Biomechanical response of bovine temporomandibular joint disc to prolonged tensile stress

This study was designed to evaluate the influence of prolonged tensile stress on the viscoelasticity of the temporomandibular joint (TMJ) disc. Twenty discs from 10, 3-year-old cattle were used. Tensile stress of 1.5 MPa was applied to specimens from the discs for 10, 20, 40 and 60 min. Following the prescribed period of tension for creep, the specimens were removed from the tension device and any recovery observed for 20 min. In all specimens, strain increased at the onset of stress application and reached almost steady conditions after 5 min. Although, the strain became slightly larger when the creep time was longer, no significant differences were found in the strains between any two tests with different periods of creep. The residual strain increased significantly with creep duration, and similarly the degree of recovery decreased significantly. In 10- and 20-min creep tests, the residual strains were 0.1 and 1.0%, the specimens in 40- and 60-min tests revealed irreversible changes in length. It was concluded that continuous loading for >40 min causes creep damage in bovine TMJ disc, and that prolonged sustained tension affects the recovery of joint homeostasis.

The importance of tail temperature monitoring during tail-flick test in evaluating the antinociceptive action of volatile anesthetics

BACKGROUND

Tail-flick (TF) latency can be influenced by tail-skin temperature (TT), and treatments that raise TT can mimic hyperalgesia on a TF test. As volatile anesthetics can raise TT via heat redistribution, their antinociceptive action can be hidden or obscured in a TF test. We tested the hypothesis that TT monitoring improves the efficiency of TF tests in evaluating the antinociceptive action of volatile anesthetics.

METHODS

The relationship between TT and TF latency was first explored under varied TTs in 12 rats. Then, TT and TF latency were measured before and during isoflurane exposure (1.2%). In the low temperature group (n=6), rats were prewarmed mildly to increase TT during isoflurane exposure. In the high temperature group (n=6), rats were prewarmed enough to prevent a TT increase during isoflurane exposure.

RESULTS

There was a highly significant correlation between TT and TF latency, that is, TF latency decreased as TT increased. In the low temperature group, there was a significant increase in TT during isoflurane exposure, while an increase in TF latency did not reach statistical significance. Tail-flick latency corrected by a change in TT showed a significant increase. In the high temperature group, TF latency increased significantly during isoflurane exposure without an increase in TT.

CONCLUSIONS

Isoflurane inhalation can induce an increase in TT, which can obscure its antinociceptive action as evaluated by a TF test. Monitoring TT during a TF test is important to efficiently evaluate the antinociceptive action of volatile anesthetics.

[Useful tools for prone position: ProneView and OPTI-GARD]

For prone position except for neurosurgery or cervical spinal surgery, head and neck are usually turned sideways on the pillow. This position has a risk of injuries to eyes, nose, lips, ears, or facial nerve and inducing neck pain after surgery. We introduce new tools to avoid these complications from prone position. The ProneView consists of a plastic helmet with a window for eyes, nose and mouth, a sponge to fit the face attached to the helmet, and a mirror to watch eyes, nose and lips. The OPTI-GARD is the glasses made by a sponge with a plastic windows to protect eyes. Using the ProneView and the OPTI-GARD together, patient's neck and head can be kept at neutral position with eyes, nose, lips, and ears being kept free from any pressure. In addition, we can check the position of the face easily by mirror. Therefore, the ProneView and the OPTI-GARD must be useful to decrease injuries to eyes, nose, lips, ears, and facial nerve, and neck pain in prone position.

