Background: Circumferential pulmonary vein isolation (CPVI), achieved by cryoballoon ablation (CBA) or by irrigated-tip radiofrequency catheter ablation (RFA), has been used to isolate the area surrounding the pulmonary veins (PVs) in patients with paroxysmal atrial fibrillation (AF). Although studies have shown circumferential RFA to be comparable to CBA in terms of arrhythmia-free survival and the overall complication rate, there has been no reported comparative quantification of the resulting acute ablated areas of the left atrial endocardial surface. Therefore, we conducted such a study. Methods and Results: The study involved 40 patients (32 men, 8 women; mean age, 62.2 ± 10.4 years) who were undergoing CBA or circumferential RFA for AF (paroxysmal AF, n = 24; persistent AF, n = 16). A detailed 3-dimensional electroanatomic map of the left atrium (LA) was created and merged onto the pre-procedural computed tomography (CT) of the LA, and the ablation areas, interpreted as low voltage areas, were quantified and compared between the 2 CPVI methods. The low voltage areas were significantly larger in the CBA patient group than in the circumferential RFA patient group (40.6 ± 13.8 vs. 31.46 ± 15.8 cm², respectively, ρ = 0.00287). Conclusions: Our acute phase data indicate that CBA produces a larger PV-LA surface isolation area compared with point-by-point circumferential CF-based RFA.

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Background: Acute myocardial ischemia results in an increase in extracellular K⁺ ([K⁺]_e) and a decrease in extracellular pH (pH_e). We examined the effects of these changes on conduction and the effective refractory period (ERP) during acute myocardial ischemia. Methods: We inserted K⁺- sensitive electrodes into the mid-myocardium and bipolar plunge electrodes into the subendocardium and subepicardium of in-situ canine hearts. A unipolar electrode was inserted into the mid-myocardium. The carotid artery was shunted to the LAD through a roller pump, and KCl was infused into the side arm of the shunt. Systematic metabolic acidosis (MA) and respiratory acidosis (RA) were induced in 10 animals each by infusion of NH₄Cl and inhalation of CO2, respectively. Results: Under regional hyperkalemia (([K⁺]_e = 10.23 ± 1.15 mM in the MA group and 9.28 ± 1.19 mM in the RA group), the intramyocardial conduction time (CT) increased by 20%. The CT did not change under RA or MA alone. When regional hyperkalemia plus MA ([K⁺]_e = 8.94 ± 1.87, pH = 7.06 ± 0.06) or RA ([K⁺]_e = 9.33 ± 0.63, pH = 6.75 ± 0.20) were both induced, the CT increased further by 50% compared to the control/baseline state. The ERP did not change significantly with regional hyperkalemia or regional hyperkalemia plus RA or MA. Conclusion: Our data indicate that the fall in pHe that results from myocardial ischemia enhances the conduction slowing induced by the rise in [K⁺]_e.

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Some authors have speculated that elephant lymph nodes would resemble those of pigs, with unusual morphological characteristics. We investigated this issue with the primary concern of clarifying the histological structure of the elephant lymph node. The node consisted of several lymphoid segments of various sizes, with medullary substance between adjacent segments. Each segment consisted of a thickened cortex, located in the outer half, and the medulla, occupying the inner half. Afferent lymphatics entering the node divided into capsular and trabecular branches, and opened into the subcapsular sinus at multiple sites or ended up at the intermediate sinuses at various depths. The cortical lymphoid tissue broadly extended under the capsule and along the trabeculae containing lymphatic branches. The medulla was made up of the medullary cords and sinuses, and was interlaced by coarse networks of medullary trabeculae. These results indicate that the elephant lymph node is rather more comparable to those of bovines and canines.

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Objective: The laparoscopic percutaneous extraperitoneal closure (LPEC) procedure has been performed intensively in pediatric health care centers in Japan. The objective of this study was to describe the outcome of the LPEC procedure, including safety and efficacy, compared with conventional open repair of pediatric inguinal hernias, based on a personal series in the municipal general hospital. Results: The mean operative time of the LPEC procedure was significantly lower in the male bilateral hernia group (36.7 ± 11.2 min, n = 43) and higher in the female unilateral group (25.3 ± 9.4 min, n = 87) compared with conventional open repair for each group. Minor postoperative complications of the LPEC procedure were seen in five cases: recurrent hernia (n = 2), surgical site infection (n = 1), umbilical port-site hernia (n = 1), with no difference from the conventional hernia repair group. Conclusion: The LPEC procedure can be a safe and efficacious approach for repair of pediatric inguinal hernia.

