SYNTAX Score and 1-Year Outcomes in the OPTIVUS-Complex PCI Study Multivessel Cohort

BACKGROUND

The optimal revascularization strategy in patients with multivessel disease and intermediate SYNTAX score (SS) has not been fully elucidated. This study aimed to investigate the clinical outcomes of optimal intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) stratified by SS.

METHODS

This was a substudy of the OPTIVUS-Complex PCI study Multivessel Cohort, which aimed to meet the prespecified criteria for optimal stent expansion after IVUS-guided PCI. A total of 1,005 patients were divided into 3 groups according to SS: low, ≤22; intermediate, 23 to 32; and high, ≥33. The primary end points were major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of death, myocardial infarction, stroke, or coronary revascularization.

RESULTS

The cumulative 1-year incidence of the primary end point was significantly higher in patients with high SS than in those with intermediate or low SS (25.0%, 10.9%, and 9.5%, respectively; p = 0.003). This difference was mainly caused by the incidence of coronary revascularization. In the multivariable Cox proportional hazards models, the excess risk of patients with high versus low SS remained significant for the primary end point (hazard ratio 3.19, 95% confidence interval 1.65 to 6.16, p <0.001), whereas the excess risk of patients with intermediate versus low SS was no longer significant (hazard ratio 1.20, 95% confidence interval 0.72 to 2.01, p = 0.46).

CONCLUSIONS

After IVUS-guided multivessel PCI, patients with intermediate SS had a similar 1-year risk of MACCE to that of patients with low SS, whereas patients with high SS had a higher 1-year risk of MACCE than those with low SS.

Sex Differences in Long-Term Clinical Outcomes in Patients With Atrial Fibrillation Undergoing Coronary Stent Implantation

BACKGROUND

Patients with concomitant atrial fibrillation (AF) and coronary stenting are at high risk for both cardiovascular and bleeding events. We aimed to evaluate the influence of sex on long-term clinical outcomes in this patient subset.Methods and Results:We identified 1,450 patients with AF and coronary stenting in a patient-level pooled database from 3 Japanese studies, and compared 3-year clinical outcomes between men and women (n=1,075, and n=375, respectively). The cumulative 3-year incidence of all-cause death was significantly higher in women than in men (26.5% vs. 17.2%, log-rank P<0.001), although after adjusting for confounders, the excess mortality risk of women relative to men was no longer significant (hazard ratio (HR): 1.12, 95% confidence interval (CI): 0.85-1.46, P=0.42). There were no significant differences in the adjusted 3-year risks for myocardial infarction or stroke between men and women (HR: 1.25, 95% CI: 0.62-2.40, P=0.52, and HR: 1.15, 95% CI: 0.75-1.74, P=0.52, respectively). However, both the cumulative 3-year incidence of and adjusted risk for major bleeding were significantly higher in women than in men (17.0% vs. 11.3%, log-rank P=0.002, and HR: 1.47, 95% CI: 1.03-2.07, P=0.03).

CONCLUSIONS

Among patients with concomitant AF and coronary stenting, there were no significant differences in the adjusted 3-year risks for all-cause death, myocardial infarction, and stroke between men and women. However, women as compared with men were associated with excess adjusted risk for major bleeding.

Hydrogen sulfide donor micelles protect cardiomyocytes from ischemic cell death

Hydrogen sulfide, an important gaseous signaling molecule in the human body, is known to protect cardiomyocytes from ischemia, a condition characterized by insufficient oxygen supply to the cells. Here we show that a nanosized H₂S donor micelle releases H₂S intracellularly and prevents cardiomyocyte apoptosis in an in vitro ischemia model.

The Frictional Coefficient of the Temporomandibular Joint and Its Dependency on the Magnitude and Duration of Joint Loading

In synovial joints, friction between articular surfaces leads to shear stress within the cartilaginous tissue, which might result in tissue rupture and failure. Joint friction depends on synovial lubrication of the articular surfaces, which can be altered due to compressive loading. Therefore, we hypothesized that the frictional coefficient of the temporomandibular joint (TMJ) is affected by the magnitude and duration of loading. We tested this by measuring the frictional coefficient in 20 intact porcine TMJs using a pendulum-type friction tester. The mean frictional coefficient was 0.0145 (SD 0.0027) after a constant loading of 50 N during 5 sec. The frictional coefficient increased with the length of the preceding loading duration and exceeded 0.0220 (SD 0.0014) after 1 hr. Application of larger loading (80 N) resulted in significantly larger frictional coefficients. In conclusion, the frictional coefficient in the TMJ was proportional to the magnitude and duration of joint loading.

