Articles In Press | Year-2024 | Volume-7

For type 2 diabetes (T2D), the recommended meal has shifted from calorie restriction (CR) to a low carbohydrate diet (LCD). LCD gained worldwide prevalence through the efforts of Atkins and Bernstein, and we further developed LCD both medically and socially through the Japan LCD Promotion Association (JLCDPA). The beneficial and convenient methods of LCD include petite, standard, and super LCD, which have carbohydrate ratios of 40%, 26%, and 12%, respectively. For these three types, the approximate permitted carbohydrate amounts in each meal appear to be 20g, 30g, and 40g. Some foods with lower carbohydrate content include eggs (0.1g), a piece of cheese (0.2g), chicken meat (180g) (0.4g), and Japanese tofu (300g) (4g).

Spontaneous Pneumothorax is a potentially life-threatening condition that is brought on when air makes its way into the pleural spaces resulting in decreased negative pressure between the pleural membranes without trauma or injury occurring. Spontaneous pneumothorax was reported as an adverse complication of severe acute respiratory syndrome brought on by SARS-COV-2. It is thought spontaneous pneumothorax may be a consequence of the breakdown of elastic fibers within the lung tissue. This breakdown is believed to be caused by the body’s own immune response in particular by innate lymphoid cells (ILCs) which have been shown to be elevated in response to intracellular pathogens like viruses, but additional research is needed to clearly state a causal relationship between SARS-CoV-2 and the immune-mediated formation of pneumothorax. Limited studies look at the link between the pathophysiology of Pneumothorax and COVID-19, which is why the patient from this case is of interest. We present a unique case of a 27-year-old male presenting to the Emergency Department complaining of difficulty breathing, chest pain, and fatigue who had prior tested positive for COVID-19. A diagnosis of pneumothorax was made by chest x-ray. In this report, we discuss the pathophysiology, imaging, and management related to pneumothorax and its connection to COVID-19.

Sporadic or inherited deficiencies in the production or activity of the tumor suppressor P53 lead to Li-Fraumeni Syndrome (LFS), a multi-organ tumorigenic condition. Glioblastoma multiforme (GBM), a tumor that commonly presents with a median age of 64, has a higher chance of appearing in much younger patients who have LFS [9]. Since the implementation of the 2016 Toronto Protocol to increase cancer surveillance in LFS patients, three cases of LFS-GBM have been discussed [11-13]. Here, we report a case of LFS in an 18-year-old male who had a seizure due to a GBM that had evaded a full-body MRI six months prior. Furthermore, we discuss the potential quality of life (QOL) benefits of providing patients with a shorter brain MRI screening interval: better survival outcomes and peace of mind. Though there may be a rise in the financial cost with an increase in the number of MRI scans, the prevalence of aggressive tumors that must be treated early for a better prognosis warrants more frequent screening. Furthermore, we address the importance of expanding clinical knowledge on GBM in the LFS setting as well as addressing the benefits of the protocol through statistical studies.

Background: Prostatectomy offers the greatest potential for a definitive cure for localized prostate cancer. Closure devices for secundum atrial septal defects have a good safety and efficacy profile. Simultaneous operation of the two types of surgery has not been reported to date.
Case Presentation: A 65-year-old man was admitted to receive laparoscopic radical prostatectomy for prostate cancer under general anesthesia. The chest CT imaging unexpectedly showed that the heart and the pulmonary artery were obviously enlarged. Subsequently, a secundum atrial septal defect (ASD) with left-to-right shunt measuring 27*23mm was observed on transthoracic echocardiography (TTE). After a multi-disciplinary team (MDT) consisting of departments of urology, cardiac surgery, and anesthesiology was assembled to discuss the surgical procedure, an atrial septal defect closure device was scheduled to be implanted, followed by laparoscopic radical prostatectomy. The patient underwent both surgeries and was successfully discharged from the hospital.
Conclusions: Adequate perioperative assessment and management are crucial for patients. We should pay more attention to patients with cardiac disease undergoing both cardiac and non-cardiac surgery.

Background: Acute pulmonary edema following cardiopulmonary bypass (CPB) is a serious complication, the etiology of which could be classified into two groups: cardiogenic and noncardiogenic.
Case presentation: We present a 42-year-old male with multiple pulmonary bullae scheduled for mitral valve and aortic valve replacement. Acute pulmonary edema occurred approximately 1 hour after weaning from CPB. The diagnosis of non-cardiogenic pulmonary edema was established with changes in pathophysiology and findings on ultrasound. The patient was promptly treated and transferred to the ICU uneventfully.
Conclusions: This case report highlights the changes in pathophysiology combined with ultrasound findings to establish a diagnosis in the operating room. We also emphasize the perioperative management of noncardiogenic pulmonary edema.

