[Case of urgent surgical cricothyrotomy in CICV situation during induction of anesthesia for hemostasis after tonsillectomy]

A 38-year-old man (BMI 31) underwent bilateral tonsillectomy for sleep apnea syndrome under general anesthesia without any airway difficulty. On the fifth post-operative day excessive bleeding occurred suddenly. Emergency tracheostomy was planned, not under local anesthesia but general anesthesia in the presence of otolaryngologists for urgent tracheostomy, since the patient could not lie in the supine position. Tracheal intubation was tried using rapid sequence technique. However, excessive bleeding in the oral cavity did not allow successful direct laryngoscopy, resulting in CICV situation. When CICV situation was con- firmed associated with SpO2 91%, surgical cricothyrotomy was started by otolaryngologists. SpO2 decreased to 13% associated with heart rate of 38 beats · min-1 immediately before restoration of ventilation and oxygenation. After hemostasis, he showed uneventful post-operative course. On the occasion of airway management for excessive laryngopharyngeal bleeding, emergency surgical crycothyrotomy should be performed immediately before the fall of oxygen tension, if rapid sequence tracheal intubation had failed.

[Case of Rh (-) patient's right lobectomy of the liver with massive hemorrhage evading allogeneic blood transfusion by hemodilutional autologous blood transfusion]

A 44-year-old man (ASA-PS 1) underwent right lobectomy of the liver under total intravenous anesthesia with propofol, remifentanil, ketamine and rocuronium. In order to evade allogeneic blood transfusion, 1,200 g of the patient's blood was taken and hemodilution was induced for autologous blood transfusion (HAT) after the induction of anesthesia. As intraoperative blood loss amounted to about 4,000 g, Hb level decreased from 13.6 to 6.2 g x dl(-1). However, as intraoperative hemodynamics was relatively stable with crystalloidal and colloidal transfusion with no ischemic change on ECG and no metabolic acidosis, autologous blood transfusion was withheld. After returning the autologous blood, Hb increased to 9.8 g x dl(-1). Any postoperative complications related to the low Hb level were not recognized. HAT is a useful method to evade or at least decrease the amount of allogeneic blood transfusion by anesthesiologists.

[Rectus sheath block and transversus abdominis plane block for a patient with Lambert-Eaton myasthenic syndrome undergoing low anterior resection]

A 55-year-old male with Lambert-Eaton myasthenic syndrome underwent low anterior resection. Before anesthetic induction, his arterial blood gas analysis showed chronic hypercapnia (pH 7.404, Paco2 59 mmHg, BE 9.1). Anesthesia was induced with propofol, remifentanil and ketamine. Uneventful tracheal intubation was achieved after superior laryngeal nerve block without using muscle relaxants. Then ultrasound-guided bilateral rectus sheath block and transversus abdominis plane block were performed using 60 ml of 0.375% ropivacaine. Anesthesia was maintained with propofol, remifentanil monitoring bispectral index. Good surgical condition was maintained even without using muscle relaxants. Although only a small amount of morphine was required during the early postoperative days, his postoperative course was smooth and uneventful. The present case shows that ultrasound-guided rectus sheath block and transversus abdominis plane block are safe and useful for abdominal surgery in patients with neuromuscular disease.

Chemical shift tensor determination using magnetically oriented microcrystal array (MOMA): 13C solid-state CP NMR without MAS

Chemical shift tensors for the carboxyl and methyl carbons of L-alanine crystals were determined using a magnetically oriented microcrystal array (MOMA) prepared from a microcrystalline powder sample of L-alanine. A MOMA is a single-crystal-like composite in which microcrystals are aligned three-dimensionally in a matrix resin. The single-crystal rotation method was applied to the MOMA to determine the principal values and axes of the chemical shift tensors. The result showed good agreement with the literature data for the single crystal of L-alanine. This demonstrates that the present technique is a powerful tool for determining the chemical shift tensor of a crystal from a microcrystal powder sample.

