Relationship between critical care nutrition and post-intensive care syndrome in surviving ventilated patients with COVID-19: a multicenter prospective observational study

The impact of nutrition therapy in the acute phase on post-intensive care syndrome (PICS) remains unclear. We conducted a multicenter prospective study on adult patients with COVID-19 who required mechanical ventilation for more than three days. The questionnaire was mailed after discharge. Physical PICS, defined as less than 90 points on the Barthel index (BI), was assigned as the primary outcome. We examined the types of nutrition therapy in the first week that affected PICS components. 269 eligible patients were evaluated 10 months after discharge. Supplemental parenteral nutrition (SPN) >400 kcal/day correlated with a lower occurrence of physical PICS (10% vs 21.92%, p = 0.042), whereas the amounts of energy and protein provided, early enteral nutrition, and a gradual increase in nutrition delivery did not, and none correlated with cognitive or mental PICS. A multivariable regression analysis revealed that SPN had an independent impact on physical PICS (odds ratio 0.33, 95% CI 0.12-0.92, p = 0.034), even after adjustments for age, sex, body mass index and severity. Protein provision ≥1.2 g/kg/day was associated with a lower occurrence of physical PICS (odds ratio 0.42, 95% CI 0.16-1.08, p = 0.071). In conclusion, SPN in the acute phase had a positive impact on physical PICS for ventilated patients with COVID-19.

Relation between nutrition therapy in the acute phase and outcomes of ventilated patients with COVID-19 infection: a multicenter prospective observational study

BACKGROUND

Optimal nutrition therapy has not yet been established for the acute phase of severe coronavirus disease 2019 (COVID-19) infection.

OBJECTIVES

We aimed to examine the effects of nutrition delivery in the acute phase on mortality and the long-term outcomes of post-intensive care syndrome (PICS).

METHODS

A multicenter prospective study was conducted on adult patients with COVID-19 infection requiring mechanical ventilation during an intensive care unit (ICU) stay. Daily total energy (kcal/kg) and protein (g/kg) deliveries in the first week of the ICU stay were calculated. The questionnaire for PICS evaluation was mailed within a median of 6 mo after hospital discharge. The primary outcome was in-hospital mortality, and secondary outcomes were the PICS components of physical impairment, cognitive dysfunction, and mental illness.

RESULTS

Among 414 eligible patients, 297 who received mechanical ventilation for 7 d or longer were examined. PICS was evaluated in 175 patients among them. High protein delivery on days 4-7 correlated with a low in-hospital mortality rate. In contrast, high protein delivery on days 1-3 correlated with physical impairment. A multivariate logistic regression analysis adjusted for age, sex, BMI, and severity revealed that average energy and protein deliveries on days 4-7 correlated with decreased in-hospital mortality (OR: 0.94; 95% CI: 0.89, 0.99; P = 0.013 and OR: 0.40; 95% CI: 0.17, 0.93; P = 0.031, respectively). Nutrition delivery did not correlate with PICS outcomes after adjustments. In the multivariate regression using a restricted cubic spline model, in-hospital mortality monotonically decreased with increases in average nutrition delivery on days 4-7.

CONCLUSIONS

In patents with COVID-19 on mechanical ventilation for ≥7 d, nutrition delivery in the late period of the acute phase was monotonically associated with a decrease in in-hospital mortality. Adequate protein delivery is needed on days 4-7.This trial was registered at https://www.umin.ac.jp as UMIN000041276.

Usefulness of INTELLiVENT-ASV for postoperative ventilator-associated pneumonia: a case report

Background

INTELLiVENT®-ASV (iASV) is a respiration mode on the Hamilton G5. The ventilator uses a closed-loop mechanism that automatically adjusts settings related to oxygenation and ventilation.

Case presentation

A 47-year-old man underwent reconstruction surgery with free musculocutaneous flap for tongue resection. After surgery, the patient entered the ICU, and the iASV, which automatically changed only the percent minute volume (%MV) in respiration mode, was selected. On the second day, ventilator-associated pneumonia (VAP) was diagnosed, and the antibiotic treatment was changed. Using the settings of the iASV, automated FiO2 and positive end-expiratory pressure (PEEP) control were added to the ventilator mode. The patient’s oxygenation was improved.

Conclusions

In a patient who developed VAP after surgery, ventilation was continued using iASV, and automated changes in PEEP and FiO2 settings were successfully made according to the open lung strategy, under short-staffed circumstances.

Effects of pre-surgical nasoalveolar moulding on maxillary arch and nasal form in unilateral cleft lip and palate before lip surgery

OBJECTIVES

To investigate the effects of pre-surgical nasoalveolar moulding (PNAM) on the maxillary arch and nasal form in patients with unilateral cleft lip and palate (UCLP).

SETTING AND SAMPLE POPULATION

This is a retrospective case series study. The subjects were infants with complete UCLP who were treated with PNAM (n = 18) at Kagoshima University Medical and Dental Hospital (Japan) between 2006 and 2013.

MATERIAL AND METHODS

Maxillary dental casts and facial photographs were taken at the time of the first visit and immediately prior to lip surgery to evaluate the maxillary arch and nasal form changes. The dental casts were scanned with a laser scanner, and changes in the 3-Dimensional coordinates of anatomical landmarks and alveolar cleft width were analysed. Moreover, we investigated the correlation between the changes in the maxillary alveolar arch and nasal form.