Background: Acute aortic dissection poses a life-threatening condition that typically necessitates immediate surgical intervention, such as total arch replacement. However, hypoxemia is a severe complication in such surgeries, potentially resulting in organ dysfunction, prolonged hospital stays, and even mortality. Hypoxemia presents significant challenges to anesthesiologists. Through this case, we can enhance our comprehension of anesthetic management for total arch replacement.
Case presentation: A 43-year-old man with acute type A aortic dissection underwent total arch replacement. After a smooth surgery, severe hypoxemia occurred during weaning off cardiopulmonary bypass. Initial interventions, including airway suction and recruitment maneuvers, failed to improve oxygenation. Further investigations found left lung atelectasis and pleural effusion on transesophageal echocardiography, with minimal improvement after drainage. Fiberoptic bronchoscopy revealed extensive tenacious secretions occluding the airways. Conventional suctioning was ineffective due to high sputum viscosity. Ultimately, techniques including pulmonary lavage, bronchoscopic suctioning, and repeated lung recruitment controlled the refractory hypoxemia. The patient recovered after treatment in the intensive care unit.
Conclusions: It is worth noting that our case highlights the challenges posed by severe hypoxemia during total arch replacement surgery. The successful management of this complication underscores the importance of a multidisciplinary approach and close monitoring during the perioperative period. Individualized anesthetic management plays a critical role in addressing severe hypoxemia during total arch replacement surgery.

The patient is a 55-year-old male with type 2 diabetes (T2D). In his 20s, 30s, and 50s, his body weight was 80 kg, 95 kg, and 90 kg, respectively. HbA1c was 10.9% in March 2023, and he was prescribed imeglimin (Twymeeg) as an oral hypoglycemic agent (OHA). HbA1c decreased to 9.3%, 7.2%, and 6.8% within just 3 months. His body weight also decreased from 86 kg to 82 kg during this period. Liver function tests showed improvement between March and May 2023, with AST decreasing from 54 to 24 U/L, ALT from 121 to 28 U/L, and GGT from 45 to 18 U/L, respectively. This suggests an improvement in fatty liver.

Thoracoscopy, as a minimally invasive surgical technique in the field of thoracic surgery, has been widely utilized due to its minimally invasive nature, cost-effectiveness, and short hospital stay. Most thoracoscopic surgeries involve intraoperative single-lung ventilation, aiming to maintain intraoperative oxygen saturation (SPO₂) above 93% by increasing the respiratory rate and administering a high concentration of oxygen. However, the high concentration of oxygen administered during surgery and postoperative pain in thoracic surgery often result in decreased ventilation and hypoxia in patients. This case report details a patient who underwent bilateral thoracoscopic surgery with single-lung ventilation on both sides, subsequently developing oxygen-associated hypercapnia in the post-anesthesia care unit (PACU) and necessitating reintubation.

Background: Common modalities for breast cancer screening include regular clinical breast exams (73%), annual breast sonograms (73%) for high-risk groups, and mammograms (71.5%) recommended every 3 years for high-risk groups. Despite a higher sensitivity of 89.4%, MRI is underutilized, especially among high-risk groups with the means for the test. Kenyan guidelines recommend mammography for normal-risk populations, omitting MRI for routine screening in average-risk populations. This study explores an intriguing case of a 60-year-old post-menopausal lady, with no hormone replacement history, three parities, and a smoking habit. She presented with a left-sided benign cyst but revealed an ominous, undetected lesion on the right breast, emphasizing the limitations of conventional screening modalities.
Method: The patient was admitted for abdominal pain due to gastroenteritis and a breast lump on the left breast for 3 months with a strong family history of breast cancer, so she requested screening for the same. In the process, we found axillary and mediastinal lymph nodes, but the left breast showed a simple harmless cystic lesion. The right breast confirmed a lesion with irregular borders that looked suspicious, and a biopsy confirmed ductal carcinoma of the right breast.
Results: The right breast that had no symptoms or signs, and no abnormality on mammogram, ultrasound, or CT scan, had a grade 3a Ductal Cancer in its initial stage that was seen on a simultaneous MRI. Conclusion: MRI could be a better choice for screening early breast cancer in high-risk groups and in those who can afford the test.

Japanese cuisine revolves around rice as a staple, accompanied by various innovations. Among these, Japanese seasoning sprinkle (furikake) has garnered attention due to its rich history, delightful taste, versatility in cooking applications, clinical nutrition, and research contributions. Furikake is crafted from ingredients such as fish, seaweed, eggs, meat, beans, sesame seeds, fermented soybeans (natto), vegetables, fruits, and others.
There are four main types of furikake: dry, soft, freeze-dried, and oil-based. It also plays a role in research, particularly in improving taste abnormalities. In Japanese nursing homes, residents frequently pair furikake with rice, supplying essential trace elements like Fe, Zn, Mg, and Mn, thereby promoting both physical and mental health.

