Effectiveness of patient and staff cohorting to reduce the risk of vancomycin-resistant enterococcus (VRE) acquisition: a retrospective cohort study during a VRE outbreak in Japan

BACKGROUND

Patient and staff cohorting is part of a bundle approach in the response to multi-drug-resistant organisms, but its effectiveness is not fully clarified. This study compared the risks of acquiring vancomycin-resistant Enterococcus faecium (VREfm) at a hospital during a VREfm outbreak based on contact characteristics in order to better understand the effectiveness of cohorting.

METHODS

Exposure came from contact with patients with VREfm (infectors), including existing patients with VREfm and patients who acquired VREfm during the study period. Contact was defined as length of contact time, degree of sharing space, and care by the same nurses as those caring for infectors between January and March 2018. The outcome was VREfm acquisition as determined through monthly stool or rectal screening cultures. Incidence rates were calculated based on contact patterns, and incidence rate ratios (IRRs) were compared.

FINDINGS

Among 272 inpatients (4038 patient-days), 43 patients acquired VREfm with the same or similar pulsotype. Incidence rates were 8.45 per 1000 patient-days when susceptible inpatients were on the same ward as an infector but cared for by different nurses (reference), 16.96 when susceptible inpatients were on the same ward as an infector and cared for by the same nurses [IRR 2.01, 95% confidence interval (CI) 0.62-10.28], and 52.91 when susceptible inpatients shared a room with an infector (IRR 6.26, 95% CI 1.61-35.40).

CONCLUSION

Compared with susceptible inpatients in a different room from infectors and not being cared for by the same nurses, the risk of VREfm acquisition could be six times higher for susceptible inpatients who are in the same room as infectors, and could be double for susceptible inpatients cared for by the same nurses as infectors.

Vba4p, a vacuolar membrane protein, is involved in the drug resistance and vacuolar morphology of Saccharomyces cerevisiae

In the vacuolar basic amino acid (VBA) transporter family of Saccharomyces cerevisiae, VBA4 encodes a vacuolar membrane protein with 14 putative transmembrane helices. Transport experiments with isolated vacuolar membrane vesicles and estimation of the amino acid contents in vacuoles showed that Vba4p is not likely involved in the transport of amino acids. We found that the vba4Δ cells, as well as vba1Δ and vba2Δ cells, showed increased susceptibility to several drugs, particularly to azoles. Although disruption of the VBA4 gene did not affect the salt tolerance of the cells, vacuolar fragmentation observed under high salt conditions was less prominent in vba4Δ cells than in wild type, vba1Δ, and vba2Δ cells. Vba4p differs from Vba1p and Vba2p as a vacuolar transporter but is important for the drug resistance and vacuolar morphology of S. cerevisiae.

Successful control of an outbreak of GES-5 extended-spectrum β-lactamase-producing Pseudomonas aeruginosa in a long-term care facility in Japan

BACKGROUND

Little is known about multidrug-resistant Pseudomonas aeruginosa (MDRP) outbreaks in long-term care facilities (LTCFs).

AIM

To describe an MDRP outbreak in an LTCF and to clarify risk factors for MDRP acquisition.

METHODS

Patients who were positive for MDRP at an LTCF from January 2013 to January 2014 were analysed. A descriptive analysis, a case-control study, and a microbiological analysis were performed.

FINDINGS

A total of 23 MDRP cases were identified, 16 of which were confirmed in sputum samples. Healthcare workers were observed violating hand hygiene procedures when performing oral, wound, and genital care. Nasogastric tube and oxygen mask use was associated with MDRP acquisition in the respiratory tract, which might have been confounded by poor hand hygiene. Sharing unhygienic devices, such as portable oral suction devices for oral care, and washing bottles and ointments for wound and genital care with inadequate disinfection could explain the transmission of MDRP in some cases. Isolates from 11 patients were found to be indistinguishable or closely related by pulsed-field gel electrophoresis and harbouring the blaGES-5 gene. Subsequent enhanced infection control measures were supported by nearby hospitals and a local public health centre. No additional cases were identified for a year after the last case occurred in January 2014.

CONCLUSION

An outbreak of MDRP with an antimicrobial resistance gene, blaGES-5, occurred in a Japanese LTCF. It was successfully controlled by enhanced infection control measures, which neighbouring hospitals and a local public health centre supported.

A combination of ultrasound-guided rectus sheath and transversus abdominis plane blocks is superior to either block alone for pain control after gynecological transumbilical single incision laparoscopic surgery

PURPOSE

To investigate the efficacy of the combination of ultrasound-guided rectus sheath (RS) and transversus abdominis plane (TAP) blocks compared with TAP or RS block alone in gynecological single-incision laparoscopic surgery (SILS).

MATERIALS AND METHODS

Bilateral TAP blocks (Group A, n = 12), TAP and RS blocks (Group B, n = 12), and RS blocks (Group C, n = 12) with 40 ml ropivacaine/patient were performed for ovarian tumor SILS. The analgesic effects were evaluated using a numerical rating scale (NRS) at zero, six, 12, 24, and 48 hours post-surgery.