RESULTS

Regarding the maxillary alveolar arch form, the anterior points of the major segment had moved significantly to the cleft side just prior to the time of lip repair, and the alveolar cleft width was significantly decreased. For nasal form, the inclination and displacement of the columella were significantly improved. The improvement of columella inclination was moderately correlated with the posterior movement of the anterior points of the major segment.

CONCLUSIONS

These findings indicate that PNAM for infants with UCLP enhanced symmetry in the maxillary alveolar arch and nasolabial form. In addition, the posterior movement of the anterior points of the maxillary alveolar arch was correlated with the improvement of columella deformation.

Colonoscopic features and malignant potential of sessile serrated adenomas: comparison with other serrated lesions and conventional adenomas

AIM

Sessile serrated adenomas/polyps (SSA/Ps) have been proposed as precursors of colorectal cancer. The aims of this investigation were to compare the endoscopic findings of SSA/Ps with those of other serrated lesions and to compare the histological findings of SSA/Ps with those of conventional adenomas.

METHOD

We retrospectively reviewed colonoscopy records at our institution from 1984 to 2013 and identified cases of endoscopically or surgically resected conventional adenomas and serrated lesions, including SSA/Ps, hyperplastic polyps (HPs) and traditional serrated adenomas (TSAs). The colonoscopic findings of SSA/Ps were compared with those of the other two serrated lesions and histological findings were compared among all groups of lesions.

RESULTS

There were 79 HPs in 68 patients, 77 SSA/Ps in 63 patients, 167 TSAs in 145 patients and 6324 conventional adenomas in 4129 patients. The inverted type and flat-elevated type were more frequent among SSA/Ps than among the other two types of serrated lesions. Magnifying colonoscopy revealed that a round and open pit pattern, expanded crypt openings and varicose microvascular vessels were more frequently observed among SSA/Ps than among the other types. The incidence of high-grade dysplasia or carcinoma among SSA/Ps (13.0%) was significantly higher than that among HPs (0%, P < 0.001) and equivalent to that among conventional adenomas (12.3%).

CONCLUSION

SSA/Ps have colonoscopic features distinct from those of HPs and TSAs. The malignant potential of SSA/Ps seems to be equal to that of conventional adenomas.

Acute respiratory distress syndrome due to Strongyloides stercoralis infection in a patient with cervical cancer

A 62-year-old woman complained of diarrhea and vomiting after receiving chemotherapy for cervical cancer in association with high doses of corticosteroids. Two months later, the patient developed acute respiratory distress syndrome, and numerous Strongyloides stercoralis parasites were found in the intrabronchial discharge. Ivermectin was administered daily until nematodes were no longer detected in the sputum, and the patient's condition was successfully rescued. Antibodies for human T-cell lymphotropic virus-1 (HTLV-1) were positive. HTLV-1 infection and the administration of corticosteroids are known risk factors for strongyloides hyperinfection syndrome. Therefore, physicians should consider this disease in the differential diagnosis of patients from endemic areas who present with gastrointestinal symptoms under these risk factors.

A Japanese pediatric patient with coexisting systemic lupus erythematosus and familial Mediterranean fever

This case report describes a Japanese girl with systemic lupus erythematosus who had recurrent fevers and erythema nodosum. She was later found to carry the complex allele E148Q/R202Q/P369S/R408Q of MEFV, the gene responsible for familial Mediterranean fever.

Vascular hyperpermeability in pulmonary decompression illness: 'the chokes'

Decompression illness (DCI) develops during or after diving. Pulmonary decompression illness ('Chokes') is rarely seen because the affected individual usually dies in the water. We encountered a rare and interesting case. A 60-year-old man complained of leg pain after diving. Despite rapid transfer to a nearby hospital, advanced respiratory failure and shock had set in. He was then transferred to our hospital for hyperbaric oxygen therapy (HBOT). On account of his poor general condition, we initially treated him in the intensive care unit without HBOT, where he showed extreme hyperpermeability and a high level of serum procalcitonin (PCT; 20.24 ng/mL). Despite large-volume fluid therapy, severe intravascular dehydration and shock status remained. We assume that the injured endothelial cells induced vascular hyperpermeability and increased levels of inflammatory cytokines leading to the high serum PCT level. PCT might be a useful stress marker of endothelial damage and severity in DCI, including Chokes.

[Utility of target controlled infusion technique for deciding the fentanyl infusion rate for post-cholecystectomy pain management in a patient on anticoagulant therapy]

The fentanyl infusion rate was controlled by employing a target controlled infusion (TCI) technique under anticoagulant therapy for postoperative pain management. A 59-year-old woman with atrial fibrillation and mitral stenosis was scheduled for open cholecystectomy. Heparin was continuously infused for anticoagulant therapy. Sevoflurane and remifentanil were used for induction and maintenance of anesthesia. At completion of the operation, her consciousness was checked and the endotracheal tube was then removed under fentanyl TCI (effect-site concentration: Ce = 2.0 ng x ml(-1)). In this case, the spontaneous breathing rate was stable (10-12 x min(-1)) under fentanyl TCI. She had no complaints of pain(pain at rest: VAS 20 mm). The breathing rate in this case provided indication for postoperative pain management. The TIVAtrainer simulation makes the exchange from TCI infusion to continuous infusion easy. And the spontaneous breathing monitoring is useful for postoperative pain measurement of laparotomy cases.

