It is recognized that neuropathic pain is very difficult to treat in pain-clinic practice. The reason that it is difficult to treat is considered a complexity of the mechanisms. Therefore, treatment of this condition must be done with adequate treatment strategies and/or pharmacological application.
  In this article, the author describes nerve fibers, ectopic ion-channel, the contribution of nerve growth factor and lysophosphatidic acid to the development of ephapse and allodynia, the contribution of Glia to development of neuropathic pain, etc., concerning the mechanisms of neuropathic pain. Pharmacological management is also described.

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  Early repolarization (ER) is diagnosed as a J wave >0.1mV with or without ST-segment elevation (>0.1mV) in more than 2 leads. The mechanisms for J wave and ST elevation have been well established in Brugada syndrome and the same are considered to be applicable to ER. Occasional cases with ER-associated idiopathic ventricular fibrillation (VF) have been reported since 1985 and a link between ER and VF was definitively established in 2008. However, ER is common in the general population and its risk stratification is essential. A prominent J wave, located in the inferior or extensive leads, is risky, and isoproterenol or quinidine can suppress VF and VF storms.

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  Traditionally, many residents have acquired knowledge and learned skills by observing senior doctors in the university and its affiliated hospitals. This system has been effective for providing communities with physicians, but the view of medical students and junior residents is that the content and goals of the training program are not clear and the scale of the program is limited. In the Shikoku-Honshu Medical Bridge training program, complementary training is provided by four universities in Shikoku Island, and attractive programs through exchanges with Kobe University and Nippon Medical University, as well as career planning support, are also provided. It is expected that the excellent residency program, the mentorship for residents and the opportunities for self-actualization given to residents will create medical specialists who will stay in the community and contribute to its medical care.

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  The laryngeal mask airway (LMA) is a useful device, even in children, for not only routine airway management during surgery but also airway management in the presence of intubation difficulties or during an emergency, fiberoptic intubation, or observation of the vocal cords. In children, the use of an LMA should be avoided when there is excessive secretion, and careful attention should be paid to the maintenance of an adequate depth of anesthesia, possible development of dislodgement, and the timing of LMA removal. Even in children, when there are no clear lesions below the glottis, the LMA can reliably be used for difficult airway functions as an airway, and, therefore, is worthy of being prepared as a rescue device. LMA-guided fiberoptic intubation is a basic procedure in adults, but difficult in children, requiring adequate preparation and practice.

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  Various video-laryngoscopes are developed by the recent advancement in optics and electronic technology and they are used widely in daily practice. However, there are few kinds of video-laryngoscopes for infants and children. Airwayscope is one of the popular video-laryngoscope in adult anesthesia and emergency care. We developed the new intlock of Airwayscope for infants and children. It is expected that the pediatric intlock under development will be marketed immediately.
  A handheld multimodal MultiView Scope is useful for direct airway management in both routine and difficult airway cases. It is easy to handle and, with the addition of an intubating styletscope and a flexible fiberscope, will become a valuable new tool for airway management in pediatric anesthesia.
  It is important that we familiarize ourselves with how to use each video-laryngoscope and know the characteristics of it. The video-laryngoscope can share the image with anesthesiologists and assistants, contributes to the safety of pediatric patients, and is useful for clinical education.