RESULTS

Umbilical pain on completion of general anesthesia was significantly less frequent in Group B (1/12) than Group A (7/12) (p = 0.03). The postoperative NRS scores were significantly lower in Group B than Group A at zero (p = 0.02) and six (p = 0.03) hours and Group C at zero (p = 0.001), six (p = 0.02), and 12 (p = 0.004) hours.

CONCLUSION

The combination of RS and TAP blocks reduced early postoperative pain compared with RS or TAP block alone for gynecological SILS.

Effectiveness of ultrasound-guided transversus abdominis plane block and rectus sheath block in pain control and recovery after gynecological transumbilical single-incision laparoscopic surgery

PURPOSE

To evaluate the effectiveness of ultrasound-guided transversus abdominis plane (TAP) and rectus sheath (RS) blocks in pain management and recovery after gynecological single-incision laparoscopic surgery (SILS).

MATERIALS AND METHODS

Abilateral TAP block (Group A, n = 9), bilateral TAP and RS blocks (Group B, n = 10), and a bilateral RS block (Group C, n = 9) with 40 ml ropivacaine per patient were conducted in 28 patients undergoing SILS for ovarian tumors. A pain score and walking distance in a 6-minute walk test (6MWT) were examined.

RESULTS

Pain scores were significantly lower on postoperative day (POD) 3 than on POD 1 in Groups B (p = 0.03) and C (p = 0.02). The walking distance on POD 3 was comparable with that before surgery in Group C (p = 0.75), but shorter in Groups A (p = 0.004) and B (p = 0.02).

CONCLUSIONS

The RS block alone was the most effective in relieving pain and accelerating general recovery after gynecological SILS.

NIH3T3 cells overexpressing CD98 heavy chain resist early G1 arrest and apoptosis induced by serum starvation

CD98 is a heterodimeric glycoprotein of 125-kDa, which consists of a 90-kDa heavy chain (hc) subunit and 35-kDa to 55-kDa light chain (lc) subunits. It is strongly expressed on the surface of proliferating normal cells and almost all tumor cells. To investigate the participation of CD98 in cellular proliferation and malignant transformation, we analyzed cell-cycle progression of NIH3T3 clones transfected with cDNA of human CD98hc. Although NIH3T3 and control transfectant cells grown to the subconfluent state were arrested in the G0/G1 phase by serum starvation, considerable portions of CD98hc-transfected cells resided at S and G2/M phases. Under serum-starved and confluent conditions, significant fractions (20-25%) of NIH3T3 and control transfectant cells contained less than 2n content DNA, indicating occurrence of apoptosis, whereas no apoptotic cells were detected in CD98hc-transfectant cells. Under serum-starved conditions, a marked increase in the levels of cyclin D1 and cyclin E and a decrease in p16 were observed in CD98hc-transfectant cells. The reverse was true for NIH3T3 and control transfectant cells. Our results suggest that resistance to G1 arrest and apoptosis by CD98 overexpression are associated with high G1-cyclins and low p16 levels.

Serine racemase binds to PICK1: potential relevance to schizophrenia

Accumulating evidence from both genetic and clinico-pharmacological studies suggests that D-serine, an endogenous coagonist to the NMDA subtype glutamate receptor, may be implicated in schizophrenia (SZ). Although an association of genes for D-serine degradation, such as D-amino acid oxidase and G72, has been reported, a role for D-serine in SZ has been unclear. In this study, we identify and characterize protein interacting with C-kinase (PICK1) as a protein interactor of the D-serine synthesizing enzyme, serine racemase (SR). The binding of endogenous PICK1 and SR requires the PDZ domain of PICK1. The gene coding for PICK1 is located at chromosome 22q13, a region frequently linked to SZ. In a case-control association study using well-characterized Japanese subjects, we observe an association of the PICK1 gene with SZ, which is more prominent in disorganized SZ. Our findings implicating PICK1 as a susceptibility gene for SZ are consistent with a role for D-serine in the disease.

Hippocampal synapsin I, growth-associated protein-43, and microtubule-associated protein-2 immunoreactivity in learned helplessness rats and antidepressant-treated rats

Learned helplessness rats are thought to be an animal model of depression. To study the role of synapse plasticity in depression, we examined the effects of learned helplessness and antidepressant treatments on synapsin I (a marker of presynaptic terminals), growth-associated protein-43 (GAP-43; a marker of growth cones), and microtubule-associated protein-2 (MAP-2; a marker of dendrites) in the hippocampus by immunolabeling. (1) Learned helplessness rats showed significant increases in the expression of synapsin I two days after the attainment of learned helplessness, and significant decreases in the protein expression eight days after the achievement of learned helplessness. Subchronic treatment of naïve rats with imipramine or fluvoxamine significantly decreased the expression of synapsin I. (2) Learned helplessness increased the expression of GAP-43 two days and eight days after learned helplessness training. Subchronic treatment of naïve rats with fluvoxamine but not imipramine showed a tendency to decrease the expression of synapsin I. (3) Learned helplessness rats showed increased expression of MAP-2 eight days after the attainment of learned helplessness. Naïve rats subchronically treated with imipramine showed a tendency toward increased expression of MAP-2, but those treated with fluvoxamine did not. These results indicate that the neuroplasticity-related proteins synapsin I, GAP-43, and MAP-2 may play a role in the pathophysiology of depression and the mechanisms of antidepressants.