Potent suppression of stretch reflex activity after systemic or spinal delivery of tizanidine in rats with spinal ischemia-induced chronic spastic paraplegia

BACKGROUND

Spasticity and rigidity are serious complications associated with spinal traumatic or ischemic injury. Clinical studies show that tizanidine (Tiz) is an effective antispasticity agent; however, the mechanism of this effect is still not clear. Tiz binds not only to α2-adrenoreceptors (AR) but also to imidazoline (I) receptors. Both receptor systems (AR+I) are present in the spinal cord interneurons and α-motoneurons. The aim of the present study was to evaluate the therapeutic potency of systematically or spinally (intrathecally [IT]) delivered Tiz on stretch reflex activity (SRA) in animals with ischemic spasticity, and to delineate supraspinal or spinal sites of Tiz action.

EXPERIMENTAL PROCEDURES

Animals were exposed to 10 min of spinal ischemia to induce an increase in SRA. Increase in SRA was identified by simultaneous increase in recorded electromyography (EMG) activity and ankle resistance measured during computer-controlled ankle dorsiflexion (40°/3 s) in fully awake animals. Animals with increased SRA were divided into several experimental subgroups and treated as follows: (i) Tiz administered systemically at the dose of 1 mg kg(-1), or IT at 10 μg or 50 μg delivered as a single dose; (ii) treatment with systemic Tiz was followed by the systemic injection of vehicle, or by nonselective AR antagonist without affinity for I receptors; yohimbine (Yoh), α2A AR antagonist; BRL44408 (BRL), α2B AR antagonist; ARC239 (ARC), nonselective AR and I(1) receptor antagonist; efaroxan (Efa), or nonselective AR and I(2) receptor antagonist; idazoxan (Ida); (iii) treatment with IT Tiz was followed by the IT injection of selective α2A AR antagonist; atipamezole (Ati). In a separate group of spastic animals the effect of systemic Tiz treatment (1 mg/kg) or isoflurane anesthesia on H-reflex activity was also studied.

RESULTS

Systemic and/or IT treatment with Tiz significantly suppressed SRA. This Tiz-mediated anti-SRA effect was reversed by BRL (5 mg kg(-1)), Efa (1 mg kg(-1)), and Ida (1 mg kg(-1)). No reversal was seen after Yoh (3 mg kg(-1)) or ARC (5 mg kg(-1)) treatment. Anti-SRA induced by IT Tiz (50 μg) was reversed by IT injection of Ati (50 μg). Significant suppression of H-reflex was measured after systemic Tiz treatment (1 mg/kg) or isoflurane (2%) anesthesia, respectively. Immunofluorescence staining of spinal cord sections taken from animals with spasticity showed upregulation of α2A receptor in activated astrocytes.

CONCLUSIONS

These data suggest that α2A AR and I receptors, but not α2B AR, primarily mediate the Tiz-induced antispasticity effect. This effect involves spinal and potentially supraspinal sites and likely targets α2A receptor present on spinal neurons, primary afferents, and activated astrocytes. Further studies using highly selective antagonists are needed to elucidate the involvement of specific subtypes of the AR and I receptors in the antispasticity effect seen after Tiz treatment.

[Volume reduction surgery for giant coronary sinus with valvular heart disease; report of a case]

A 64-year-old male with giant left atrium and giant coronary sinus, who had aortic valve regurgitation, prosthesis valve paravalvular leakage in mitral position and prosthesis valve malfunction in tricuspid valve position, was successfully treated with double valve replacement, paravalvular leakage repair and volume reduction of left atrium and coronary sinus. Giant coronary sinus was about 70 mm in diameter and was thought to be induced by persistent left superior vena cava, high right atrium pressure and prosthesis valve malfunction in tricuspid valve position. Lung volume was so much increased by volume reduction of left atrium and coronary sinus and patient's symptoms were much improved.

[Full-thickness resection of the focus site for adolescent idiopathic ventricular tachycardia]

We present a case of a 14-year-old male with incessant idiopathic ventricular tachycardia for which both pharmacological and catheter ablation treatments failed. Curative surgery was performed on this patient. By intraoperative epicardial isochronous mapping, arrhythmogenic focus was identified in the right ventricular infundibulum between the large conus branch and the proximal right ventricular coronary branch. After cryoablation both from the epi- and endo-cardial sides failed to terminate the arrhythmia, subsequent full-thickness resection of the identified focus was performed. There was no postoperative recurrence of tachyarrhythmia In idiopathic ventricular tachycardia, arrhythmogenic focus is not always situated on the endo- or epicardial side. Full-thickness resection of the focus site might be necessary in such patients as we experienced this time.

[Reoperation for postoperative pseudoaneurysm after repair for acute aortic dissection associated with disseminated intravascular coagulation and chronic renal failure]

We report a very high risk case of reoperation for pseudoaneurysm after ascending aortic replacement for acute aortic dissection in a 78-year-old man with chronic renal failure and disseminated intravascular coagulation (DIC). Computed tomography 5 years after the 1st operation showed huge pseudoaneurysm originated from the distal anastomosis and the angiogram showed moderate aortic regurgitation. Hemodialysis and congestive heart failure associated with DIC complicated his general condition. Preoperative DIC score was 7 with D-dimer of 39.8 microg/ml. The patient underwent reoperation through night anterior thoracotomy. At 20 degrees C of urinary bladder temperature, we started re-median sternotomy and ablated the adhesion. When the pseudoaneurysm ruptured, we started hypothermic circulatory arrest with selective cerebral perfusion immediately. And Bentall operation and hemi-arch replacement were performed. Postoperative recovery required long period and he was transferred to another hospital at 3 months after the surgery. Postoperative data showed reduction of DIC score to 3.