Shear Properties of the Temporomandibular Joint Disc in Relation to Compressive and Shear Strain

Shear stress can result in fatigue, damage, and irreversible deformation of the temporomandibular joint disc. Insight into the dynamic shear properties of the disc may give insight into the mechanism inducing tissue failure due to shear. We tested the hypothesis that the dynamic shear properties of the disc depend on the amount of shear and compressive strain. Twenty-four porcine discs were used for dynamic shear tests. The specimens were clamped between the plates of a loading apparatus under compressive strains of 5%, 10%, and 15%. Dynamic shear was applied to the specimen by a sinusoidal strain of, respectively, 0.5%, 1.0%, and 1.5%. Both the dynamic elasticity and viscosity were proportional to compressive strain and inversely proportional to shear strain. These shear characteristics suggest a significant role of compressive and shear strain on the internal friction of the disc.

A comprehensive search for mutations in the PKD1 and PKD2 in Japanese subjects with autosomal dominant polycystic kidney disease

To elucidate the genotypic and phenotypic characteristics of autosomal dominant polycystic kidney disease (ADPKD) in Japanese populations, we performed a comprehensive search for mutations in PKD1 and PKD2 in 180 Japanese ADPKD patients from 161 unrelated families. We identified 112 (89 PKD1 and 23 PKD2) mutations within 135 families. Patients with PKD2 mutations account for 23.6% of all Japanese ADPKD families in this study. Seventy-five out of the 112 mutations have not been reported previously. The estimated glomerular filtration rate (eGFR) decline was significantly faster in patients with PKD1 mutations than in those with PKD2 mutations (-3.25 and -2.08 ml min(-1)  year(-1) for PKD1 and PKD2, respectively, p < 0.01). These results indicate that mutations within PKD1 and PKD2 can be linked to most of the cases of Japanese ADPKD, and the renal function decline was faster in patients with PKD1 mutations than in those with PKD2 mutations also in the Japanese ADPKD. We also found that PKD2 mutations were more frequent in Japanese ADPKD than that in European or American ADPKD.

Transient decreases in Bispectral Index without associated changes in the level of consciousness during photic stimulation in an epileptic patient

This case report describes a patient with a history of epileptic seizures who showed unusual decreases in the Bispectral Index (BIS) attributable to the induction of abnormal slow electroencephalographic (EEG) waves by photic stimulation, without any associated decrease in his level of consciousness. After starting anticonvulsive therapy, photic stimulation no longer induced abnormal EEG activity nor decreased BIS values. These findings suggest that BIS values may not accurately reflect a patient's actual level of consciousness in the presence of epilepsy-related abnormal EEG activity and that the BIS monitor may be able to track such EEG changes.

Transition of mouse de novo methyltransferases expression from Dnmt3b to Dnmt3a during neural progenitor cell development