Pregnenolone and dehydroepiandrosterone administration in neonatal rats alters the immunoreactivity of hippocampal synapsin I, neuropeptide Y and glial fibrillary acidic protein at post-puberty

It is well documented that neurosteroids administered during the neonatal period influence the development of several brain systems. In our previous study, pregnenolone administered to rats during the neonatal period altered adenosinergic and dopaminergic functions in the striatum and cerebral cortex. The present study examined the effects of the treatment with pregnenolone and dehydroepiandrosterone (DHEA) from the postnatal day (P) 3-P7 on synapsin I (a marker for presynaptic terminals) and glial fibrillary acidic protein (GFAP: a marker for astroglia) levels in the hippocampus of Sprague-Dawley rats at 3 and 7 weeks of age. In addition, neuropeptide Y and dynorphin A immunoreactivity was measured. The administration of pregnenolone and DHEA to neonatal rats significantly altered the expression of synapsin I in the dentate gyrus and CA3 region at post-puberty but not at pre-puberty. A significantly greater expression of GFAP-immunoreactive astrocytes or processes was demonstrated in the pregnenolone- and DHEA-treated groups at both pre-puberty and post-puberty. A significant increase in the number and size of GFAP-immunoreactive astrocytes and in the extension of arborization was seen in the overall hippocampus. The number of neuropeptide Y-positive cells in the hilus region was also significantly increased in the neurosteroid-treated group at post-puberty. No differences were detected in dynorphin A immunoreactivity among the experimental groups. These results of this study suggest that pregnenolone and DHEA play an important role in the development of hippocampus.

Actigraphic assessment of the preoperative hypnotic effects of brotizolam and zopiclone

Brotizolam and zopiclone have a common ability to bind to the benzodiazepine recognition site and have been used as useful preoperative hypnotics. The aim of the present study was the quantitative evaluation of the preoperative hypnotic effects of brotizolam and zopiclone by actigraphy. Forty patients received brotizolam 0.25 mg (group B) or zopiclone 7.5 mg (group Z) in randomized manner at 21:30 on the night before surgery. Sleep and awake was identified by wrist activity measured with a motion-logger actigraph. Sleep time was assessed in total period from 22:00 to 6:00 and its 4 subdivided 2-hour periods (22:00-24:00, 24:00-2:00, 2:00-4:00, 4:00-6:00). The total sleep time in group B (448 +/- 23 min) was significantly longer than that in group Z (416 +/- 43 min). Group Z showed a significant reduction in sleep time in period 4 (4:00-6:00), compared with other periods, whereas group B did not show any difference among 4 periods. In comparison of each period between 2 groups, group B showed significant longer sleep time in period 4. An actigraphic assessment of sleep time has demonstrated the quantitative difference of the effects of brotizolam and zopiclone as preoperative hypnotics.

[An investigation of therapeutic effectiveness and the mechanism of oral appliance therapy on obstructive sleep apnea syndrome]

In order to investigate the effectiveness and the mechanism of action of oral appliances (OA) on obstructive sleep apnea syndrome (OSAS), a series of studies including overnight polysomnography, both ultrafast MRI and measurement of intraesophageal pressure during daytime naps and cephalometric analysis while awakening were performed on 19 OSAS patients before and during the treatment. In all cases, a significantly decreased apnea hypopnea index (AHI), shortened apnea duration, and a significant elevation in the lowest value of nocturnal arterial oxygen saturation, in comparison with the pretreatment values, were recognized during treatment with OA. The number of patients who responded to OA treatment, i.e., those whose AHI decreased by more than 50% of the pretreatment value, was 13 (68.4%). In cases with an AHI of 30 per hour of sleep or more before treatment, the number of arousals decreased and the percentage in stage 3 + 4 increased significantly during the use of OA. Cephalometric analysis revealed the anteroinferior advancement of the mandible, the anterosuperior movement of the hyoid bone and increase of upper airway area with OA in the cases studied. An MRI of the upper airway during sleep showed that glossopharyngeal obstruction disappeared with the use of OA in all cases, and velopharyngeal obstruction disappeared in nearly half of the cases. Moreover, the fluctuation of the intraesophageal pressure during sleep decreased significantly with OA. There were no differences in clinical background (e.g., age, body mass index, pretreatment value of AHI, and upper airway characteristics) in patients who AHI had decreased to less than 50% and those in whom it remained over 50%. These results confirmed the effectiveness of the treatment with OA. OA can be recommended for OSAS patients with not only glossopharyngeal obstruction, but also velopharyngeal obstruction, which is the most common cause of OSAS.