[Endotracheal intubation with a lighted stylet in a patient with difficult airway from the first and second brancheal arch syndrome]

A 28 year-old-woman with the first and second brancheal arch syndrome was scheduled for the lift of the inferior part of the right ear. Difficult intubation was expected because of the mandibular hypoplasia. We chose a lightwand stylet for tracheal intubation. Anesthesia was induced with sevoflurane slowly increased to 5% in nitrous oxide 3 l.min-1 with oxygen 3 l.min-1. A spiral tube with 6.5 mm inner diameter (Safety-Flex, Mallinckrodt Medical, Ireland) was attached to the lightwand stylet (Surch-Light, Aaron, U.S.A.) and shaped to fit to pharyngo-laryngeal curve. Under spontaneous breathing, the tube was successfully inserted without laryngoscopy. No traumatic events occurred. Usually fiberoptic laryngoscopy requires more skill, more expensive equipment, and more time to prepare than the lightwand stylet technique. Moreover profuse secretions or blood in the oropharynx sometimes inhibit clear vision by fiberoptic laryngoscopy. The lightwand stylet is simple and inexpensive and it is useful for tracheal intubation in patients with difficult airway from the first and second brancheal arch syndrome.

[Anesthetic management using propofol and fentanyl for transrectal ultrasound-guided prostatic biopsy]

We prospectively evaluated the efficiency of the anesthetic management using propofol and fentanyl for the transrectal, ultrasound-guided, prostatic biopsy. In the anesthetic management for the transrectal, ultrasound-guided, prostatic biopsy, it is required to obtain enough muscle relaxation of the anal sphincter for placing the transrectal ultrasound probe and to secure immobilization of the patient during the prostatic biopsy. Eight patients undergoing the transrectal, ultrasound-guided, prostatic biopsy participated in this study. Without premedication, anesthesia was induced using fentanyl (100 micrograms) and target-controlled infusion of propofol with an estimated blood concentration of 3 micrograms.ml-1. We obtained both sufficient muscle relaxation of the anal sphincter and complete immobilization of the patient during the prostatic biopsy in all patients. Moreover, this anesthetic management assured short awakening time from anesthesia and low incidence of adverse effects. From these results, we conclude that the anesthetic management using propofol and fentanyl for the transrectal, ultrasound-guided, prostatic biopsy is efficient and practical.

Do the effects of a protease inhibitor, ulinastatin, on elastase release by blood transfusion depend on interleukin 6?

OBJECTIVE

Blood transfusion induces polymorphonuclear leukocyte elastase (PMNE) and interleukin 6 (IL-6). IL-6 would activate neutrophils to release PMNE. Ulinastatin, a protease inhibitor, inhibits PMNE release by blood transfusion. The purpose of this study was to investigate whether the effects of ulinastatin on PMNE release by blood transfusion come through inhibition of IL-6.

DESIGN

Semirandomized, controlled clinical trial.

SETTING

Surgical center in a university hospital.

PATIENTS

Patients age 35-70 yrs undergoing gastrectomy were enrolled in this study until the four study groups had 12 patients each.

INTERVENTIONS

Half of the enrolled patients received ulinastatin at random. After surgery, patients were divided into the following four groups: group A received neither blood transfusion nor ulinastatin, group B received only blood transfusion, group C received only ulinastatin, and group D received both blood transfusion and ulinastatin. The infusion of ulinastatin 300,000 units was started at manipulation of the stomach in the group C and at the start of blood transfusion in the group D.

MEASUREMENTS AND MAIN RESULTS

Segmented neutrophil count and plasma concentrations of PMNE and IL-6 were measured. In addition, PMNE and IL-6 concentrations in every unit of concentrated red blood cell transfused and these concentrations in the plasma of the recipient after every unit of transfusion were measured.

RESULTS

Blood transfusion increased plasma concentrations of PMNE and IL-6, and the PMNE release from segmented neutrophil. The increase of plasma PMNE but not IL-6 concentration after each unit of blood transfusion was inhibited by ulinastatin. However, ulinastatin did not inhibit the increase of plasma concentrations of PMNE and IL-6 by surgical stimuli of gastrectomy.

CONCLUSIONS

Ulinastatin 300,000 units might be useful to inhibit blood transfusion-induced increase of PMNE but not IL-6. The inhibition of PMNE increase by ulinastatin was independent of IL-6.