Dnmt3a and Dnmt3b, which are known as functional de novo methyltransferases, are responsible for creating genomic methylation patterns during mammalian development. Recently, we have shown that specific expression of Dnmt3b in epiblast, embryonic ectoderm, hematopoietic progenitor cells and spermatogonia cells is followed by Dnmt3a expression (Watanabe D, Suetake I, Tada T, Tajima S (2002) Stage- and cell-specific expression of Dnmt3a and Dnmt3b during embryogenesis. Mech Dev 118:187-190; Watanabe D, Suetake I, Tajima S, Hanaoka K (2004) Expression of Dnmt3b in mouse hematopoietic progenitor cells and spermatogonia at specific stages. Gene Expr Patterns 5:43-49). In this study, we analyzed the expression of mouse de novo methyltransferases during development of the nervous systems. In the embryonic olfactory epithelium (OE), Dnmt3b was specifically expressed in Mash1 positive globose basal cells (i.e. transiently amplifying neural progenitor cells), while Dnmt3a was expressed in immature olfactory receptor neurons. Dnmt3b-positive cells were rarely observed in the adult OE, but were increased in regenerating OE with intranasal ZnSO(4) administration. Dnmt3b was also detected in the E8.5 neural plate, E10.5 spinal cord and retina cells, while Dnmt3a was expressed in postmitotic young neurons. Furthermore, Dnmt3b was specifically expressed in ES cells, while Dnmt3a was transiently expressed during neural cell differentiation of ES cells. Dnmt3b is specifically expressed in progenitor cells during hematopoiesis, spermatogenesis and neurogenesis, suggesting an important role in the initial steps of progenitor cell differentiation. Dnmt3a is expressed in postmitotic young neurons following the Dnmt3b expression. Dnmt3a may be required for the establishment of tissue-specific methylation patterns of the genome. The coordinated expression of de novo methyltransferases from Dnmt3b to Dnmt3a suggests conserved mechanisms of de novo methylation of the genome and different functions for Dnmt3b and Dnmt3a during progenitor cell development.

[Anesthesia for thoracic surgery in elderly patients]

Aging and advances in medical technology have lead to a rise in the number of patients of advanced age undergoing surgery. This is also observed in thoracic surgery. Aging itself is not a disease, but it is one of the risk factors of perioperative complications. Individual assessment of patients is required to ascertain the organ system capacity and functional reserve. The management of anesthesia is based on the characteristic changes in the elderly, related to physiology and pharmacokinetics, taking account of possible perioperative complications.

Load independence of temperature-dependent Ca2+ recirculation fraction in canine heart

Intramyocardial Ca(2+) recirculation fraction (RF) critically determines the economy of excitation-contraction coupling. RF is obtainable from the exponential decay of the postextrasystolic potentiation of left ventricular (LV) contractility. We have shown that RF remains unchanged despite increasing LV volume (LVV) at normothermia, but decreases with increasing temperature at a constant LVV. However, it remains unknown whether the temperature-dependent RF was not due to the simultaneously changed peak LV pressure (LVP) at a constant LVV. We hypothesized that this temperature-dependent RF would be independent of the simultaneous change in LVP. We used nine excised, cross-circulated canine hearts and allowed their LVs to contract isovolumically. During stable regular beats at 500 msec intervals, we inserted an extrasystolic beat at 360 msec interval followed by the postextrasystolic beats (PESs) at 500 msec intervals. We equalized the temperature-dependent peak LVPs of the regular beats at 36 degrees C and 38 degrees C to the peak LVP level of the stable regular beat at 33 degrees C by adjusting LVV. We fitted the same equation: nEmax = a.exp[-(i - 1)/tau(e)] + b.exp[-(i - 1)/tau(s)]cos[pi(i - 1)] + 1, used before to the normalized Emax (maximum elastance) values of PESi (i = 1-6) relative to the regular beat Emax. RF given by exp(-1/tau(e)) decreased by 19% to 38 degrees C from 33 degrees C. The temperature coefficient (Q(10)) of 1/RF was significantly greater than 1.3. The present results indicated a similar temperature dependence of RF and its Q(10) to those we observed previously without equalizing peak LVP. Thus, the temperature-dependent RF is independent of ventricular loading conditions.

Is the ARX index a more sensitive indicator of anesthetic depth than the bispectral index during sevoflurane/nitrous oxide anesthesia?

BACKGROUND

During general anesthesia, hypnotic components have been monitored with electroencephalogram. The bispectral index is derived from a cortical electroencephalogram, but the A-line ARX index is the electroencephalographic response to auditory stimuli. The purpose of this study was to compare the changes of the A-line ARX index and the bispectral index during sevoflurane - nitrous oxide anesthesia.

METHODS

One hundred females aged 30-60 years, and scheduled for partial mastectomy, were divided into two groups. Anesthesia was induced with sevoflurane 5% and nitrous oxide in oxygen for 3 min. A laryngeal mask airway was inserted, and anesthesia was maintained with sevoflurane 1-2% and nitrous oxide in oxygen. During surgery, the sevoflurane end-tidal concentration was kept at 0.5%, 1%, or 2% for 5 min before each measurement. Blood pressure, heart rate, and the A-line ARX index (n = 50), and the bispectral index (n = 50) were measured.