Relationship between hypersomnia and respiratory disorder during sleep in Prader-Willi syndrome

To assess whether hypersomnia in Prader-Willi syndrome (PWS) patients is related to the respiratory disorder during sleep (RDDS), we made a systematic evaluation regarding the relationship between the two disorders in three patients. All patients showed hypersomnia manifested as the long duration of night sleep and shortened sleep latencies of multiple sleep latency test. Although magnetic resonance imaging and laboratory studies revealed obstruction of the upper airway and mild increase of esophageal pressure during sleep, the number of other apneic episodes or awakenings was not as frequent. From the above results, we speculate that the mechanism of excessive daytime sleepiness in PWS is not caused by RDDS and quite resembles that of essential hypersomnia.

Age-specific effects of noradrenergic alpha-2 agonist clonidine on the development of amygdaloid kindling in developing rats

The effects of clonidine on the development of amygdaloid kindling were studied in rats of various ages (14, 21, 28 and 70 postnatal days). Administration of clonidine (0.2, 0.5 mg/kg i.p.) caused a significant retardation of kindling development in the 28-day-old rats as well as in the adult rats, whereas, in the 14-day-old rats, the development of kindling was significantly facilitated by clonidine. No significant effect of clonidine was observed in the 21-day-old rats. These results indicate that in rats the effects of clonidine on the development of amygdaloid kindling vary during development.

Development of computerized screening system for dementia and its preliminary field test

The population of aged persons is increasing along with an extension of the average span of human life. Therefore, the number of persons who suffer from dementing disorders is also increasing. Because the various psychotic symptoms and behavioral problems are frequently observed in persons with dementia, the families taking care of such people require help to reduce their mental and physical load. Therefore, maintenance and enhancement of the social support system for aged persons are urgent issues. Early identification is important because immediate recognition of dementia people and appropriate follow up treatment can prevent the progress of the disease. Clinical interviews are one general method for detecting patients with dementing disorders, and the Hasegawa Dementia Scale is one of the most popular methods in Japan. The test takes about 10 min per person, but it requires a lot of time and burden for medical staff to screen patients with dementia from the increasing number of aged persons. Therefore, new methods for assessing cognitive functions are requested. A computerized assessment system was developed for dementia which is based on the Hasegawa Dementia Scale. This system was designed for aged persons with no previous computer experience to operate easily by making efficient use of multimedia. In this paper, the system and preliminary results of the field-test are reported.

Autonomic function in the early stage of panic disorder: power spectral analysis of heart rate variability

Previous studies of autonomic nervous system (ANS) function in panic disorder (PD) patients have yielded conflicting results. We speculate that these differences might result from the variety of clinical stages of PD. In order to investigate this, we compared ANS activity in untreated patients in the early stage of PD with control subjects using power spectral analysis of electrocardiogram R-R intervals (PSR-R) in supine rest and during head-up tilt, which was performed according to the maximum entropy method (MEM). It recognizes two main components: high-frequency power (HF), which mainly reflects cardiac parasympathetic activity, and low-frequency power (LF), which reflects both cardiac sympathetic and parasympathetic activity. The patients with PD had significantly higher values for all components of PSR-R only in tilt position total power (TP), LF, and HF than did the control subjects (P<0.01, <0.01, <0.02, respectively). However, the LF/HF ratio which indicated sympathovagal balance did not differ significantly between the two groups in tilt position. Our findings suggest that patients with PD in the early stage of illness have co-activation of sympathetic and parasympathetic nervous systems, which might act to maintain a balance between the two autonomic systems.

Postpartum dissecting aneurysm of the superior cerebellar artery--case report

A 37-year-old female with toxemia of pregnancy suffered sudden headache and loss of consciousness on the day following a cesarean delivery. Computed tomography revealed subarachnoid hemorrhage (SAH). Vertebral angiography revealed a fusiform dilatation near the origin of the right superior cerebellar artery (SCA) with distal luminal narrowing. She underwent surgery within 24 hours of the ictus. A SAH clot was carefully removed from the prepontine cistern, and subadventitial discoloration was seen in the wall of the right SCA just distal to the aneurysmal protuberance (rupture site). The dissecting aneurysm was treated with body clipping by directly clipping the rupture site and with additional wrapping of the proximal SCA, including the aneurysmal protuberance and discolored site. The postoperative clinical course was uneventful. Postoperative angiography revealed complete obliteration of the aneurysm and patency of the SCA. Therapeutic intervention should be considered for patients with ruptured dissecting aneurysm who present with recurrent SAH.

Clinical efficacy of prosthetic mandibular advancement on obstructive sleep apnea syndrome

In order to clarify the efficacy and indication of prosthetic mandibular advancement (PMA) on obstructive sleep apnea syndrome (OSAS), we made a comparison of both the polysomnographic findings and the upper airway configuration between before and during PMA on 19 OSAS patients. During PMA, there was a significant decreased apnea hypopnea index compared to before treatment. The changes in magnetic resonance imaging of the upper airway during sleep with PMA indicated that the treatment is regarded to be the first choice for OSAS patients with glossopharyngeal obstruction. In addition to that, the treatment might be considered for use in velopharyngeal obstruction.