The synergistic interaction between midazolam and clonidine in spinally-mediated analgesia in two different pain models of rats

Both midazolam, a benzodiazepine gamma-aminobutyric acid type A receptor agonist, and clonidine, an alpha2-adrenergic receptor agonist, induce spinally-mediated analgesia. We investigated the analgesic interaction of spinally-administered midazolam and clonidine in their effects on acute and inflammatory nociception. Rats implanted with lumbar intrathecal catheters were injected intrathecally with saline (control), midazolam (1 to 100 microg), or clonidine (0.1 to 3 microg) to test for their responses to thermal stimulation to the tail (tail-flick test) and subcutaneous formalin injection into the hind paw (formalin test). The effects of the combination of midazolam and clonidine on both stimuli were tested by isobolographic analysis by using the 50% effective doses. The general behavior and motor function were examined as side effects. When combined, the 50% effective doses of midazolam (clonidine) decreased from 1.57 microg (0.26 microg) to 0.29 g (0.05 microg) in the tail-flick test and from 1.34 microg (0.12 microg) and 1.21 microg (0.13 microg) to 0.05 microg (0.005 microg) and 0.13 microg (0.015 microg) in Phase 1 and 2 of the formalin test, respectively. Side effects did not increase by using the combination. These results suggest a favorable combination of intrathecal midazolam and clonidine in the management of acute and inflammatory pain after proper neurotoxicologic studies.

IMPLICATIONS

Spinally-administered midazolam, a benzodiazepine, and clonidine, an alpha2-adrenergic receptor agonist, have significant synergistic effects on thermally-induced acute and formalin-induced inflammatory pain.

Hemolysis in stored red blood cell concentrates: modulation by haptoglobin or ulinastatin, a protease inhibitor

OBJECTIVE

Polymorphonuclear leukocyte elastase may injure various tissues. The release of polymorphonuclear leukocyte elastase induced by various stimuli was reported to be inhibited by a protease inhibitor, ulinastatin. In stored blood preparations, polymorphonuclear leukocyte elastase increases depending on the storage days as hemolysis increases. We hypothesized that polymorphonuclear leukocyte elastase might be one of the factors inducing hemolysis in stored blood. Haptoglobin binds to free hemoglobin to reduce hemolysis. The purpose of the study was to investigate the effects of ulinastatin on hemolysis in blood preparations in comparison with haptoglobin.

DESIGN

In vitro study.

SETTING

Laboratory in a university hospital.

SUBJECTS

Nine 2-day-old packs of red blood cell concentrates (CRC) in 400 mL each of mannitol, adenine, glucose, phosphate, and citrate (MAP) (MAP-CRC) from the Japan Red Cross Society.

INTERVENTIONS

Each MAP-CRC was divided into three different packs of equal amount and was treated with 10 mL of saline (control group), 200 units of haptoglobin, or 50,000 units of ulinastatin. They were stored at 4 degrees C.

MEASUREMENTS AND MAIN RESULTS

Supernatant concentrations of total and free hemoglobin, total haptoglobin, polymorphonuclear leukocyte elastase, and potassium were measured for 25 days. Free haptoglobin concentration was calculated. Total and free hemoglobin concentrations increased significantly depending on the storage days in the control group, whereas haptoglobin and ulinastatin groups showed no increase. Total and free haptoglobin concentrations were significantly higher in the haptoglobin group than in the other two groups. Free haptoglobin concentrations were 0 after 5 days of storage in the control and ulinastatin groups. Polymorphonuclear leukocyte elastase concentrations increased with the increase in storage days without any differences among the three groups. Potassium concentration increased according to the storage and showed the highest value in the control group.

CONCLUSIONS

Adding haptoglobin or ulinastatin to MAP-CRC was useful to suppress hemolysis during storage of the preparation. The polymorphonuclear leukocyte elastase might not be involved in the mechanisms of hemolysis in MAP-CRC stored for 25 days.