RESULTS

Blood pressure and heart rate increased following laryngeal mask airway insertion and blood pressure decreased at 2% sevoflurane in both groups similarly. The A-line ARX index, but not the bispectral index, increased significantly by laryngeal mask airway insertion and skin incision. The A-line ARX index decreased at 2% sevoflurane compared with 0.5%, while the bispectral index remained unchanged.

CONCLUSION

During sevoflurane-nitrous oxide anesthesia, the A-line ARX index might be a more sensitive indicator of anesthetic depth than the bispectral index.

Cerebral ischaemia during cardiac surgery in children detected by combined monitoring of BIS and near-infrared spectroscopy

BACKGROUND

Children frequently suffer transient cerebral ischaemia during cardiac surgery. We measured cerebral ischaemia in children during cardiac surgery by combining two methods of monitoring.

METHODS

We studied 65 children aged between 5 months and 17 yr having surgery to correct non-cyanotic heart disease using hypothermic cardiopulmonary bypass (CPB). During surgery, we measured the Bispectral Index (BIS) and regional cerebral haemoglobin oxygen saturation (SrO2) with near-infrared spectroscopy (NIRS). Cerebral ischaemia was diagnosed if both SrO2 and BIS decreased abruptly when acute hypotension occurred. In each patient, the relationship between SrO2 and arterial blood pressure (AP) was indicated by a plot of mean SrO2 against simultaneous mean AP.

RESULTS

We noted 72 episodes of cerebral ischaemia in 38 patients. Sixty-three ischaemic events were during CPB. Cerebral ischaemia was less frequent in older patients. Cerebral ischaemia was more common and more frequent in children under 4 yr old. Haematocrit during CPB was lower and SrO2 was more dependent on AP in children under 4 yr.

CONCLUSIONS

Children less than 4 yr of age are more likely to have cerebral ischaemia caused by hypotension during cardiac surgery. Ineffective cerebral autoregulation and haemodilution during CPB may be responsible.

Usefulness of epidural anesthesia in gynecologic laparoscopic surgery for infertility in comparison to general anesthesia

BACKGROUND

Although the advantages of epidural anesthesia in open surgery have been established, its usefulness in the setting of laparoscopic surgery remains to be studied.

METHODS

Patients undergoing laparoscopic surgery for infertility were randomly administered epidural anesthesia (group A, n = 11) or general anesthesia (group B, n = 9). The operation was performed under 4 mmHg pneumoperitoneum and in the 20 degrees Trendelenburg position. Respiratory function tests using a spirometer and blood gas analysis were performed during the intra- or perioperative period. Pain status was evaluated with visual analog scale scoring. The number of postoperative recovery days needed to resume daily activities was obtained by a questionnaire.

RESULTS

Respiratory rate, minute volume, P(a)CO2, % vital capacity (VC), and forced expiratory volume in 1 s (FEV1) % were virtually constant throughout the study period in group A, whereas %VC was decreased immediately after operation in group B (p < 0.05). Minute volume immediately after operation was significantly increased in group B compared with group A (p < 0.01), suggesting shallow respiration in women undergoing general anesthesia. Observed pain scores on abdominal pain, shoulder pain, and dyspnea were very low during operation in group A. Pain scores immediately and 3 h after operation were also minimal in group A, whereas abdominal pain scores at these points were significantly higher in group B than those in group A (both p < 0.01). The number of days required for a half reduction in wound pain, trotting, and full recuperation for group A were less than those for group B (p < 0.05).

CONCLUSIONS

Epidural anesthesia, when used in laparoscopic surgery for infertility treatment, has advantages over general anesthesia in terms of analgesic effects, postoperative respiratory function, and a return to preoperative daily activities.

Self-reported recovery time of daily activity after bone marrow harvesting from healthy donors

PURPOSE

The study was planned to describe and compare the resumption of daily activity after bone marrow harvesting (BMH) under general anesthesia with different anesthetic agents, isoflurane, sevoflurane and propofol.