[Ultrasound guidance facilitates arterial catheterization]

Ultrasound-guided arterial catheterization has been attempted, and its effectiveness demonstrated. We encountered 3 cases in which arterial catheterization (A-line) was difficult for the following reasons: the arterial lumen was narrow due to arteriosclerosis; the pulse of the radial artery was weak because of swelling in the arm and heart failure; and the deep artery was too hard for the needle to penetrate it. Using ultrasound guidance, arterial catheterization could be smoothly performed in all cases. Thus, ultrasound-guided arterial catheterization is effective for cases in which arterial catheterization using the usual palpation technique is difficult.

Aberrant halt of syringe pump motion: an improved system to prevent false setting of the syringe

A syringe pump is used to inject precise doses of drugs having a strong action; for example, vasoactive drugs. Unexpected and undetected halt of a syringe pump can lead to potentially life-threatening complications. We experienced a sudden halt in the movement of a syringe pump (Terufusion syringe pump; Terumo, Tokyo, Japan) in two patients while administering norepinephrine in the intensive care unit (ICU). Fortunately, the patients had only transient hypotension, which was immediately detected and promptly treated, without any untoward sequelae. As a result of the occurrence of such cases, we conducted a detailed investigation of the causes of this sudden halt in the syringe pump. We could not reproduce the aberration of the syringe pump and thus could not specify the cause in the first patient. In the second patient, however, a false setting on the syringe was suspected to be the cause of the problem. In order to prove this, we tried to reproduce the situation where a syringe pump, due to a false syringe setting, abruptly terminated while giving a "syringe loss" warning, after a period of precise functioning. Once we had determined how a false setting of the syringe could occur without the syringe pump giving off an alarm from the onset, we collaborated with the Terumo Company to revise their current instruction manual to incorporate this as a warning. We also helped in the development of a new model, including a new safety feature that would prevent a false setting of the syringe from occurring at all. This new model was released in December 2003.

Development of baclofen tolerance in a rat model of chronic spasticity and rigidity

Systemic or spinal treatment with baclofen has been associated with the development of tolerance in patients with chronic spasticity. In the present study, we used a rat model of spinal ischemia-induced spasticity to characterize the development of baclofen tolerance after chronic intrathecal (i.t.) baclofen infusion. Following the induction of spinal ischemia and the development of behavioral spasticity, animals were implanted with i.t. catheters connected to osmotic pumps to continuously infuse baclofen (1.0 microg/0.5 microl/h). Hindleg peripheral muscle resistance (PMR) was measured periodically after initiation of chronic infusion and after bolus i.t. baclofen injection (1.0 microg). Peripheral muscle resistance was significantly decreased at the onset of baclofen infusion, however, after 5-7 days of infusion a progressive return of spasticity was noted, where baseline PMR values returned to preinfusion levels. At the same time, the efficacy of bolus i.t. baclofen treatment also decreased, where after 5 days of baclofen infusion 1.0 microg (i.t.) baclofen only reduced PMR by 10% (compared to 40-50% preinfusion). Baclofen efficacy progressively returned once continuous infusion was stopped. These data demonstrate that transient spinal ischemia leads to the development of spasticity which is sensitive to spinal baclofen. Chronic i.t. infusion leads to a progressive development of tolerance. This model offers potential to study tolerance mechanisms after spinal injury, and aid in drug discovery for use in baclofen-tolerant patients.

Transcranial motor-evoked potentials monitoring can detect spinal cord ischemia more rapidly than spinal cord-evoked potentials monitoring during aortic occlusion in rats

In this study, we evaluated the efficacy of transcranial motor-evoked potentials (tc-MEPs), compared with segmental spinal cord-evoked potentials (SCEPs), for detecting spinal cord ischemia (SCI) and assessed the relationship between neurological outcome and tc-MEPs or SCEPs in the rat aortic occlusion model. In the rats, SCI was induced by aortic occlusion for 10 min with a balloon catheter. At first, tc-MEPs (Group A: n = 6) or segmental SCEPs (Group B: n = 6) was recorded during SCI. Second, in using the quantal bioassay for the relationship between an interval of aortic occlusion and the probability of positive response in tc-MEPs or segmental SCEPs, the P50(MEP) and P50(SCEP) which represent the interval of aortic occlusion associated with 50% probability of assessment of ischemic spinal cord dysfunction by tc-MEP and SCEP were analyzed. The amplitude of tc-MEPs decreased significantly at 30 s and disappeared completely at 2 min after aortic occlusion. In Group B, it took about 6 min after aortic occlusion to diminish SCEP signal amplitude by approximately 50%. P50(MEP) obtained in the quantal analysis was 0.3 +/- 0.1 min. P50(SCEP) was calculated as 6.2 +/- 0.5 min that was significantly (P < 0.01) longer than P50(MEP). Our data indicated that tc-MEP monitoring could detect the onset of SCI so rapidly in comparison with segmental SCEP monitoring, which could provide therapeutic windows in a surgical approach that includes spinal cord protection.