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  A horrifying CICV scenario is fortunately extremely rare in pediatric anesthesia practice. Very few anesthetists thus have previous experience to handle airway emergencies in children. In a CICV situation, supraglottic airways such as Laryngeal Masks may occasionally work. If these devices fail to provide ventilation/oxygenation, rapid tracheal access is required to restore oxygenation. However, the pediatric cricothyroid membrane is small, particularly in neonates, and identifying its position can be difficult in a hypoxic, struggling child. Due to higher oxygen consumption per body weight as well as smaller functional residual capacity of the lungs compared to adults, children desaturate rapidly once ventilation becomes impossible. Although it is usually quicker to place a catheter via the cricothyroid membrane than to perform tracheostomy, the time required for needle cricothyrotomy may be too long to prevent hypoxic damage. Transtracheal jet ventilation (TTJV) is not a technique without risks. It is important to confirm exhalation via a narrowed upper airway between jet ventilation, otherwise serious barotrauma easily occurs. Use of a kink-resistant catheter is highly recommended and knowledge of the correct driving pressure of the TTJV apparatus is essential. Considering the anatomical and physiological restrictions in children, decision-making is of paramount importance, more than it is in adult DAM. In pediatric Difficult Airway Management, anesthetists should therefore more readily abandon persistent intubation attempts and to consider waking up the child from anesthesia while mask ventilation is still maintained.

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  We retrospectively reviewed 47 patients (median age : 21 months) who underwent foreign body removal from 1995 to 2009 at our institution. The most common foreign bodies were nuts and plastic items. Coughing and wheezing were present in 34% and abnormal chest x-ray findings were detected in 28%. Flexible fiberoptic laryngoscopy was performed in all patients before the induction of general anesthesia. Anesthesia was induced by sevoflurane inhalation (62%) or by intravenous administration of thiamylal (38%), and maintained using sevoflurane without spontaneous breathing. A neuromuscular blocking agent was administered in 53% of patients. Desaturation below 95% of SpO₂ occurred in 26% cases, and temporary assisted ventilation was required. No other adverse events occurred. Understanding the advantages and disadvantages of anesthetic techniques utilized for foreign body removal in children will lead to a safer and better outcome.

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  The society of postoperative pain service (POPS) was established to standardize postoperative pain service in order to improve the quality of life and safety of patients after surgery. We performed a nationwide survey in October 2009 on postoperative pain control. This survey revealed the average strategy used in Japan for postoperative pain control after abdominal surgery.
  The results showed that patient-controlled epidural analgesia (PCEA) and intravenous patient-controlled analgesia (IV-PCA) are widely used in Japan for postoperative pain control after abdominal surgery. In most cases where PCEA is performed, a disposable PCEA infusor (settings : continuous infusion, 4 ml/h; PCA, 3 ml; filling time, 30-60 min) is used together with 300 ml of 0.2% ropivacaine and 300 ml of fentanyl (3 μg/ml). For most of the patients in whom IV-PCA is performed, a disposable IV-PCA infusor (settings : continuous infusion, 1 ml/h; PCA, 1 ml; filling time, 10 min) is used together with fentanyl (25 μg/ml).

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  The preoperative fluid and electrolyte management method in Japan, like in EU countries and the US, may be changed to the oral rehydration therapy from the conventional method. The change can benefit patients and healthcare professionals as it helps decrease the burden associated with the practice of conventional preoperative management such as long fasting or parenteral therapy. In this regard, anesthesiologists should be aware of the data on the safety and efficacy of preoperative consumption of clear fluids and should also have sufficient reason for the use of oral rehydration therapy including selection of fluids consumed by patients. We consider that the rehydration method, which is considered safe and acceptable for both patients and doctors, should satisfy two conditions. The first condition is that the method should be equivalent to the parenteral therapy in the provision of fluid and electrolytes, and the second condition is that the fluids consumed by the patients should be excreted into the small intestine from the stomach in a timely manner. We believe that oral rehydration therapy is the most suitable, as is the oral method for preoperative fluid and electrolyte management in surgical patients, because it satisfies those two conditions.