[A case of hypernatremia treated with human atrial natriuretic peptide]

We describe a case of 65-year-old obese female patient with pulmonary embolism and life-threatening hypernatremia after removal of craniopharyngioma. On the 18th day after neurosurgical procedure, pulmonary embolism developed abruptly. Immediately after placement of inferior vena cava filter, surgical removal of the pulmonary thrombus was performed under cardiopulmonary bypass. Although mechanical ventilatory support and infusion of noradrenaline were required postoperatively, the trachea was extubated on the 10th postoperative day. Meanwhile, daily serum Na level increased gradually and reached 178 mEq x l(-1). We suspected that dehydration and pituitary dysfunction were mainly responsible for the hypernatremia. Human atrial natriuretic peptide (hANP) was infused from the 2nd to the 4th postoperative day, and her urinary Na excretion became increased and serum Na level became normal. After discontinuation of hANP, urinary Na excretion became decreased again and serum Na levels increased transiently. However, her consciousness level and cardiopulmonary condition improved and she was discharged from the ICU after twelve days of ICU stay. HANP may be useful for treatment of life-threatening hypernatremia.

[Anesthetic management for EXIT (ex-utero intrapartum treatment) of a twin gestation: one normal and one with a large epignathus]

We experienced cesarean section of a twin gestation of which one was normal and the other had a large epignathus. Anesthesia was induced with rapid administration of propofol and suxamethonium, then her trachea was intubated and operation was started. Anesthesia was maintained with 3% sevoflurane in 100% oxygen. Five minutes from the start of the surgery, the first baby was born with Apgar score of 3/7. One minute later, the head of the second with large epignathus was out of the uterus. But we judged that her trachea was difficult to intubate, but she showed spontaneous respiration. Then we inserted a tracheal tube (ID 2 mm) to her nose for the airway, and she was carried into the infant warmer after amputating the umbilical cord. After the delivery, sevoflurane was discontinued, and propofol, fentanyl and ketamine were started. Cesarean section was finished with total blood loss of 1,900 g including amniotic fluid. In the infant warmer, tracheostomy was performed on the second baby, and the baby was carried to NICU. Thirteen days later, the epignathus was extracted without complication. General anesthesia with inhalational agent is usually chosen for cesarean section with EXIT. For EXIT, uterine relaxation and fetal akinesia are necessary, but deep inhalational anesthesia causes massive bleeding, hypotension and loss of spontaneous respiration of the fetus. Twin gestation with one normal and the other with airway trouble has many problems. We have to consider mother, normal baby and troubled baby during EXIT. We should treat them appropriately with prudence.

[Case of Rett syndrome monitored with BIS and neuromuscular monitor during total intravenous anesthesia]

We describe a case of 8-year-old female patient with Rett syndrome undergoing bilateral tonsillectomy and adenotomy. She was monitored with BIS and neuromuscular monitor using TOF during total intravenous anesthesia (TIVA) with propofol, remifentanil, ketamine and rocuronium. A relatively high infusion rate of propofol (10 mg x kg x hr(-1)) was maintained to keep BIS between 60 and 70 during the surgical procedure, and rocuronium 10 mg IV was administered for tracheal intubation without its further administration during the surgical procedure. Although prolonged effects of anesthetics, analgesics and neuromuscular blockade were reported frequently, she took uneventful course during anesthesia and surgery. Her recovery from anesthesia and neuromuscular blockade was also smooth associated with satisfactory sedated states. BIS and neuromuscular monitor may be useful in TIVA for a patient with Rett syndrome.

Virus activation and immune function during intense training in rugby football players

Epidemiological studies suggest that highly trained athletes are more susceptible to upper respiratory tract infections (URTI) compared with the general population. Upper respiratory symptoms (URS) often appear as either primary invasion of pathogenic organisms and/or reactivation of latent viruses such as Epstein-Barr virus (EBV). The purpose of this study was to examine the relationship between EBV reactivation and the appearance of URS during intensive training in collegiate rugby football players. We evaluated EBV-DNA expression in saliva and examined the relationship between onset of URS and daily changes in EBV-DNA as well as secretory immunoglobulin A (SIgA) levels among 32 male collegiate rugby football players during a 1-month training camp. The EBV-DNA expression tended to be higher in subjects who exhibited sore throat (p=0.07) and cough (p=0.18) than that of those who had no symptoms, although their differences were not significant. The SIgA level was significantly lower 1 day before the EBV-DNA expression (p<0.05). The number of URS increased along with the EBV-DNA expression and decrease of SIgA levels. These results suggest that the appearance of URS is associated with reactivation of EBV and reduction of SIgA during training.