Influence of the descending thoracic aortic cross clamping on bispectral index value and plasma propofol concentration in humans

BACKGROUND

In this study, the authors investigated changes in Bispectral Index (BIS) values and plasma propofol concentrations (Cp) after aortic cross clamping in the descending thoracic aortic aneurysm repair surgery during propofol anesthesia.

METHODS

Prospectively, in 10 patients undergoing thoracic aortic surgery during total intravenous anesthesia with propofol, BIS values were recorded during cross clamping of the descending thoracic aorta. In this study, the rate of propofol infusion was controlled to keep the BIS value between 30 and 60 throughout surgery. Simultaneously, Cp values in the blood samples taken from the right radial artery (area proximal to cross clamping) and the left femoral artery (area distal to cross clamping) were measured.

RESULTS

Approximately 15 min after initiating aortic cross clamping, BIS values in all cases started to decrease abruptly. Cp values of samples taken from the radial artery after cross clamping of the aorta were significantly (P < 0.05) increased compared with pre-cross clamp values (1.8 +/- 0.4 microg/ml), and the mean Cp after aortic cross clamping varied between 3.0 and 5.3 microg/ml. In addition, there were significant differences in the Cp values between radial arterial and femoral arterial blood samples throughout aortic cross clamping. Cp values in samples from the radial artery were approximately two to seven times higher than those from the femoral artery.

CONCLUSIONS

This study showed that Cp values increased and BIS values decreased rapidly after aortic cross clamping in thoracic aortic aneurysm repair surgery during propofol anesthesia. These findings suggested that all anesthesiologists should control the infusion rate carefully, taking the abrupt changes in its pharmacokinetics into consideration, especially during cross clamping of the descending thoracic aorta.

Intrathecal Nicorandil and Small-Dose Morphine Can Induce Spastic Paraparesis After a Noninjurious Interval of Spinal Cord Ischemia in the Rat

We investigated the interaction between nicorandil, a K(+)ATP channel opener, and morphine on motor function after a noninjurious interval of spinal cord ischemia in the rat. Spinal ischemia was induced by aortic occlusion for 6 min with a balloon catheter in Sprague-Dawley rats. All animals received intrathecal (IT) injection of morphine (1-60 microg) 1 h after ischemia. In addition to IT injection of morphine, group M (control), group MN (combination of morphine and nicorandil), and group MNG (combination of morphine, nicorandil, and glibenclamide) received IT saline, nicorandil (10 microg), and both glibenclamide (10 microg) and nicorandil (10 microg) after 150 min of reperfusion, respectively. A quantal bioassay for the effect of IT morphine on neurological function after ischemia was performed to calculate 50% effective dose values (ED50) for inducing paraparesis at 3 h of reperfusion. The ED50 in group M and group MN was 15.1 +/- 4.9 microg and 2.9 +/- 1.0 microg of IT morphine, respectively (P < 0.05). In Group MNG, the dose-response curve shifted back to the right and the ED50 for inducing paraparesis was 11.6 +/- 4.7 microg of IT morphine. The present study demonstrates that IT small-dose morphine combined with nicorandil induces spastic paraparesis after noninjurious interval of spinal cord ischemia in the rat.

Mu and delta, but not kappa, opioid agonists induce spastic paraparesis after a short period of spinal cord ischaemia in rats

BACKGROUND

Intrathecal (IT) morphine given after a short interval of aortic occlusion in a rodent model induced transient spastic paraparesis via opioid receptor-predicted actions in spinal cord. To determine the role(s) of spinal opioid receptor subtypes we investigated whether IT administration of various selective opioid receptor agonists can induce paraparesis following a short period of spinal cord ischaemia in rats.

METHODS

In Sprague-Dawley rats implanted with an IT catheter, spinal cord ischaemia was induced for 6 min using an intraaortic balloon. Mu ([D-Ala2, N-Me Phe4, Gly-ol5] enkephalin), kappa (U50488H) or delta ([D-Pen(2,5)] enkephalin) selective agonists were injected intrathecally 30 min after reperfusion. A separate group of animals was used to investigate the dose-response effect on this motor dysfunction. For this purpose, three doses of mu, kappa, or delta agonists were injected intrathecally after ischaemia. After IT injection, recovery of motor function was assessed periodically using the motor deficit index (0=complete recovery; 6=complete paraplegia).

RESULTS

IT administration of mu and delta but not kappa agonists produced dose-dependent effects in the induction of spastic paraparesis. In addition, this spasticity induced by IT mu and delta agonists was reversed completely by IT naloxone and naltrindole, respectively.

CONCLUSION

These results suggest that the effect of various opioids on motor function after a short period of spinal cord ischaemia depends upon individual opioid receptor subtypes.

Unanticipated full stomach at anesthesia induction in a type I diabetic patient with asymptomatic gastroparesis

We encountered a case of unanticipated full stomach at anesthesia induction, despite a 12-h fasting period, in a type I diabetes patient with diabetic neuropathy presenting for elective vitrectomy for proliferative diabetic retinopathy. The patient had ingested seaweed 24 h prior to the surgery, and it was later found in the aspirated gastric content. Gastrointestinal dysfunction due to diabetic neuropathy and the high fiber content of the ingested seaweed are the probable causes of unanticipated full stomach in our case.