Identification of novel single nucleotide substitutions in the NKp30 gene expressed in human natural killer cells

Cytotoxicity of natural killer (NK) cells is regulated by a balance of signals from two kinds of NK receptors, activating receptors and inhibitory receptors. Natural cytotoxicity receptors (NCR) family, which consists of NKp30, NKp44 and NKp46, is a major human activating NK receptor. NKp30 has been mapped to the HLA class III region near tumor necrosis factor (TNF) family loci. We have analyzed the NKp30 gene of healthy Japanese and found two synonymous substitutions in the coding region, c.111G>A and c.156C>T, and also identified two single-nucleotide polymorphisms (SNPs) in the promotor region, -201G>A and -163G>C. Furthermore, it was confirmed that these polymorphisms of the NKp30 gene show strong linkage disequilibria with each other and with HLA-DRB1 or TNFA polymorphisms. Since susceptibilities to certain diseases were mapped near this region, the NKp30 polymorphisms could be useful genetic markers.

[Acute myocardial infarction in the postoperative period in an elderly man with low coronary risk factor before the operation]

An 86-year-old man complicated by severe asthma developed myocardial infarction after the operation of abdominal aortic aneurysm. Emergency coronary angiography (CAG) revealed 99% stenosis of main trunks of left coronary artery (LMT). Because the patient had been without major coronary risk factors, it was difficult to predict coronary lesions preoperatively. Elderly patients have frequently latent complications not detected by usual consultation. Therefore, in elderly patients, we have to evaluate each individual risk factor more rigidly, and perform more thorough preoperative tests, including CAG.

[Diagnosis and assessment of pain]

Good management of pain depends on accurate assessment. We describe some approaches to the measurement of pain or suffering, including visual analogue scale, the MacGill Pain Questionnaire and behavioral observation scale. Patient's self-reporting provides the most valid information, because pain is a personal and subjective. Behavioral approaches to pain measurement, such as behavioral observation scale are useful for pain assessment for infants, children without language skills. Intravenous barbiturate, phentolamine(alpha-adrenergic antagonist), lidocaine(Na channel blocker), morphine(opioid), or ketamine(NMDA antagonist) may contribute to pain assessment as diagnostic tools for the investigation of the etiology of pain, especially neuropathic pain.

Propofol-induced bronchoconstriction: two case reports

IMPLICATIONS

Bronchoconstriction was induced by anesthetic induction with propofol in two patients with allergic diseases. One had severe bronchospasm improved by epinephrine. Propofol should be used with caution in patients with allergic disease.

[The effects of the fat component of propofol solution of ketogenesis during propofol anesthesia]

To examine the effects of the fat component in propofol solution on the fat metabolism during propofol anesthesia, we measured the urine ketone body (UKB) and blood concentrations of 3-hydroxybutyrate (3-OHBA) and glucose. The anesthesia was maintained with propofol, fentanyl, and vecuronium. Infusion fluid without glucose was used while we measured the concentration of 3-OHBA. UKB was detected only when the concentration of 3-OHBA was more than 400 mumol.ml-1. The blood concentration of 3-OHBA increased in proportion to the total amount of propofol solution, while UKB did not show any such relationship. Furthermore, the rate of increase of 3-OHBA was larger in the group whose concentration of 3-OHBA was higher than the normal range. The blood concentration of glucose ranged within the normal fasting level. There were no cases who needed special treatment for hyperketonemia in this study. We concluded that 3-OHBA was a more sensitive indicator of ketogenesis than UKB, and that ketogenesis was accelerated both by propofol anesthesia with the lipidemic solution of propofol and by fasting before surgery. The acceleration of ketogenesis was especially marked in the patients with hyperketonemia.

