with an American Society of Anesthesiologists physical status of 1-3 who were not expected to have difficult airway, the Airtraq DLTM and the AWS-200TM were randomly used for DLT intubation. The primary outcome was intubation time. The secondary outcomes included exposure time, the glottis view with the Macintosh and study videolaryngoscopes, the number of attempts before successful intubation, the intubation difficulty scale (IDS) score, and the subjectively rated ease of blade insertion and DLT advancement. RESULTS: No significant differences were observed in patient characteristics. In all patients, DLT intubation was successful at the first attempt. Intubation time was significantly shorter in the Airtraq DLTM group (17.2±0.9 seconds, range = 9.6-29.4 seconds) than in the AWS-200TM group (21.6±1.1 seconds, range = 13.1-33.9 seconds) (P = 0.005). No significant differences were observed in any other outcomes. CONCLUSION: In patients who were not expected to have difficult airway, DLT intubation with the Airtraq DLTM required significantly less time than with the AWS-200TM.

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An important role of voltage-gated sodium channels (VGSCs) in many different pain states has been established in animal models and humans wherein sodium channel blockers partially ameliorate pain. However, behavioral tests for screening analgesics that exhibit pharmacologic action by acting on VGSCs are rarely reported, and there are no studies on antinociception using veratrine as a nociceptive agent. The aim of the present study was to examine the amount of nociceptive behavior evoked by subcutaneous administration of veratrine into the hind paw and investigate whether veratrine can be used as a VGSC agonist to test the pharmacological properties of candidate analgesics via sodium channel blockade. We report for the first time that intraplantar injection of veratrine produced a reproducible nociceptive response in mice. Furthermore, several sodium channel blockers, namely carbamazepine, valproate, mexiletine, and the selective Nav1.7 inhibitor PF-04856264, but not flecainide or pilsicainide, reduced veratrine-induced nociception. In contrast, calcium channel blockers gabapentin and ethosuximide did not change veratrine-induced nociception. The veratrine test in mice might be a useful tool, at least in part, to evaluate the potential analgesic effect of sodium channel blockers.

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Neuropathic pain (NeP) results from injury to, or disease of, the peripheral or central components of the neural systems involved in pain. In contrast to inflammatory pain, NeP can persist after healing from the initial injury has resolved. Antipyretic agents, such as non-steroidal anti-inflammatory drugs, steroids, and acetaminophen are ineffective, while specific agents such as gabapentinoids, antidepressants, antiepileptics, and opioids are effective in treating NeP. In this review, we address the definition of NeP, pharmacotherapy for NeP in Japan, pain classification, setting goals for successful NeP medication, and the Japanese algorithm for the pharmacotherapy of NeP with specific prescription guidance.

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Increasing healthcare costs have pressured govern- ment finances and threatened the sustainability of the national health insurance program introduced by the government, namely the Diagnosis Procedure Combi- nation/Per-Diem Payment System (DPC/PDPS) estab- lished in 2003, a prospective payment system for inpa- tients as part of changes to the provider reimburse- ment system to ensure the long-term sustainability of the healthcare insurance program. Under the DPC/ PDPS system, anesthesiologists can help reduce medi- cal costs by applying peripheral nerve blocks (PNB), because many databases have verified that they improve surgical outcomes and reduce hospital stays. These outcomes confer a considerable advantage upon healthcare insurance, demand for which has surged due to rapid population aging and significant progress in medicine. The present study compares general and neuraxial anesthesia to determine the advantages of PNB in terms of reducing medical costs.

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Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used groups of drugs. NSAIDs are divided into two major groups : cyclooxy- genase (COX)-2-selective inhibitors (COXIBs) and non- selective NSAIDs based on the mechanism of action. The analgesic and anti-inflammatory effects of NSAIDs are produced through the prevention of prostaglandin production by inhibition of COX activity. The pharma- cological effects and the risk profiles of the different NSAIDs are largely determined by their differential ability to inhibit the COX-1 and/or COX-2 enzymes. The NSAID-related adverse events are (1) gastroin- testinal toxicity (2) renal toxicity (3) cardiovascular risk. The hypersensitivity to NSAIDs is also major adverse event Inhibition of the constitutive isoform of COX-1, specific IgE and T cell cause NSAIDs induced anaphylaxis/asthma/urticaria. The prevention and managements of adverse effects of NSAIDs and COXIBs are reviewed.

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Katakori is a symptom name that is unique to Japan, and refers to myofascial pain syndrome-like clinical signs in the shoulder girdle. Various methods of pain relief for katakori have been reported, but in the present study, we examined the clinical effects of multi-acupuncture point injections (MAPI) in the acupuncture points with which we empirically achieved an effect, as well as the anatomical sites affected by liquid medicine. The subjects were idiopathic katakori patients (n = 9), and three cadavers for anatomical investigation. BL-10, GB-21, LI-16, SI-14, and BL-38 as the WHO notation were selected as the acupuncture point. Injections of 1 mL of 1% w/v mepivacaine were introduced at the same time into each of these points in the patients. Assessment items were the Pain Relief Score and the therapeutic effect period. Dissections were centered at the puncture sites of cadavers. India ink was similarly injected into each point, and each site that was darkly-stained with India ink was evaluated. Katakori pain in the present study was significantly reduced by MAPI. Regardless of the presence or absence of trigger points, pain was significantly reduced in these cases. Dark staining with India ink at each of the points in the anatomical analysis was as follows: BL-10: over the rectus capitis posterior minor muscle and rectus capitis posterior major muscle fascia; GB-21: over the supraspinatus muscle fascia; LI-16: over the supraspinatus muscle fascia; SI-14: over the rhomboid muscle fascia; and BL-38: over the rhomboid muscle fascia. The anatomical study suggested that the drug effect was exerted on the muscles above and below the muscle fascia, as well as the peripheral nerves because the points of action in acupuncture were darkly-stained in the spaces between the muscle and the muscle fascia.

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The purpose of this article is to provide an overview of some of the important information related to safety and tolerability of duloxetine. Duloxetine, a potent reuptake inhibitor of serotonin and noradrenaline, is effective for the treatment of major depressive disorder, anxiety disorder, and painful diabetic neuropathy (PDN). Duloxetine is safe and well-tolerated across indications, with few reported serious side effects. Common adverse events are consistent with the pharmacology of the molecule and are mainly referable to the gastrointestinal and the nervous systems. Duloxetine should not be used in combination with CYP 1A2 inhibitors or nonselective, irreversible monoamine oxidase inhibitors. Duloxetine has a generally favorable side effect profile and dosing is simple. Nausea is the most common side effect, but it occurs less frequently if treatment is initiated at 30 mg . day-1 and titrated after one week to 60 mg . day-1, an efficacious dosage at which pain relief can occur within one week. Clinical trials have demonstrated the analgesic efficacy of duloxetine for PDN and fibromyalgia in addition to improvements in quality-of-life measurements. Furthermore trials for osteoarthritis, headache, and the pain associated with Parkinson disease may provide insight into alternative uses for duloxetine.

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We report the effective use of epidural block in three patients with 'painful legs and moving toes' syndrome, which is characterized by involuntary movements of the toe (and sometimes of the foot) and excruciating pain in the leg. Several treatments had been unsuccessful in the management of the three patients reported including baclofen, benzodiazepines, carbamazepine and antidepressants. In two patients, lumbar sympathetic block was performed, the symptoms being alleviated temporarily in one patient. In contrast, injections of mepivacaine into epidural space suppressed pain and movements in all patients. In one patient, symptoms disappeared for many years after several epidural blocks. In the remaining two patients, epidural injections were repeated when the symptoms were severe.

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