Clinical efficacy and indication of acetazolamide treatment on sleep apnea syndrome

The efficacy and indication of acetazolamide treatment on patients with sleep apnea syndrome (SAS) were discussed from assessing the changes of polysomnographic findings with the treatment in 75 SAS patients. For the patients as a whole, respiratory disorder variables improved significantly during the treatment. However, the number of acetazolamide treatment responders who showed a decrease of apnea hypopnea index (AHI) to 50% or less of the pretreatment value numbered only 34 (45.3%). The lower values of body mass index and AHI in the responder group indicated that monotherapy with acetazolamide is the treatment choice only for mild SAS cases without obesity. However, combined treatment with acetazolamide and uvulopalatopharyngoplasty was thought to be beneficial for severe cases.

Treatment of periodic leg movement disorder and restless leg syndrome with talipexole

In order to investigate the bedtime dose of talipexole, a D2 and alpha2 stimulant, on patients with periodic leg movement disorder (PLMD) and restless leg syndrome (RLS), we made a comparison of polysomnographic findings and subjective symptom ratings before and during 4 weeks of the treatment on five cases with RLS and PLMD. A significant decrease in both the frequencies of periodic leg movements and subjective symptom ratings and significant improvement of sleep composition were recognized during the treatment. We speculate that the combination of the agonistic action of D2 and alpha2 receptor with the drug might not only suppress PLMD and RLS but also improve sleep quality.

Mechanism of action and therapeutic indication of prosthetic mandibular advancement in obstructive sleep apnea syndrome

Prosthetic mandibular advancement (PMA) was applied to nine patients with obstructive sleep apnea syndrome (OSAS) and its therapeutic usefulness, mechanism of action, and clinical indication were discussed based on polysomnographic findings and serial examination of upper airway before and during PMA treatment. Apnea hypopnea index significantly decreased during PMA treatment compared with the value before treatment (P < 0.01) and the rate of the treatment responder counted 78.1%. Cephalometric variables indicated forward and inferior advancement of mandible in our subjects. Magnetic resonance imaging of the upper airway during sleep revealed a marked improvement of velophanryngeal obstruction in most subjects. In addition, intraesophageal negative pressure during sleep decreased significantly. Our results confirmed the high therapeutic efficacy of PMA for OSAS and indicated forward advancement of the mandible and decrease of negative pressure loading on upper airway with PMA might suppress velopharyngeal collapse. Thus, PMA was regarded as one of the treatments of choice for OSAS occurring based on with velopharyngeal narrowing.

Plasma concentration of immunoreactive vascular endothelial growth factor and its relation to smoking

We determined the plasma concentration of immunoreactive vascular endothelial growth factor (IR-VEGF) and searched for a relationship between it and the degree of microangiopathy. The plasma VEGF level was measured using an enzyme immunoassay in 110 non-insulin-dependent diabetes mellitus (NIDDM) patients with varying degrees of nephropathy or retinopathy (RP) and in 39 healthy controls and 30 nondiabetic patients for comparison. One fourth of the control subjects, 60% of whom were currently smokers, had plasma levels of IR-VEGF higher than the lower limit (15.6 pg/mL) of detection for this assay, whereas this was the case in half of the NIDDM patients. Plasma IR-VEGF was detectable in all patients with cerebral infarction, chronic renal failure, and severe infection, suggesting that tissue hypoxia might be a common cause for the elevation of plasma VEGF in these disorders. The prevalence of measurable plasma IR-VEGF levels increased in parallel with increases in the urinary albumin excretion rate ([UAER] 35.1% for UAER <30 mg/24 h, 54.8% for UAER 30 to 300 mg/24 h, and 61.3% for UAER >300 mg/24 h; P < .05 v UAER <30 mg/24 h). The mean measurable plasma concentration tended to increase with increasing UAER. However, there was no such correlation with the severity of RP. Smoking caused an acute increase of plasma IR-VEGF in only 22.6% (12 of 53) of the patients with a smoking habit. In conclusion, these findings suggest that circulating IR-VEGF may be linked to the progression of nephropathy, and smoking may facilitate this process by causing tissue hypoxia in susceptible patients.

Glycemic control and prevention of retinopathy in Japanese NIDDM patients. A 10-year follow-up study

OBJECTIVE

To examine glycemic control for the prevention of retinopathy in early diagnosed Japanese NIDDM patients.

RESEARCH DESIGN AND METHODS

There were 137 patients with NIDDM but without retinopathy who first visited our facility from 1983-1985. Their age at diagnosis ranged from 30-65 years, with a disease duration of < 3 years. The optic fundi were examined at least annually. The prevalence of retinopathy in the 10th year after registration in the study was compared in four groups stratified by mean HbA1c values for 10 years. Multiple logistic regression analysis was used to assess the relationship between retinopathy and covariates.

RESULTS

None of the patients with a mean HbA1c < 6% had retinopathy. The prevalence of retinopathy was 17.2% in the group with a mean HbA1c of 6-6.9%, 14.3% in the group with a mean HbA1c of 7-7.9%, 41.9% at a mean HbA1c of 8-8.9%, and 54.8% when the mean HbA1c exceeded 9%. The prevalence of retinopathy increased with the increase in the mean HbA1c values over 10 years (trend, P < 0.005). Multiple logistic regression analysis revealed that mean HbA1c was the only significant risk factor for the development of retinopathy.