Background: Aspiration of gastric contents during the induction of general anesthesia remains a significant cause of mortality and morbidity in anesthesia. We report an 18-year-old patient with a closed atrial septal defect who developed gastric content reflux aspiration and severe aspiration pneumonia despite abstaining from drinking and fasting for more than 12 hours.
Case Presentation: An 18-year-old female patient with congenital heart disease (atrial septal defect) had no previous history of gastroesophageal reflux. After fully abstaining from drinking and fasting (more than 12h), conventional anesthesia was induced, and after the patient’s spontaneous breathing and consciousness disappeared, the patient was assisted with mandibular support with both hands and mask pressure. The induction process was smooth. When preparing for intubation, a large amount of yellow fluid was found in the patient’s mouth. Intubation was performed immediately after suction. Aspiration pneumonia still occurs after the operation even if the patient is treated promptly.
Conclusions: As the incidence of perioperative pulmonary aspiration is relatively low, precautions to prevent aspiration tend to be overlooked. We should be alert to the complications of gastric contents regurgitation aspiration in patients with sufficient abstention and fasting during general anesthesia intubation.

Background: Factors such as abstinence from drinking, fasting, intestinal preparation, and stress responses can contribute to issues like inadequate blood volume, hypoglycemia, and electrolyte imbalances. The ASA classification presently serves as a primary assessment standard globally. In response to prevailing clinical challenges, we propose enhancing the preoperative assessment for elderly patients undergoing painless gastroenteroscopy. This enhancement involves incorporating the Frailty score, bedside ultrasound, and bedside laboratory results alongside the ASA classification, to establish a comprehensive assessment system. This holistic approach aims to monitor patients’ fluid balance, electrolyte levels, and blood glucose changes, facilitating precise interventions and optimized anesthesia strategies. The ultimate goal is to diminish perioperative adverse events, especially those related to the cardiovascular system, thereby enhancing prognosis, outcomes, and patient satisfaction among the elderly.
Methods: This study is a randomized controlled trial conducted at a single center. It includes 204 patients scheduled for painless gastroenteroscopy. Eligible subjects will be randomly assigned to either Group A or Group B. Pre-anesthesia assessments will be conducted twice – during the preoperative visit and upon entry to the endoscopy center on the examination day. Evaluation parameters will encompass the Edmonton Frail Scale (EFS), bedside ultrasound measurements including inspiratory IVCDmax, expiratory IVCDmin, and calculation of the inferior vena cava collapse index (IVC-CI). Additionally, serum electrolyte (potassium) and blood glucose levels will be measured. Patients in Group A will receive specific interventions based on predetermined criteria. The primary endpoint is anesthesia-related adverse events. The measurements will be performed perioperatively, post-treatment, and at 1 day, 3 days, and 7 days after the end of treatment.

Various discussions have continued concerning low carbohydrate diet (LCD) and calorie restriction (CR). The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have gradually recognized LCD as the recommendation for nutritional treatment. Recent reports have shown the predominance of LCD with clinical evidence from the accumulated data of the Nurses’ Health Study (NHS) and Health Professionals Follow-up Study (HPFS), with analyses of total LCD scores (TLCDS). Using TLCDS to analyze 139 thousand person-years, the hazard ratio (HR) of total mortality was 0.87 for TLCDS and 0.76 for vegetable (VLCDS). Authors continue developing LCD activities through the Japan LCD Promotion Association (JLCDPA).

This case report explores the application of photostimulated fat grafting from laser-assisted liposuction for penile girth augmentation. The patient, a 25-year-old male with normal penile length, sought the procedure due to dissatisfaction with his girth. The procedure involved the use of a 1210-nm diode laser (Lipo One STEP HD, DMC Group, Brazil) to stimulate adipocytes, which were then aspirated and grafted onto the penis. The patient reported satisfaction with the results, with no adverse events noted. This report contributes to the scientific literature by detailing the potential of photostimulated laser-assisted liposuction in penile girth augmentation, highlighting its efficacy and safety. The patient’s perspective underscores an improvement in self-esteem and quality of life post-procedure. This technique offers a novel approach in aesthetic surgery, demonstrating promising results in various applications.