METHODS

Sixty-five adult healthy allogenic donors (26 women, 39 men; 37.0 +/- 9.5 years of age; ASA class I or II) were studied. BMH was performed under general anesthesia with isoflurane, sevoflurane, or propofol as the main anesthetic agent. On day 1, donors were asked how soon they could resume five daily activities: talking, walking, drinking, eating, and reading.

RESULTS

Although there was considerable variation in resumption time within and among these five activities, 77% of donors resumed all of these basic daily activities within 12 h after BMH. Donors who received propofol resumed talking significantly faster than those who received sevoflurane or isoflurane, but the choice of main anesthetic agent did not affect the time of resumption of other activities. Lower preoperative hemoglobin concentration and greater decline of hemoglobin concentration on day 1 were significantly associated with slower resumption of walking and reading.

CONCLUSION

Although the choice of main anesthetic agent and anemia affected postoperative recovery, 77% of donors could resume these five daily activities within 12 h.

Detection of cerebral hypoperfusion with bispectral index during paediatric cardiac surgery

BACKGROUND

The bispectral index (BIS) may indicate changes in cerebral activity when the cerebral circulation is affected by acute hypotension.

METHODS

We measured BIS and cerebral haemoglobin saturation (Sr(O(2))) by near-infrared spectroscopy in 10 children undergoing cardiac surgery.

RESULTS

We noted 14 episodes of simultaneous decreases in Sr(O(2)) and BIS during acute hypotension in five children. An acute decrease in BIS, which coincided with a decrease in Sr(O(2)) suggesting a reduction in cerebral blood flow, was associated with acute slowing of the raw EEG waveforms.

CONCLUSIONS

Our findings suggest that an acute decrease in BIS during acute hypotension indicates cerebral hypoperfusion, and that cerebral hypoperfusion caused by hypotension may occur frequently during paediatric cardiac surgery.

Dynamic shear properties of the temporomandibular joint disc

Shear stress might be an important factor associated with fatigue failure and damage of the temporomandibular joint disc. Little information, however, is available on the dynamic behavior of the disc in shear. Since the disc is an anisotropic and viscoelastic structure, in the present study the dependency of the dynamic shear behavior on the direction and frequency of loading was examined. Ten porcine discs were used for dynamic shear tests. Shear stress was applied in both anteroposterior (A-P test) and mediolateral (M-L test) directions. The dynamic moduli increased as the loading frequency increased. The dynamic elasticity was significantly larger in the A-P test than in the M-L test, although the dynamic viscosity was similar in both tests. The present results suggest that non-linearities, compression/shear coupling, and intrinsic viscoelasticity affect the shear material behavior of the disc, which might have important implications for the transmission of load in the temporomandibular joint.

Association of HLA-A*3303-B*4403-DRB1*1302 haplotype, but not of TNFA promoter and NKp30 polymorphism, with postherpetic neuralgia (PHN) in the Japanese population

Herpes zoster is a common disease caused by reactivation of the varicella zoster virus (VZV). In a small number of herpes zoster patients, pain persists beyond 4 weeks or more after healing of vesicular eruptions; this condition is termed postherpetic neuralgia (PHN). Positive associations of human histocompatibility leukocyte antigens (HLA) class I antigens, A33 and B44, with PHN in the Japanese population have been reported. Our hypothesis is that susceptibility genes to PHN might exist in the HLA region and the study objective is to further examine possible associations of genes in HLA class I, II and III regions, HLA-A, -B, -DRB1, tumor necrosis factor alpha (TNFA) promoter, and a natural killer cell activating receptor, NKp30 polymorphisms with PHN. Although TNFA or NKp30 in the class III region had been considered as a candidate locus, we found no associations of TNFA promoter or NKp30 polymorphisms with PHN in this study. We demonstrated that HLA-A*3303, -B*4403 and -DRB1*1302 alleles were significantly associated with PHN (P = 0.0007 for A*3303, P = 0.001 for B*4403 and P = 0.001 for DRB1*1302). The frequency of the HLA-A*3303-B*4403-DRB1*1302 haplotype was also significantly higher in the PHN patients than in the healthy controls (P = 0.0039). Our results suggest that this haplotype might be related to the pathogenesis of PHN.

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.