Changes in Helicobacter pylori status in patients with rheumatoid arthritis under non-steroidal anti-inflammatory drugs

BACKGROUND

The role of Helicobacter pylori infection in rheumatoid arthritis (RA) patients during treatment with non-steroidal anti-inflammatory drugs (NSAID) is still unclear.

METHODS

By means of endoscopy and biopsy, gastroduodenal lesions and H. pylori status were repeatedly examined in 88 RA patients at intervals ranging from 26 to 49 months. Histology and culture were applied to determine H. pylori status. Serial changes in gastroduodenal lesions and histologic score for mucosal atrophy were compared among groups classified by initial and second H. pylori status.

RESULTS

There were 28 patients with continuously positive H. pylori infection (CP group), 33 patients with continuously negative H. pylori infection (CN group), 7 patients in whom H. pylori status became negative (PN group), and 20 patients in whom H. pylori status could not be determined (UD group). Age, duration and species of NSAID, disease activity of RA, gastroprotective drugs applied and the prevalence of gastroduodenal mucosal lesions were not different among the groups at either the initial or the second examination. In the PN group, the score for mucosal atrophy at the second examination was significantly lower than at the initial examination, whereas no difference was found for the CP, CN and UD groups. Overall, histologic score for mucosal atrophy was higher in H. pylori-positive patients than in H. pylori-negative patients at both initial and second examination.

CONCLUSIONS

In RA patients using NSAIDs, H. pylori infection may not affect the course of gastroduodenal lesions and activity of RA, but the infection contributes to mucosal atrophy.

Inflammatory myoglandular colorectal polyps: a case series of nine patients

Inflammatory myoglandular polyp is an uncommon benign colorectal polyp. We treated nine cases of histologically verified inflammatory myoglandular polyp. The polyps were identified as a pedunculated protrusion located in the distal part of the large intestine. On colonoscopy, eight polyps had a smooth, spherical, and hyperemic surface, accompanied by a patchy mucous exudate. Magnification endoscopy revealed a rugged surface composed of smooth nodules. These colonoscopic findings corresponded to hyperplastic glands with occasional cystic dilation and inflamed stroma with proliferation of smooth-muscle fibers. Inflammatory myoglandular polyp appears to be a distinctive clinical entity, with a unique appearance on colonoscopy.

Intrathecal administration of morphine, but not small dose, induced spastic paraparesis after a noninjurious interval of aortic occlusion in rats

We sought to investigate the dose-response relationship for the effect of intrathecal morphine on the transient spastic paraparesis after short-lasting spinal ischemia in rats. Spinal ischemia was induced by aortic occlusion for 6 min with a balloon catheter in rats previously implanted with an intrathecal catheter for drug delivery. After ischemia, the animals were allowed to recover, and 3, 10, or 30 microg of morphine or saline was injected intrathecally at 30 min after reperfusion. In a separate group, the quantal bioassay for the effect of intrathecal morphine on neurological function after ischemia was performed to calculate 50% effective dose values for inducing paraparesis at 2 h of reperfusion. Subsequently, histopathology of the spinal cord was assessed at 48 h of reperfusion. Intrathecal injection of 30 or 10 micro g of morphine, but 3 micro g of neither morphine nor saline, caused a progressive development of hindlimb spasticity. The 50% effective dose values for inducing paraparesis were 16.1 +/- 1.5 microg in assessing behavioral analysis at 2 h after intrathecal morphine. Histopathological analysis of spinal cords in the 30- microg group revealed the presence of dark-staining alpha-motoneurons in lumbosacral segments. We conclude that spinal administration of a large dose of morphine after transient aortic occlusion may be associated with a potential risk of paraparesis and the corresponding development of neurological dysfunction. Careful attention should be paid when intrathecal morphine is used for pain control after thoracoabdominal aortic aneurysm repair.

IMPLICATIONS

Spinal administration of large-dose morphine after transient aortic occlusion may be associated with a potential risk of irreversible spinal neuronal degeneration and the corresponding development of neurological dysfunction.

Propofol reduces spinal motor neuron excitability in humans

IMPLICATIONS

We investigated in humans whether changes in spinal motor neuron excitability correlate with the predicted propofol concentration (Cpt) achieved by a target-controlled infusion system. Propofol suppressed F-wave persistence in a Cpt-dependent manner, indicating that propofol depresses spinal motor neuron excitability at clinically relevant concentrations.

Helicobacter pylori infection in rheumatoid arthritis: effect of drugs on prevalence and correlation with gastroduodenal lesions

OBJECTIVE

The aim of this study was to investigate the impact of Helicobacter pylori infection on clinical features in patients with rheumatoid arthritis (RA) under medication with non-steroidal anti-inflammatory drugs.

METHODS

One hundred and eighty-four patients with RA were tested for the presence of H. pylori infection. Clinical features and gastroduodenal lesions were compared between H. pylori-positive and -negative patients.

RESULTS

One hundred and thirteen patients were positive and 71 patients were negative for H. pylori. The age, severity of RA, prevalence of gastrointestinal symptoms and gastroduodenal lesions and the class of gastroprotective drugs were not different between the two groups. Reflux oesophagitis was less frequent and sulphasalazine was less frequently administered in the H. pylori-positive group.

CONCLUSIONS

The severity of RA, prevalence of gastroduodenal lesions other than reflux oesophagitis and the application of gastroprotective drugs do not seem to depend upon H. pylori infection in RA patients. Sulphasalazine may be protective against H. pylori infection.