CONCLUSIONS

Our results support the concept that an early diagnosis and better control lessen the risk for the development of retinopathy in Japanese NIDDM patients.

[Neonatal apnea after general anesthesia--effects of intraoperative hyperventilation and serum ionized Ca concentration]

The relationship between neonatal apnea following general anesthesia and serum ionized calcium (Ca2+) concentration was examined in 13 neonates who had received intraoperative hyperventilation. In all cases, preoperative serum Ca2+ concentration was within normal limits. The anesthesia was maintained by nitrous oxide and oxygen. At the end of anesthesia, the incidence of abnormal breathing such as apnea, periodic breathing or subcostal retraction and their activity were investigated. Five minutes after intravenous administration of 2% CaCl2 solution (16 mg.kg-1), the same parameters were compared with the values before CaCl2 administration. As we used only Ca2+ free solution for fluid therapy during operation, serum Ca2+ concentration decreased gradually under general anesthesia, but after CaCl2 administration, it increased and the incidence of abnormal breathing decreased. To determine the relationship between hyperventilation and the incidence of abnormal breathing, the data were analyzed by dividing the patients into two groups based on PaCO2 level, a lower PaCO2 group (intraoperative PaCO2 < 30 mmHg, n = 5) and a higher PaCO2 group (PaCO2 > or = 30 mmHg, n = 8). But there was no significant relationship between them. In conclusion, this study demonstrates that the Ca administration has a favorable effect on respiratory system and motor activity, but we cannot relate the incidence of postoperative abnormal breathing to the degree of hyperventilation.

Isolation of a carrot gene expressed specifically during early-stage somatic embryogenesis

We report the first successful isolation by subtractive hybridization of a gene expressed specifically during somatic embryogenesis. Embryogenic cell clusters, 32-50 microns in diameter, were isolated by sieving and density-gradient centrifugation. The cDNA library was constructed from proglobulars which were formed from embryogenic cell clusters 3 days after transfer to auxin-free modified Lin and Staba's medium. For use as probe in screening, the same cDNA used for library construction was enriched for specific sequences using subtractive hybridization. The cDNA used for subtraction was prepared from suspension cultures 5 days after subculturing in auxin-containing medium. Nine independent differentially expressed cDNA clones were obtained from a screen of 150,000 recombinant phages. Northern analysis indicated one of these, CEM6, to be expressed specifically during somatic embryogenesis. In addition, one hybridizing transcript was detected in plantlet cotyledons, and two transcripts were detected in hypocotyls. Two separate and distinct hybridizing transcripts are expressed specifically in hypocotyl tissue. The amino acid sequence deduced from the nucleotide sequence of the CEM6 cDNA indicates that it encodes a glycine-rich protein containing a hydrophobic signal-sequence like domain. Its early embryo-specific expression and sequence characteristics suggest an important role as a cell wall protein in embryogenesis.

Isolation and characterization of homeobox-containing genes of carrot

Homeodomains (HDs) are DNA-binding domains that have been well characterized in animals, and HD proteins are thought to be regulators of transcription. To investigate the regulation of gene expression during somatic embryogenesis in carrot, an attempt was made to isolate cDNA clones that encode HD proteins. A cDNA library from carrot somatic embryos was screened with a degenerate oligonucleotide probe that corresponded to a conserved amino acid sequence of HDs, and one cDNA clone (CHB1) encoding an HD protein was isolated. The amino acid sequence deduced from the nucleotide sequence of this clone contained a putative leucine zipper motif adjacent to the anticipated HD. The homeodomain/leucine zipper (HD-Zip) sequence of this cDNA was used for further screening, and five additional independent clones (CHB2 through CHB6) were isolated. Although the HD-Zip sequences encoded by these clones were similar to each other, the sequences beyond the HD-Zip regions varied greatly. Transcripts corresponding to CHB1 through CHB6 were expressed at different times during somatic embryogenesis. In particular, transcripts corresponding to CHB2 were expressed in close association with the early development of embryos.

Dropout of young non-insulin-dependent diabetics from diabetic care

We investigated the follow-up status and prognosis of 109 patients with non-insulin-dependent diabetes mellitus aged from 10 to 19 years old (66 males and 43 females). Patients who had not attended hospital for at least 20 months up to the end of September 1990 were regarded as defaulters, and were surveyed by questionnaire. There were 62 defaulters (56.9%) among the 109 patients originally enrolled in diabetes care. The defaulters had a significantly higher body mass index (both males and females), mean arterial blood pressure, and fasting blood glucose level than the patients still attending the diabetes clinic, as well as a significantly worse lipid profile. The main reason given for non-attendance was a busy schedule. Compared with patients attending the diabetes clinic, a lower percentage of the defaulters remained on a diet or took regular exercise. Rapid eating was more common among the defaulters than the attendees (92.9% vs. 60%, P = n.s.). Thus, the lifestyle of the defaulters seemed to be undesirable for young diabetic patients. These findings emphasize the importance of effective education and follow-up for young obese patients with non-insulin-dependent diabetes mellitus.