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  The effect of lateral positioning on airway seal of the laryngeal mask airway (LMA) was compared between ProSeal LMA (PLMA) and the flexible LMA (FLMA). One hundred and twenty anesthetized, non-paralyzed patients were assigned to FLMA/supine, FLMA/lateral, PLMA/supine, and PLMA/lateral groups. The oropharyngeal leak pressure (OLP) for the size 4 LMA was determined during inflation of the cuff from 0-30 ml in 3-ml increments and at a 60 cmH₂O intracuff pressure. Lateral positioning significantly reduced the OLP for both devices at each cuff volume except for 6 ml, and the maximum differences in median OLP between the positions were 6.5 cmH₂O for FLMA and 10 cmH₂O for PLMA. The OLP for PLMA in a lateral position and that for the FLMA in a supine position were similar at each cuff volume over the inflation range of 3-30 ml. The median OLPs at a 60 cmH₂O intracuff pressure were 22, 16.5, 28, and 22.5 cmH₂O for FLMA/supine, FLMA/lateral, PLMA/supine, and PLMA/lateral groups, respectively. The LMA forms a poorer seal in a lateral than the supine position. PLMA in a lateral position provides a comparable seal to the FLMA in the supine position.

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  We compared the utility of the Macintosh laryngoscope (McL) and Pentax-Airway Scope^® (AWS) during chest compressions for patients transported to our emergency room. A total of 54 patients were randomized into two groups : McL, n=26, and, AWS, n=28. The use of AWS was associated with fewer interruptions in chest compression (P<0.05) and a higher rate of successful intubation (P<0.05). The intubation time during chest compressions did not differ significantly between the two groups. However, in patients with oropharyngeal discharge including vomitus and/or saliva, the intubation time was significantly longer with AWS than with McL (61.5 [range 60.0-80.0]s vs. 28.0 [range 25.0-42.3]s, P<0.05). AWS is effective in intubation during CPR, enabling uninterrupted chest compressions and enhancing the success rate of intubation. By contrast, AWS may be disadvantageous for patients whose oropharyngeal space had to be suctioned to remove discharge. Choice of devices for tracheal intubation should be based on the presence of discharge in the oropharynx, even when the AWS is available.

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  Drug-eluting coronary stent (DES) placement has been widely appreciated to treat coronary artery disease. However, long-term dual antiplatelet therapy is absolutely needed to prevent stent thrombosis in DES-implanted patients. Currently, no reliable evidence exists regarding perioperative antithrombotic management in previous DES-implanted patients requiring elective noncardiac surgery. Here we present a case of life-threatening stent thrombosis 24 months after DES placement, possibly because of discontinuation of dual-antiplatelet therapy 2 days prior to gastric cancer surgery. The patient went into cardiac arrest 2 hours after surgery. Emergent cardiac catheterization showed total occulusion of the coronary artery with space in-stent thrombosis. One year later, he underwent emergent laparotomy because he had recurrence of cancer followed by active abdominal bleeding. At that time, dual-antiplatelet therapy was not stopped and cardiac events didn't occur. We suggest that serious consideration should be given to continuing dual-antiplatelet therapy in the perioperative period for abdominal surgery patients with DES placement.

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  The patient was a 77-year-old woman. Emergent laparotomy was scheduled for recurrent bowel obstruction. General anesthesia combined with epidural anesthesia was administered. Epidural catheter was inserted at T10-11, and general anesthesia was induced with propofol and fentanyl. After induction, the Sellick maneuver was performed to avoid aspiration pneumonitis. But, after the Sellick maneuver, her heart rate suddenly decreased to 40 beats/min and cardiac arrest was observed for about 8 seconds. After the discontinuation of Sellick maneuver, her heart beat recovered immediately. Because the hemodynamic state was stable without administration of the catecholamine, the surgery was performed.
  During the induction of general anesthesia with propofol and fentanyl, we should consider cardiac arrest due to vagal reflex induced by Sellick maneuver stimulating the superior laryngeal nerve.

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  A 44-year-old male was scheduled for a posterior fossa procedure in the sitting position under general anesthesia. After anesthesia was induced, a catheter was placed in the internal jugular vein and a transesophageal echocardiography (TEE) probe was placed in the esophagus. TEE detected some air bubbles when the occipital bone was fenestrated and about 10 ml of air was aspirated from the catheter at the superior vena cava, before any decrease in the value on the end-tidal carbon dioxide monitor. There were no clinical features of air embolism after the surgeon closed the small hole at the superior sagittal sinus. TEE is suggested to be useful for early detection of air bubbles in the heart of patients undergoing a posterior fossa procedure in the sitting position.