Electrolytic partial fluorination of organic compounds. 55. Highly regio- and stereoselective anodic monofluorination of 2,3-dihydrochroman-4-one and chromone derivatives

Anodic monofluorination at the position alpha to the oxygen atom of the (E)-3-benzylidene-2,3-dihydrochroman-4-one derivatives was successfully carried out to provide the corresponding 2-fluorochromanones selectively. This is the first regioselective electrochemical fluorination of fused-type, oxygen-containing heterocyclic compounds. Anodic fluorination of a chromone derivative also gave a similar fluorinated chromanone stereoselectively.

Difference in degree of mucosal atrophy between elevated and depressed types of gastric epithelial tumors

BACKGROUND

The significance of atrophy in the background mucosa and Helicobacter pylori infection in the morphogenesis of gastric epithelial tumors has not yet been investigated.

METHODS

The degree of mucosal atrophy, as determined by a histological analysis and the serum pepsinogen (PG) levels, and H. pylori status were investigated in patients with elevated adenoma (EA group; n = 40), elevated early cancer of intestinal type (ECI group; n = 30), depressed early cancer of intestinal type (DCI group; n = 37) and depressed early cancer of diffuse type (DCD group; n = 33), and the findings were then compared to those in 91 controls.

RESULTS

At all sites of the stomach, the histologic score of atrophy was higher in the EA group and in the ECI group than in the controls. In the DCI group, the histologic score of atrophy in the antrum was higher than in the controls, but no such difference in the score was found in the DCD group. The PG I/II ratios in the EA, ECI and DCI groups were significantly lower than in the controls, and the value was also different between the ECI and DCI groups. While H. pylori prevalence was higher in all groups than in the controls, a logistic regression analysis which included the grade of atrophy as a determinant revealed the infection to be an independent associated factor for the DCD group.

CONCLUSIONS

The difference in the background mucosal atrophy seems to contribute to different macroscopic types in gastric epithelial tumors. This seems to be the case especially for cancer of intestinal type.

Electroytic partial fluorination of organic compounds. 52. Regio- and diastereoselective anodic fluorination of thiazolidines

Anodic fluorination of N-benzoyl, N-acethyl-, and N-formylthiazolidine derived from L-cysteine was carried out in dimethoxyethane (DME) and acetonitrile containing various supporting fluoride salts using an undivided cell. Highly regioselective fluorination proceeded to provide the corresponding 5-monofluorinated thiazolidine derivatives in good yields in DME, and the diastereoselectivitiy was moderate to high regardless of the supporting fluoride salts. The diastereoselectivitiy of the fluorination was greatly affected by the bulkyness of the subsitituent on the nitrogen atom, and N-benzoylthiazolidine gave much higher diastereoselectivity compared with N-formyl derivative. The fluorination of the thiazolidines was not achieved by commercially available fluorinating reagents such as N-fluoropyridinium salts.

Electrolytic partial fluorination of organic compounds. 54. Anodic mono- and trifluorination of thiochroman-4-one derivatives and the factors affecting product selectivity

Anodic fluorination of (E)-3-benzylidene-2,3-dihydrothiochroman-4-one and 3-benzyl-1-thiochromone derivatives under a variety of electrolytic conditions was found to provide selectively or exclusively the same fluorinated products: (E)-3-benzylidene-2,3-dihydro-2-fluorothiochroman-4-ones. In addition, di- and trifluorinated derivatives were also obtained depending on the starting heterocycles and electrolytic conditions. The factors affecting the product selectivity were also examined.

The interaction of somatosensory evoked potentials between mixed-sensory nerves and sensory-sensory nerves

The interactions between two different nerves occur by occlusion or inhibition when two nerves share the synaptic connections. In our previous study, we have demonstrated that posterior tibial nerve and peroneal nerve sensory inputs interact with each other, i.e., preceding stimulus to one nerve suppresses the somatosensory evoked potential (SEP) of the other nerve when two stimuli are delivered in close sequence. The course of suppression follows two phases; the first one occurring at short interstimulus intervals (ISIs) of the two nerves less than 10 msec, and the second one being at around 30 msec ISI after partial recovery following the first suppression phase. In that study, we have postulated that the second phase suppression was equivalent for the movement induced "gating" mechanism. In this study, the interactions of mixed nerve (posterior tibial) and sensory nerve (sural), and also sensory (sural) and sensory (saphenous) nerves were examined. We found that the mixed nerve (posterior tibial) exerted similar dual phases of suppression (as was seen in posterior tibial--peroneal nerve study) on to the sural nerve SEP, but the reverse was not true. Also the sensory and sensory nerve interactions were not mutually equal; the sural nerve stimulation caused two phases suppression but the reverse condition did not show significant suppression. The above findings suggest (1) interference input from the sensory nerve to the mixed nerve is much weaker than the reverse condition, and (2) sensory and sensory nerves interactions occur but two nerves' interference inputs are not necessarily equal and one could dominant the other.

A study of mismatch negativity in newborns

BACKGROUND

Although newborns are presumed to have cognitive ability, studies on the objective cognitive ability of neonates are making little progress.

METHODS

We gave auditory and visual stimuli to newborns whose conceptional age ranged from 35 to 43 weeks and recorded the mismatch negativity (MMN) that is said to reflect the process by which stimuli are detected automatically. We compared the waveform and latency of the MMN.