Occurrence of organo-arsenicals in jellyfishes and their mucus

Water-soluble arsenic compound fractions were extracted from seven species of jellyfishes and subjected to analysis by high-performance liquid chromatography-inductively coupled plasma mass spectrometry (HPLC-ICP-MS) for arsenicals. A low content of arsenic was found to be the characteristic of jellyfish. Arsenobetaine (AB) was the major arsenic compound without exception in the tissues of the jellyfish species and mucus-blobs collected from some of them. Although the arsenic content in Beroe cucumis, which preys on Bolinopsis mikado, was more than 13 times that in B. mikado, the chromatograms of these two species were similar in the distribution pattern of arsenicals. The nine species of jellyfishes including two species treated in the previous paper can be classified into arsenocholine (AC)-rich and AC-poor species. Jellyfishes belonging to Semaostamae were classified as AC-rich species.

Lactate levels in cirrhotic patients undergoing liver resection

BACKGROUND/AIMS

The role of lactate in liver ischemia-reperfusion injury in cirrhosis has not been clarified.

METHODOLOGY

One hundred patients with hepatocellular carcinoma who underwent partial liver resection under Pringle's maneuver were included in this study. Blood lactate was measured before the operation, three times during the surgery and on the first postoperative day to calculate its rate of accumulation or elimination. Aminotransferase levels were also recorded perioperatively. We calculated the rate of lactate accumulation during the pre-ischemic and ischemic phases and the elimination rate during the post-ischemic phase, and examined the correlation between these results and the clinical findings.

RESULTS

The rate of lactate accumulation during the pre-ischemic and ischemic phases was correlated with the preoperative indocyanine green retention rate (P = 0.04 and P = 0.004, respectively). The indocyanine green retention rate tended to be correlated with the rate of lactate elimination during the post-ischemic phase (P = 0.06).

CONCLUSIONS

The blood lactate profile might be a reliable indicator of liver function during the perioperative period in cirrhotic patients who undergo liver resection with Pringle's maneuver.

[Anesthetic management for gastrojejunostomy in a patient with hemiplegia and recurrent laryngeal nerve palsy]

A 70-year-old man who had undergone a low anterior resection for primary rectal cancer 9 years before complained of anorexia, hemiplegia, and recurrent laryngeal nerve palsy. The anorexia was caused by duodenal stenosis due to swollen lymph nodes, the hemiplegia was caused by a metastatic brain tumor, and the recurrent laryngeal nerve palsy was caused by metastases of the cancer to the mediastinal space. Metastases were also found in the bilateral lungs, liver, ureter, and cervical vertebra. In choosing the anesthesia for the gastrojejunostomy to improve the malnutrition of this patient, we decided, on the basis of the patient's full stomach, malnutrition, hypovolemia, hemiplegia, cerebral compression, recurrent laryngeal nerve palsy, renal dysfunction, and respiratory dysfunction, to use thoracic epidural anesthesia rather than spinal anesthesia or general anesthesia. Thoracic epidural anesthesia could provide sufficient analgesia, and the operation was uneventful. In anesthetic management of an end-stage patient undergoing a palliative operation like this, we should consider the purpose of the operation, its complications, and further complications which may be induced by anesthesia in order to plan out an anesthetic regimen unlikely to lead to harmful events in perioperative period.

[Anesthetic management of a hyper-obese patient by target-controlled infusion (TCI) of propofol and fentanyl]

We gave total intravenous anesthesia to an over-100% hyper-obese patient using target-controlled infusion (TCI) of propofol and fentanyl. To keep him asleep, we maintained his BIS in a range of 40 to 60 by adjusting the target concentration of propofol. For the target concentration of fentanyl, we chose 2 ng.ml-1 at incision and 1.6 ng.ml-1 during the operation. At the patient's emergence from anesthesia, his estimated blood concentration of propofol was 1.51 micrograms.ml-1 and his BIS was 80. The relationship between BIS value and effect-site concentration of propofol was almost the same as that assessed in ordinary adults of a normal weight. We conclude that the estimated concentration of propofol is a good indicator of the effect of propofol and that TCI is a useful technique in obese patients as well as in ordinary adults.