Liver abscesses pose a significant clinical challenge, particularly when complicated by underlying conditions such as cholangiocarcinoma. This case report describes the management of a complex, multiloculated liver abscess in a 50-year-old patient with a multifaceted medical history.
A 50-year-old female with a history of cholangiocarcinoma and associated complications presented with progressive odynophagia and chest pain amidst a backdrop of multiple comorbidities, including diabetes mellitus, gastrointestinal disorders, and a complex surgical history. On admission, she exhibited tachycardia, hypertension, and laboratory findings indicative of microcytic anemia, electrolyte imbalances, and potential systemic hypoperfusion. Imaging did not reveal acute cardiopulmonary issues. Treatment for E. coli bacteremia and suspected liver abscess included antibiotics and percutaneous drainage with substantial purulent discharge. The patient’s care was further complicated by oral thrush and esophagitis managed successfully with antifungals. Palliative care was consulted. On day 34, the patient was discharged to home hospice.
This case supports the use of percutaneous drainage as a frontline treatment for multiloculated liver abscesses and underscores the need for individualized treatment approaches. It also emphasizes the role of interventional radiology in managing complex intra-abdominal infections.

Recreational nitrous oxide (N₂O) is increasingly common among young people, leading to attendant health disadvantages. Related complications primarily involve the hematological and neurological systems. We report two relatively uncommon cases of pancytopenia due to substantial N₂O inhalation. One possible cause is that N₂O toxicity results in vitamin B12 inactivation and an insufficient intake of nutrients. The patient’s symptoms partially improved after cessation of N₂O inhalation and supplementation with vitamin B12. In conclusion, if the patients presented with unexplained bone marrow failure, a history of prolonged N₂O exposure should be considered, which would greatly help in early diagnosis, therapy, and the reduction of unnecessary costs.

Recently, the medical term for nonalcoholic fatty liver disease (NAFLD) has been changed to a novel nomenclature: metabolic dysfunction-associated steatotic liver disease (MASLD). The latest report shows analyses of the National Health and Nutrition Examination Survey (NHANES III) using the fibrosis-4 index (FIB-4) and enhanced liver fibrosis (ELF). Among 6429 NAFLD cases, 99% met MASLD criteria. In another study with 4286 cases, 99% of steatosis cases met the MASLD definition, and 95.4% met the metabolic dysfunction-associated fatty liver disease (MAFLD) definition. Several biomarkers show a relationship with MASLD/MAFLD, such as BMI, T2D, HOMA-IR, central obesity, waist circumference, and CKD.

Recently, actual changes in blood glucose can be measured by continuous glucose monitoring (CGM) using FreeStyle Libre. The case involves a 67-year-old male patient with type 2 diabetes (T2D) treated with Multiple Daily Insulin (MDI) therapy, who underwent CGM. Analysis of the CGM data revealed that hyperglycemia resulted from increased carbohydrate intake and irregular meal timings and quantities. The estimated HbA1c from CGM was 6.6%, whereas the HbA1c value recorded at the outpatient clinic during the same period was 7.3%. The use of CGM applications encourages diabetic patients to be mindful of their carbohydrate intake in daily life, leading to an increased ratio of time spent in the target range (TIR).

The case involves a 74-year-old female with type 2 diabetes (T2D). HbA1c remained stable at 6% until summer 2019, but suddenly worsened to 8.4% in autumn 2019 without a certain reason. An abdominal CT scan detected a probable pancreatic tumor, which required further evaluation. Contrast-enhanced images of the arterial, portal vein, and equilibrium phase showed no staining, slight staining, and strong staining, respectively. The application of Curved Planar Reconstruction (CPR) has revealed an apparent pancreatic tumor image with three different stainings, associated with a dilated main pancreatic duct (MPD) in the pancreas body and tail and a normal MPD in the pancreas head. Consequently, CPR would be useful for diagnosis.

Purpose of Review: Remimazolam is a new short-acting benzodiazepine in the final stages of clinical development. The methods of monitoring sedation and assessing the depth of anesthesia for benzodiazepine sedative drugs have been fraught with controversy in clinical work. As a newly released short-acting anesthetic sedative drug that can be continuously pumped, appropriate anesthetic monitoring and sedation depth assessment tools can better help anesthesiologists make clinical decisions and reduce the emergence of perioperative complications in patients.
Recent Findings: Clinical trials of remimazolam have been completed at home and abroad in various phases, and much progress has been made, but the effective sedation monitoring means of remimazolam are still not conclusive.
Summary: Remimazolam has a rapid onset of action and a high rate of metabolism in the body; tissue accumulation and delayed awakening are rare. At the same time, it can be safely applied to elderly patients with a low cardiopulmonary function inhibition rate, accurate anesthesia effect, and satisfactory quality of awakening. By comparing various methods of sedation depth monitoring, the data correlation is high, which can be of significant importance for remimazolam sedation depth monitoring.