RESULTS

The mismatch negativity waveform in newborns was similar to that of adults. The MMN latency tended to shorten with an advance in conceptional age and was especially shortened between 36 and 37 weeks of fetal life. In some newborns whose clinical course indicated a possibility of their having cognitive dysfunction, the MMN latency was prolonged.

CONCLUSIONS

Newborns also have cognitive ability and MMN is useful for objectively evaluating the cognitive ability in newborns.

[Hopkins syndrome: oral prednisolone was effective for the paralysis]

We describe here a 5-year-old girl who presented flaccid paralysis of the left upper limb after recovery from bronchial asthma. T2-weighted magnetic resonance imaging of the cervical cord revealed a focal high intensity area in the left anterior horn at the C6-C7 level. She was treated with oral prednisolone, and paralysis resolved within two months. Thirty cases of Hopkins syndrome have been reported so far, but its cause remains unknown. Early administration of prednisolone might ameliorate paralysis in this syndrome.

Electrolytic partial fluorination of organic compounds. 42.(1) marked solvent effects on regioselective anodic monofluorination of 4-oxo-2-pyrimidyl sulfides

Regioselective anodic monofluorination of 4-oxo-2-pyrimidyl sulfides was investigated under various electrolytic conditions. Anodic fluorination was successfully carried out using Et(4)NF.4HF in dimethoxyethane (DME) to provide the corresponding alpha-fluorinated products in good yields. In contrast, acetonitrile (MeCN) was not suitable for the anodic fluorination due to the severe anode passivation during the electrolysis. A mixed solvent of DME and MeCN was found to be also effective for the fluorination, and the product yield increased with an increase of the ratio of DME to MeCN. The superiority of DME can be explained mainly in terms of the suppression of the anode passivation and enhancement of the nucleophilicity of the fluoride ions. Such marked solvent effects on the anodic fluorination were discussed in detail.

Motor-evoked potentials in a child recovering from transverse myelitis

We describe a 13-year-old female, with an inability to walk because of transverse myelitis, who demonstrated progressive recovery of both motor function and motor- evoked potentials (MEP). At 4 weeks after onset, amplitudes of MEP were decreased, latencies were prolonged, and cortical somatosensory-evoked potentials (SEP) were absent. At 6 and 12 weeks, MEP revealed progressively higher amplitudes and shorter latencies. SEP also recovered. MEP and SEP recovery paralleled clinical recovery. MEP in response to transcranial magnetic stimulation may provide guidance regarding recovery from spinal cord disorders in children.

[Diagnosis of ulcerative colitis--barium enema examination]

Barium enema is useful especially for differential diagnosis of right sided type or segmental type of ulcerative colitis from other inflammatory bowel diseases. Compared with endoscopical examination, it provides more objective informations about the range of affected colon which is necessary for the choice of treatment strategy to the reluctant case. However, as preparation procedures may cause aggravation of ulcerative colitis, an unnecessary barium study should be avoided. Even the case in remission stage, it is advisable to add 40 to 60 mg of water-soluble predonisolone to barium solution. Roentogenographic diagnosis of ulcerative colitis is not difficult, in so far as two major points are properly evaluated. The first is the presence or absence of haustration, and the second is mucosal surface of the colon, namely, multiple ulcers or erosions distributing diffusely and continuously in active stage, or granular mucosa and disarray of network pattern of colonic mucosa in remission stage.

Helicobacter pylori and mucosal atrophy in patients with gastric cancer: a special study regarding the methods for detecting Helicobacter pylori

We assessed the sensitivities of several methods for detecting Helicobacter pylori (culture, histology, rapid urease test, and serology), and evaluated the H. pylori positivity considering the degree of atrophy in the background mucosa in 202 gastric cancer patients and 101 controls. The positivity of H. pylori determined by culture (81%) was significantly higher than that determined by serology (62%) in gastric cancer patients (P < 0.001). The positivities of H. pylori determined by biopsy and/or serology in intestinal (84%) and diffuse (95%) types of gastric cancer were higher than that observed in controls (54%) (P < 0.001). Intestinal-type gastric cancer tended to occur in the atrophic mucosa, in which H. pylori positivity was not different from that in controls after adjusting for the degree of atrophy, whereas diffuse-type gastric cancer was observed more often in the nonatrophic mucosa, in which H. pylori positivity was higher than that in controls even after adjusting for the degree of atrophy.

Lack of tolerance in peripheral opioid analgesia in mice

We recently developed a sensitive peripheral analgesic test in mice. Bradykinin, a representative pain-producing substance, when given subcutaneously through a polyethylene tube into the plantar of the limb connected to a transducer, induced a flexor reflex response, in a dose dependent manner. When morphine, a mu-opioid receptor agonist, was added to the plantar through another polyethylene tube, bradykinin-induced responses were completely abolished in a naloxone-reversible manner. These peripheral analgesic effects were also observed with DAMGO, another mu-opioid receptor agonist, and U-69,593, a kappa-opioid receptor agonist, but not DSLET, a delta-opioid receptor agonist. When morphine was given subcutaneously to the back, a potent analgesia in the tail pinch test was observed. Repeated administrations of morphine once per day for 5 days showed a marked tolerance or reduction in morphine analgesia on the 6th day, while there was no significant reduction in the peripheral analgesia of morphine. These findings suggest that tolerance to morphine analgesia is mediated through synaptic plasticity in the central nervous system, but not through a receptor desensitization at the level of the single cell.