Lactate is correlated with the indocyanine green elimination rate in liver resection for cirrhotic patients

The role of lactate in liver ischemia-reperfusion injury in cirrhosis has not been clarified. Fifty patients with hepatocellular carcinoma who underwent partial liver resection under Pringle's maneuver were included in this study. We performed the indocyanine green clearance test before the operation and three times during the surgery to calculate its elimination rate. Blood lactate and base excess were measured at the corresponding times. Systolic and diastolic systemic arterial pressure, heart rate, cardiac index, and esophageal temperature were monitored. Aminotransferase levels were recorded the day before the operation, 1 h after the operation, and on the first and third postoperative days. We calculated the increase or decrease in lactate levels during the preischemic, ischemic, and postischemic phases, and examined the correlation between these results and the changes in indocyanine green elimination rate and some clinical factors. The lactate levels increased before reperfusion and began to decrease after reperfusion. The lactate increase and decrease during the ischemic and postischemic phases correlated with the change in indocyanine green elimination rate (P < 0.0001 and P = 0.02 for the respective phases). The lactate increase during the preischemic phase correlated with the duration of the preischemic phase (P < 0.0001). In cirrhotic patients who undergo liver resection with Pringle's maneuver and who do not show postoperative liver failure, the blood lactate profile might be a reliable indicator of liver metabolic capacity during surgery.

IMPLICATIONS

In cirrhotic patients who underwent liver resection with Pringle's maneuver, the lactate increase and decrease during the ischemic and postischemic phases correlated with the change in the indocyanine green elimination rate. The blood lactate profile might be a reliable indicator of liver metabolic capacity during surgery.

The analgesic interaction between intrathecal clonidine and glutamate receptor antagonists on thermal and formalin-induced pain in rats

Clonidine, an alpha(2) adrenergic receptor agonist, inhibits glutamate release from the spinal cord. We studied the interaction of intrathecally administered clonidine and glutamate receptor antagonists on acute thermal or formalin induced nociception. Sprague-Dawley rats with lumbar intrathecal catheters were tested for their tail withdrawal response by the tail flick test and paw flinches produced by formalin injection after intrathecal administration of saline, clonidine, AP-5 (a N-methyl-D-aspartate receptor antagonist), or YM872 (an alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid receptor antagonist). The combinations of clonidine and the other two agents were also tested by isobolographic analyses. Motor disturbance and behavioral changes were observed as side effects. The ED(50) values of clonidine decreased from 0.26 microg (tail flick), 0.12 microg (Phase 1) and 0.13 microg (Phase 2) to 0.036 microg, 0.006 microg, and 0.013 microg with AP-5, and 0.039 microg, 0.057 microg, and 0.133 microg with YM872, respectively. Side effects were attenuated in both combinations. In conclusion, spinally administered clonidine and AP-5 or YM872 exhibited potent synergistic analgesia on acute thermal and formalin-induced nociception with decreased side effects in rats.

IMPLICATIONS

Combinations of a spinally administered alpha(2) adrenergic receptor agonist and an a N-methyl-D-aspartate receptor antagonist or an alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid receptor antagonist exhibited potent synergistic analgesia in acute thermal and inflammatory-induced nociception with decreased side effects.

[Evaluation of emergence from total intravenous anesthesia with propofol for long neurosurgery]

In six neurosurgical patients we examined their emergence from more than six hours of total intravenous anesthesia with propofol and fentanyl. The anesthesia was maintained properly with total intravenous anesthesia with propofol and fentanyl without nitrous oxide. We calculated the estimated blood concentration of propofol from the anesthesia record using a three-compartment pharmacokinetic model. The patients were extubated after they had shown good awareness. The average time for extubation was 18 minutes after discontinuation of propofol infusion. The mean estimated concentration of propofol at the extubation was 1.36 micrograms.ml-1 (range: 1.1-1.5 micrograms.ml-1). The estimated emergence times in these cases, also calculated with the pharmacokinetic model, correlated significantly with the time from discontinuation of propofol infusion to the patients' awakening. It was concluded, first, that the estimated concentration of propofol at extubation after long anesthesia was similar to that measured in common cases, and second, that we could reduce the emergence time at the tail end of long-sustained neurosurgery by avoiding the delay in emergence.