[Two cases of tension pneumothorax caused by tracheal suction during the operation of pectus excavatum]

Rehbein's method is one of the surgical procedures for pediatric pectus excavatum, which constructs thorax by lifting and fixating the sternum using metal strut inserted into bone marrow of bilateral ribs. We experienced two pediatric cases of tension pneumothorax caused by tracheal suctioning during the operation by this method. The etiology of tension pneumothorax was thought to be as follows. A small pleural hole was made during separation of ribs from surrounding tissues and a large amount of air entered into the pleural space and check valve mechanism worked at the pleural hole when the lung was collapsed on tracheal suctioning. In anesthetic management of pectus excavatum by Rehbein's method, we should always be cautious of the possible occurrence of tension pneumothorax.

[The severity of dementia and brainstem auditory evoked potentials--the amplitude of waves I, III and V]

The correlation between the severity of dementia and the amplitudes of brainstem auditory evoked potentials (BAEPs) was studied. The subjects were 78 patients with dementia (20 males, 58 females) whose mean age was 80.5 +/- 6.7 years. Normal subjects were 9 elderly persons (2 males, 7 females) whose mean age was 79.2 +/- 6.0 years. The amplitudes of wave-I, -III and -V were measured. As for individual differences: (1) The amplitudes of BAEPs in the male group were lower than that in the female group, there was no significant difference. (2) The amplitudes of wave-V in female patients with vascular dementia were significantly lower than that of degenerative dementia. (3) The amplitudes of wave-III reduced as the duration of illness prolonged. Dividing the patients into three groups according to the severity of dementia which are mild, moderate and severe. (4) The amplitudes of the wave-V reduced significantly as the severity of dementia advanced. There was a significantly positive correlation between the amplitudes of the wave-V and the Hasegawa's dementia scores (r = 0.404759, p < 0.05) Based upon the above results, the brainstem dysfunction might progress with the severity of dementia.

The role of wet-dog shakes during amygdaloid electrical and methionine-enkephalin kindling in the rat

The role of wet-dog shakes (WDS) in the kindling phenomenon was investigated in the rat using amygdala (AM) electrical kindling (E-K group), methionine-enkephalin (ME) chemical kindling (ME-K group) and ME-chemical kindling after the completion of electrical kindling (E-M group). The AM electrical kindling was carried out with 200 microA stimulation. Repeated microinjections of 10 micrograms ME into the AM were given for ME chemical kindling. EEG and behavioral seizures were recorded from the beginning of the electrical stimulation or ME microinjection to 2 min after the end of the after-discharge (AD). The mean number of WDS in ME-K and E-M groups during the chemical kindling, in contrast to that in E-K group, was significantly decreased as the kindling stages progressed. In the ME-K group, WDS completely disappeared when the stage developed into stage 5. In all the three groups, the maximum incidence of WDS in each stage appeared near the termination of AD, which was accordant with the end of the convulsive seizures. These results suggest that WDS may be associated with the kindling stage and the end of the convulsive seizure or the AD. Furthermore, the disappearance of WDS could be a behavioral index of the fully kindled state in some kinds of kindling models.

A gene expressed preferentially in the globular stage of somatic embryogenesis encodes elongation-factor 1 alpha in carrot

We have isolated cDNA of genes that are preferentially expressed during somatic embryogenesis of carrot (Daucus carota L.) by differential screening of globular embryos and cells that are dividing in an unorganized manner. As a result of Northern-blot analysis, one of the genes identified in this way, which we refer to as CEM1, was found to be expressed at high levels in somatic embryos at the globular and heart-shaped stages. In-situ hybridization using globular embryos revealed that the mRNA transcribed from CEM1 was located preferentially in the spherical region of the globular embryo. A homology search using the amino acid sequence deduced from the nucleotide sequence of the CEM1 cDNA revealed that CEM1 encodes the eukaryotic translational elongation-factor 1 alpha.

[A case of malignant localized visceral pleural mesothelioma]

We experienced malignant localized mesothelioma of which origin was visceral pleura. According to, 1) the preoperative chest X-ray and chest CT which showed extra-pleural sign, 2) the rapid tumor growth, and 3) the result from needle biopsy, we diagnosed malignant localized mesothelioma of which origin was parietal pleura. Surgical treatment was performed, and diagnosed that its origin was visceral pleura. The tumor invaded the lung. It is dangerous to diagnose by means of needle biopsy because of malignant cell implantation. We recommend that firstly the surgical treatment should be carried out for malignant mesothelioma, which needs extended resection for preventing its recurrence.