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A less invasive and safe surgical approach using a navigation system has become popular in recent years. An electromagnetic navigation system was then developed and expanded on the conventional optical system. We experienced the use of the electromagnetic system for surgery on a patient with intractable recurrent paranasal cysts. A 61-year-old patient who had previously undergone sinus surgeries twice was referred to us due to the recurrence of right maxillary sinus cysts. We performed endoscopic sinus surgery using an electromagnetic navigation system for this intractable case. The less invasive and safe surgery was possible despite the complicated lesion. Furthermore, this approach provided easier setting and smoother surgical performance without limitation of the tracking compared with the optical system. Our experience demonstrated that the electromagnetic navigation system is more useful and valuable for paranasal sinus surgeries compared with the optical system.

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We report a case of an 81-year-old woman who had been treated conservatively under the diagnosis of acute appendicitis with abscess formation and acute pancreatitis due to gall bladder and common bile duct stone. She underwent single incision laparoscopic surgery (SILS) for calculous cholecystitis and chronic appendicitis simultaneously. The postoperative period was uneventful and the patient was discharged 5 days after the operation. While it is not easy to accumulate single incision laparoscopic operative skills earlier, SILS is a reasonable approach for esthetics and minimal invasiveness.

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Cerebrospinal fluid (CSF) otorrhea due to congenital defects in the temporal bone is one of the risks of recurrent bacterial meningitis in children. We present a case of a six-year-old girl with Hyrtl′s fissure who was diagnosed on the basis of bacterial meningitis following otitis media. She did not experience any further meningitis or CSF leak after surgical closure. CSF otorrhea with congenital defects should be listed in the differential diagnosis of patients with bacterial meningitis in the post vaccine era.

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A 56-year-old woman was admitted to our hospital due to liver dysfunction with epigastralgia and jaundice. Her laboratory data showed AST: 731 IU/L, ALT: 839 IU/L, T-B: 7.0 mg/dl, PT: 57%, ANA: ·640, and IgG: 1444 mg/dl. Liver biopsy findings and laboratory data were consistent with severe autoimmune hepatitis with acute presentation. Therefore, we started steroid therapy from the 8th hospital day, and she exhibited a benign course. Severe autoimmune hepatitis with acute presentation may develop into a more severe course and liver failure in the absence of treatment. If clinically autoimmune hepatitis is suspected, liver biopsy and initiation of steroid therapy as soon as possible are important in determining the convalescence of the patient.

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A female in 30s who fell from a height of 7 meters presented with maxilla and mandibular deflection, and bleeding from the nasal and oral cavities. CT indicated a Le Fort type II facial bone fracture. Tracheal intubation was not performed due to the lack of initial signs of airway obstruction from the hemorrhaging. After initial management, the bleeding from the nasal and oral cavities increased gradually. Therefore, the area was packed with epinephrine gauze and tracheal intubation was performed. Five hours later, increased nasal/oral bleeding was observed. Transcatheter arterial embolization (TAE) was performed at the two branches of the external carotid artery. Le Fort type II facial bone fractures are usually complicated, because multiple vessels are involved and conservative therapy alone will result in uncontrollable bleeding. We conclude that early airway management procedures, such as tracheal intubation and TAE, are important strategies for treating this type of facial bone fracture.

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We present a case of spontaneous bladder rupture in a 49-year-old woman who had undergone radical hysterectomy and pelvic radiation therapy 10 years ago. Her chief complaint was acute abdominal pain. Abdominal computed tomography revealed ascites, which contained higher levels of creatinine, indicating intraperitoneal urinary extravasation. Following conservative therapy with an indwelling catheter, intermittent self-catheterization was introduced to prevent recurrence of the rupture. Perforation of the urinary bladder should be considered in patients with acute abdomen, particularly in those with previous histories of pelvic surgical or radiation therapy.

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