Abstract P1-13-09: Marked Inhibition of Both Invasion and Proliferation by Zoledronic Acid and the Epidermal Growth Factor Receptor Inhibitor Gefitinib in a Bone-Seeking Clone of Breast Cancer

Background: Zoledronic acid (Zol) is the most potent inhibitor of bone resorption in bisphosphonates. In order to examine whether the inhibitory effect is involved in the mechanism of bone metastasis in breast cancer, a bone-seeking clone was examined. It was established by repeated sequential passages of metastatic cells from bone in nude mice and in vitro, and it exclusively metastasizes to bone with larger osteolytic lesions than MDA-MB-231 parental cells. Recent findings indicate that epidermal growth factor (EGF) signaling is also an important mediator of bone metastasis. We examined the synergistic effects of gefitinib on the proliferation and invasion of a bone-seeking clone compared with MDA-MB-231. Materials and Methods: The cellular proliferation was estimated using WST-1. Migration in the matrigel in a Boyden chamber was applied to the invasion assay.

Results: Treatment with 1 µM of Zol reduced 51% of cell proliferation in the bone-seeking clone; however, the inhibited rate was 37% in MDA-MB-231. The migration was also inhibited with 10 µM of Zol (bone-seeking clone: 69% reduction, MDA-MB-231: 54% reduction). The reduction rates of both assays by Zol treatment were significantly higher in the bone-seeking clone than in MDA-MB-231. Treatment with 10 µM of Zol plus 1 µM of gefitinib resulted in a proliferation reduction rate of 27% compared to that with 10 µM Zol treatment in the bone-seeking clone and no reduction in MDA-MB-231.

The migration reduction rate was 88% in the bone-seeking clone and no reduction in MDA-MB-231.

There was a significant difference between the bone-seeking clone and MDA-MB-231 in the reduction rates of both cellular proliferation and migration. Although the effect of gefitinib was synergistic with that of Zol in the bone-seeking clone, it was not clear in MDA-MB-231.

Conclusion: There appear to be at least two independent signaling pathways that occur in osteolytic bone metastasis. One is involved in the bone resorption of bisphosphonates, and the other is an EGFR signaling pathway. Clinically, the combination of Zol and gefitinib is suggested to be a strong therapy specific to bone metastasis.

Increased circulating cell signalling phosphoproteins in sera are useful for the detection of pancreatic cancer

BACKGROUND

Intracellular phosphoprotein activation significantly regulates cancer progression. However, the significance of circulating phosphoproteins in the blood remains unknown. We investigated the serum phosphoprotein profile involved in pancreatic cancer (PaCa) by a novel approach that comprehensively measured serum phosphoproteins levels, and clinically applied this method to the detection of PaCa.

METHODS

We analysed the serum phosphoproteins that comprised cancer cellular signal pathways by comparing sera from PaCa patients and benign controls including healthy volunteers (HVs) and pancreatitis patients.

RESULTS

Hierarchical clustering analysis between PaCa patients and HVs revealed differential pathway-specific profiles. In particular, the components of the extracellular signal-regulated kinase (ERK) signalling pathway were significantly increased in the sera of PaCa patients compared with HVs. The positive rate of p-ERK1/2 (82%) was found to be superior to that of CA19-9 (53%) for early stage PaCa. For the combination of these serum levels, the area under the receiver-operator characteristics curves was showing significant ability to distinguish between the two populations in independent validation set, and between cancer and non-cancer populations in another validation set.

CONCLUSION

The comprehensive measurement of serum cell signal phosphoproteins is useful for the detection of PaCa. Further investigations will lead to the implementation of tailor-made molecular-targeted therapeutics.

Electric and mass transport of a carbon nanotube encapsulating a copper nano-rod studied by in-situ transmission electron microscopy

Electric properties and current-induced structural changes of carbon nanotubes (CNTs) encapsulating copper nano-rods were studied by in-situ transmission electron microscopy (TEM). The diameter and the length of a copper filled CNT were 18 nm and 256 nm, respectively. The thickness of the graphite layer was about 1 nm. The bias voltage was applied between the two ends of the CNT inside the TEM, and the current as well as TEM images were recorded simultaneously. At a bias voltage of 1.4 V, the current increased to 10 microA, corresponding to a current density of 4.0 x 10(6) A/cm2, and at the same time the nano-rods inside the CNT started to move to an end of the CNT. After the movement of the nano-rods, an empty CNT was left. Resistivities of the CNT and the copper nano-rod were measured to be 3.0 x 10(-5) ohm m and 1.2 x 10(-4) ohm m, respectively.