[Anesthetic management of a neonate with esophageal atresia with double tracheoesophageal fistulae]

We reported the anesthetic management of a 1-day-old female neonate (2,110 gm) with esophageal atresia combined with double tracheoesophageal fistulae, which is classified as Gross type D. Though Gross type C was suspected preoperatively, the proximal fistula was found coincidentally during the preparation of the upper pouch. Because, for one thing, the origin of the proximal fistula was close to the end of the upper pouch (1cm), and for another, the distance between the both fistulae was short (1cm). As for the proximal fistula, it was 2 mm in diameter, and it was easily sealed with the side of the endotracheal tube. No other respiratory managements were needed except frequent suctionings of copious intratracheal secretions. On the other hand, the distal fistula, 10 mm in diameter, caused hypercapnea due to hypoventilation before gastrostomy. It was so big that it is easily intubated. This type of tracheoesophageal fistula is extraordinarily rare and its proximal fistula is difficult to find before, during, and even after operation. The missing of the proximal fistula often provokes severe respiratory infections and furthermore, sepsis postoperatively. It is concluded that in all the cases of tracheoesophageal fistula, the existence of the proximal fistula should be considered without fail and managed accordingly. To diagnose correctly, the use of preoperative bronchofiberscopy is also recommended.

[Serum catecholamine concentrations and hemodynamics during operations on 23 children with neuroblastoma]

The purpose of the present report is to reveal the relation between hemodynamic changes and serum catecholamine concentrations during operation of 23 neuroblastoma patients. The patients were aged from 6 months to 7 years (mean 1.2 year), and 20 patients (86%) were under 1 year of age. All the patients were in early stage of tumor development because they were diagnosed as neuroblastoma mainly by mass screening test for VMA and HVA in urine utilizing HPLC. This urinary mass screening test for infants is performed routinely in Japan. Operative manipulation of tumor provoked the significant elevation of blood pressure, and the increasing tendency of heart rate and rectal temperature. The mean concentrations of three kinds of serum catecholamine, epinephrine, norepinephrine and dopamine, were all very high during manipulation of tumor. Especially, the norepinephrine concentration was 90.2 times higher than the preoperative value. The children who showed high blood pressure, over 70% of the control level, showed high urinary VMA and VMA/HVA ratio preoperatively and a high norepinephrine secretion during operation. We conclude that for the anesthetic management of neuroblastoma, it is necessary to control the elevation of blood pressure even in small children, especially in the patients who have showed high values of urinary VMA and VMA/HVA ratio preoperatively.

[The severity of dementia and brainstem auditory evoked potentials--peak latency and interpeak latency]

We have examined the correlation of dementia severity and brainstem auditory evoked potentials. The subjects were 80 patients with dementia (20 males, 60 females) whose mean age was 80.7 years. Normal controls were 9 elderly subjects (2 males, 7 females) whose mean age was 80.4 years. The following parameters were measured: peak latencies (I, III and V), interpeak latencies (I-III, III-V and I-V) and interaural latency differences (V PLDs and I-V IPLDs). As for clinical items and sex differences; (1) There were sex differences recognized between peak latency of III and V, interpeak latency of III-V and I-V. (2) There was a significant difference in interaural differences of V PL Ds between vascular dementia and degenerative dementia (dementia of the Alzheimer's type and Parkinson's disease). Duration of illness had no correlation with latencies of BAEPs. Dividing the patients into three groups according to the severity of dementia which are mild, moderate and severe, (3) peak latency of III, V and interpeak latency of I-III, III-V, I-V and interaural latency differences of V PL Ds prolonged significantly with the increasing severity of dementia. From these results, it is suggested that brainstem dysfunction progresses with the increasing severity of the dementia.

Population study on the adipose tissue distribution in Japanese women born in 1948

We examined the relationship between body fat distribution and glucose metabolism and sex hormones in Japanese premenopausal women born in 1948. 1. There was a significant positive correlation shown between the waist circumference or skinfolds of the upper body, and the fasting insulin and C-peptide levels. 2. A positive correlation was seen between W2-3/H, and both insulin (r = 0.29, 0.30, P less than 0.05) and C-peptide levels (r = 0.40, 0.33, P less than 0.01, 0.05). 3. A significant negative correlation was seen between the SHBG level, and BMI (r = -0.39, p less than 0.01), W3/H (r = -0.46, P, 0.01), insulin (r = -0.28, P less than 0.05), and C-peptide (r = -0.46, P less than 0.01). 4. A significant negative correlation was seen between SHBG and W3/H (r = -0.31, P less than 0.05) after adjustment for BMI. These results suggest that the association of body fat distribution and glucose metabolism and androgeneity even if taking account of BMI, exists in non-obese women.

Adverse effects of obesity on lipid and lipoprotein levels in the patients with non-insulin dependent diabetes in the young

We studied the association of obesity with serum lipid and lipoprotein concentrations in 117 patients (62 males and 55 females) with NIDDY and in 40 nondiabetic control subjects (21 males and 19 females). Obesity at a young age was related to increased lipid and lipoprotein levels both in the patients with NIDDM and the control group. Moreover, low HDL-c levels were aggravated by diabetic status only in males. The BMI and fasting insulin level had a statistically significant correlation with the TG and HDL-c level and various atherogenic factors. Therefore, it is suggested that the lipid abnormalities seen in obesity may be associated with hyperinsulinemia. We conclude that obesity in adolescence leads to aberrations of the serum lipid and lipoprotein levels, particularly in obese males with NIDDY.