[Anesthetic management of a patient with gunshot injury in the neck and the chest]

We present a case of a 27-year-old man with gunshot injury in the neck and the chest. On admission, he had an entry wound in the neck and his chest radiograph showed left hemopneumothorax. Nasal endotracheal intubation and chest drainage were immediately performed. Angiography revealed pseudoaneurysm of the left carotid artery and fistula between the artery and the innominate vein. The patient showed progressive severe facial edema due to the fistula. Anesthesia was induced and maintained with fentanyl and sevoflurane. The carotid artery was repaired with an autologous saphenous vein graft. Although one lung ventilation (OLV) was requested for partial resection of the left lung, replacing the endotracheal tube was impossible due to severe facial edema. OLV was successfully performed by blocking the left main trunchus with a 7 Fr Fogarty catheter placed under fiberscopic monitoring. The patient recovered without any serious complications. Prompt and proper airway management is required in gun shot injury of the neck and chest.

[Preliminary report: the efficacy of clonidine hydrochloride ointment for postherpetic neuralgia]

The combination of clonidine hydrochloride, alpha 2-agonist, and opioid is useful for relieving the pain due to surgical procedures or cancer. The routes of administrations used are intravenous, intramuscular as well as intrathecal, epidural and transmucosal. However, transdermal clonidine has not been reported. We, therefore, investigated the analgesic effect of local administration of clonidine ointment. Ten patients with postherpetic neuralgia (PHN) were selected randomly. They were requested to fill out a questionnaire after applying clonidine ointment (150 micrograms/ointment 1 g) to the painful area. Items included in the questionnaire were: effectiveness, visual analog scale (VAS) before and after the administration of clonidine ointment, onset time, with or without allodynia and effectiveness to allodynia in the former case, side effects, and patients' background. Analysis of the answers indicates that clonidine ointment produced a satisfactory effect in nine patients. Onset time was within a few minutes in most patients. No patients suffered any side effects. Specific mechanism of effectiveness or the site affected has not been confirmed in this study, but considering the quick onset, it is presumed that the site where the ointment was applied was the very site that was affected. Clonidine hydrochloride ointment was effective in relieving the symptoms of PHN.

Attenuation of haemodynamic responses to tracheal intubation by the styletscope

Tracheal intubation often causes a haemodynamic response probably generated by direct laryngoscopy. The StyletScope is a new intubation device that does not require direct laryngoscopy. We prospectively measured haemodynamic changes after tracheal intubation using the StyletScope. The increase of heart rate was less during tracheal intubation with the StyletScope when compared with the Macintosh laryngoscope.

[Efficiency of bispectral index in anesthetic management of a patient with hypothyroidism]

A 72-year-old, female patient with severe hypothyroidism underwent tracheostomy using deltopectral flap. During the anesthetic management, we assessed the hypnotic level using the bispectral index and regulated the dose of general anesthetics to maintain the bispectral index at about 50. The general anesthetics caused a marked cardiovascular depression, but the condition was treatable with the intravenous administration of dopamine. Using these methods, we could anesthetize this patient safely without a prolonged awakening time from general anesthesia. Although the anesthetic requirement for patients with hypothyroidism is generally thought to be decreased, there is no practical index by which we can estimate the optimal dose of anesthetic agents for these patients. This case report shows that the assessment of the hypnotic level by the bispectral index can be utilized as an efficient index to determine the optimal dose of general anesthetics for patients with hypothyroidism.