[Case of autonomic hyperreflexia treated with intravenous nicardipine]

We describe a case of 26-year-old male patient with autonomic hyperreflexia (AH) during colostomy. He had suffered paraplegia due to the 8th cervical spinal cord injury by a traffic accident 2 years before. The anesthesia was induced and maintained with propofol, fentanyl, ketamine and vecuronium. Vital signs including blood pressure (135-145/70-80 mmHg) and heart rate (55-65 beats x min(-1)), were stable at the beginning of the operation. However, blood pressure suddenly rose (220/ 120mmHg), and heart rate decreased (43 beats x min(-1)) associated with skin eruptions on his face and shoulder when the intestinal tract procedure was started. Diagnosis of AH was made. Then nicardipine 1 mg i.v. was given followed by nicardipine 2 microg x kg(-1) x min(-1) DIV Consequently, blood pressure (140-155/ 70-85 mmHg) and heart rate (75-85 beats x min(-1)) were stabilized. The operation was finished with no evidence of any complications. Nicardipine may be preferable in a patient with upper spinal cord injury undergoing operation in the paralyzed area.

Expression and role of SNAT3 in the placenta

Glutamine is the most versatile amino acid and its plasma concentration is the highest of all amino acid. Many transporters are therefore involved in glutamine uptake or efflux. Glutamine is actively released from the placenta into fetal circulation. In this study, we examined the alteration of transporters that transport glutamine into fetal circulation as gestation progresses. High expression levels of system A and y(+)L were found in the rat placenta in the late period of pregnancy and the expression levels of these transporters increased as gestation progressed (p<0.05). On the other hand, the expression of SNAT3, the system N transporter, was detected in the early period of pregnancy and its expression level decreased as gestation progressed (p<0.05). SNAT3 was also found to be expressed in isolated human primary cytotrophoblast cells and its expression level was decreased by their differentiation into syncytiotrophoblast cells (p<0.05). Since this regulation is closely related to glutamine synthetase expression, SNAT3 may play a key role in providing glutamine corresponding to glutamine synthetase function in the early period of gestation. This is the first report on the expression of SNAT3 in the placenta in the early stage of pregnancy.

The role of limbic-hypothalamic systems in metabolic responses of phenylalanine to repeated cold exposures in rabbits

In this study we examine the effects of lesions to limbic or hypothalamic structures on the metabolic responses of phenylalanine in liver slices prepared from rabbits exposed to cold stress (-20 degrees C) for 12 hours at a fixed time once a day. The results were as follows: 1. The 1st cold exposure (cold exposure on the 1st day) had marked and various effects on phenylalanine metabolism, and the metabolic responses of phenylalanine to cold exposure gradually decreased and then completely disappeared with repetitions of exposure in intact rabbits. 2. The metabolic patterns and responses of phenylalanine to the 1st cold exposure were altered by lesioning the periventricular arcuate nucleus (ARC), ventromedial hypothalamus (VMH), stria terminalis (ST) or dorsal fornix (FX). 3. The complete abolishment of the metabolic responses to cold exposure by its repetition was observed in rabbits with lesions in the ARC or VMH as well. 4. In contrast, metabolic responses of phenylalanine to cold exposure in rabbits with lesions in the ST or FX remained even after six exposures. These results suggest that the ARC, VMH, amygdala (AMYG)-ST system and dorsal hippocampus (HPC)-FX system played a role in the metabolic regulation of phenylalanine and in the metabolic responses of phenylalanine to the 1st cold exposure and that the AMYG-ST and HPC-FX systems, but not the ARC or VMH, participated in the process of the metabolic adaptation of phenylalanine to cold exposure.

Influence of the electrical stimulation of the medial amygdala on adrenocortical sensitivity to adrenocorticotrophin in hypophysectomized rats

The effects of electrical stimulation of medial amygdala on the adrenocortical sensitivity to adrenocorticotrophin (ACTH) were investigated in hypophysectomized rats. The intravenous injection of ACTH increased the rates of 14C transfer from 14C-l-acetate into corticosterone and cortisol in the adrenal slices of hypophysectomized rats. The electrical stimulation of the medial amygdala produced a further increase in the rates of 14C transfer from 14C-l-acetate into corticosterone and cortisol. From these results, it might be suggested that the medial amygdala was capable of enhancing the adrenocortical steroidogenesis in response to ACTH.