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  Persistent left superior vena cava (PLSVC) is an anomaly caused by failure of the left precardinal vein to degenerate during the embryonic period. A patient with this anomaly is usually asymptomatic, but serious arrhythmias may occur when a catheter passes through the dilated coronary sinus.
  An adult woman was diagnosed as having PLSVC during the preoperative examination, and was scheduled to undergo mitral valve replacement. Insertion of a pulmonary artery catheter through the right internal jugular vein was unsuccessful because echography was not used before puncture. Then, a pulmonary artery catheter was inserted through the right external jugular vein uneventfully.
  The authors should reflect on the failure to use of echography before puncture. In a patient with PLSVC, the right external jugular vein can be an option when a clinician fails to catheterize the right internal jugular vein.

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  A 73-year-old man developed herpes zoster involving the right lower extremity mainly in the L4 dermatome and extending to S2 while being hospitalized in the department of respiratory medicine for chronic obstructive lung disease. His pain was too severe to be controlled by nonsteroidal anti-inflammatory drugs. Therefore, codeine phosphate was initiated to control the pain. Thereafter, the pain significantly improved. However, 13 days after the start of codeine phosphate treatment, severe shooting pain, probably due to neuropathic pain, occurred. Codeine phosphate was then switched to transdermal fentanyl patch, which is considered to be effective for neuropathic pain, and his pain was well controlled again. Two weeks later, the patient was able to withdraw from opioid therapy without any problems. Opioid rotation to fentanyl appears to be effective for the control of acute herpes zoster pain.

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  The Adamkiewicz artery, which mainly flows into the spinal cord at the level of Th9 or Th10, can sometimes lie between the levels of L3 and L5 (with a probability of about 0.5%) among the Japanese.
  If we don't pay any attention to this fact during the procedure of lumbar anesthesia, there exists some risk of damaging this important artery, and, consequently, of causing irreversible paraplegia.
  To avoid such misfortune, carefully puncturing the subarachnoid cavity only to modest depth may be one of the best preventive measures.

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  We conducted an attitude survey about airway management during cardiopulmonary resuscitation among doctors who participated in an AHA-ACLS provider course. In both initial trainee doctors and senior doctors who had more than two years' clinical experience, the frequency of use of a pocket mask, mouth-to-mouth artificial breathing, or combitube was lower than other devices and techniques (P<0.05). The frequency of use of oropharyngeal airway (OPA), nasopharyngeal airway (NPA), and cricoid pressure was significantly lower in initial trainee doctors than senior doctors (P<0.05). Both initial trainee doctors and senior doctors thought that administration of oxygen, application of an OPA or NPA, and avoiding hyperventilation were essential. Securing tracheal intubation within ten seconds was significantly less frequent in initial trainee doctors than senior doctors (P<0.05). It was suggested that training in ventilation assistance methods or devices such as OPA, NPA, or cricoid pressure, as well as in tracheal intubation, is important for initial trainee doctors.

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  Japanese physicians work long hours, with an average of 63.3 hours per week. Most of them work for 32 consecutive hours when they are on call. According to the Ministry of Health, Labour, and Welfare, 82.4% of inspected hospitals violated labor-related laws such as the Labor Standard Law, from April 2009 to March 2010.
  Until now, despite many violations of labor-related laws in Japanese hospitals, few physicians complained to the government offices that oversee occupational standards because of their shortage of legal knowledge. Furthermore, Japanese people could buy medical services at low cost from physicians including residents, who work for a long time without proper wages.
  However, Japanese medical residents were determined to be workers by the Supreme Court of Japan in 2005. Proper personnel management of physicians, including medical residents, is essential.

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