One-lung ventilation and 3D image analysis in a case of tracheal bronchus with steeply angled branching of left main bronchus: a case report

Background

Establishing one-lung ventilation (OLV) in patients with tracheal bronchus (TB) may be challenging due to its unusual bronchial anatomy. We present a case of difficult OLV in a patient with right TB and steeply angled bifurcation of the left main bronchus.

Case presentation

A 79-year-old woman was scheduled to undergo video-assisted thoracic surgery left upper lobectomy. We planned right OLV with a bronchial blocker; however, it was difficult to place the blocker in the left main bronchus due to a steep bifurcation angle. Therefore, we changed the entry angle of the lumen tip by advancing the tracheal tube to just above the tracheal bifurcation, allowing successful placement of the bronchial blocker into the bronchus.

Conclusion

For airway management in patients with TB, especially for OLV, it is essential to understand the anatomy of the trachea, bronchus, and TB and to select the appropriate device for each case.

Usefulness of real-time elastography for diagnosing lymph node metastasis of skin cancer: does elastography potentially eliminate the need for sentinel lymph node biopsy in squamous cell carcinoma?

BACKGROUND

The metastatic involvement of regional lymph nodes is the most important prognostic factor for overall survival of skin cancer patients. The sonographic technique of freehand real-time tissue elastography (RTE), which displays tissue rigidity as a colour overlay of the tissue image, was developed.

OBJECTIVE

Our purpose was to evaluate the benefit of RTE for detecting lymph node metastases of skin cancer non-invasively before operation.

METHODS

We first selected lymph nodes of skin cancer patients which had already been diagnosed by biopsy as being reactive or metastatic, and then retrospectively collected images of RTE and B-mode and colour Doppler ultrasound on those lymph nodes performed preoperatively. Twenty-one lymph nodes from 12 patients with squamous cell carcinoma (SCC), 23 lymph nodes from 14 patients with malignant melanoma (MM) and 14 lymph nodes from six patients with extramammary Paget disease (Paget) were investigated. Elastographic images were assessed on a scale of one to four according to the percentage of high elasticity (hard) area (HEA) in the lymph node.

RESULTS

In all three skin cancers, lymph nodes evaluated as grade 3 or 4 by RTE were metastatic. All lymph nodes evaluated as grade 1 or 2 by RTE were reactive in SCC, whereas some lymph nodes evaluated as grade 1 or 2 were metastatic in MM and Paget.

CONCLUSION

Real-time tissue elastography may aid in distinguishing reactive lymph nodes from metastatic ones especially in SCC.

Intracuff pressure during one-lung ventilation in infants and children

OBJECTIVE

We prospectively evaluated intracuff pressure (IP) during one-lung ventilation (OLV) to characterize potential risk associated with overinflation of the cuff used for OLV.

DESIGN

Prospective observational study over a 2-year period, in infants and children undergoing thoracic surgery. The IPs of the tracheal and bronchial balloon were measured using a manometer and compared to a previously recommended threshold of 30 cmH2O. Data were compared by the device type used to achieve OLV.

SETTING

Freestanding tertiary-care pediatric hospital.

PARTICIPANTS

Patients ≤18 years of age undergoing thoracic procedures requiring OLV.

INTERVENTIONS

Measurement of IP.

MEASUREMENTS AND MAIN RESULTS

Thirty patients were enrolled (age 5 months-18 years) with a median weight of 28 kg. Median tracheal and bronchial IPs were 32 cmH2O (range: 11, 90) and 44 cmH2O (range: 10, 100), respectively. The tracheal and bronchial IPs exceeded 30 cmH2O in 13 of 20 patients (65%) and 21 of 30 patients (70%), respectively.

CONCLUSIONS

IP was high and in excess of recommended levels in most children undergoing OLV. Continuous monitoring of IP may be indicated during OLV to address the risks involved and ensure the prevention of complications related to high IP.

TYPE OF STUDY

Prospective comparative study.

LEVEL OF EVIDENCE

Level II.

Changes in cerebral and renal oxygenation during laparoscopic pyloromyotomy

Although a laparoscopic approach may be preferred over open procedures for abdominal surgery, there are limited data on the effect of laparoscopic procedures on cerebral and renal oxygenation in neonates and young infants. Here, we evaluated the effect in neonates and infants. In this two-center prospective observational study, we evaluated changes in cerebral and renal regional oxygen saturation (rSO₂) in infants during laparoscopic pyloromyotomy. Intraoperative hemodynamic and respiratory parameters and rSO₂ were recorded. For the primary outcome, these parameters were compared at incision and at the end of pneumoperitoneum. The study cohort included 25 infants with a mean age of 40 ± 10 days and weight of 4.0 ± 0.6 kg. IAP at the beginning of laparoscopy was 10 ± 2 mmHg (range 7-15 mmHg). Although both cerebral and renal rSO₂ decreased from incision compared to the end of laparoscopy, the decrease reached statistical significance only for cerebral rSO₂ (81 ± 12 to 76 ± 16, p = 0.033). Similarly, the increase in fractional tissue oxygen extraction (FTOE) was only statistically significant for cerebral FTOE (0.18 ± 0.12 to 0.23 ± 0.16, p = 0.037). No change in hemodynamic or respiratory parameters was found. Although there was a decrease in cerebral rSO₂ and increase in cerebral FTOE during pneumoperitoneum, the values did not decrease below those noted before anesthetic induction.

Use of remifentanil in general anesthesia for neonatal non-cardiac surgery: a case series

OBJECTIVE

This case series aimed to summarize our experience in usage of remifentanil in neonates undergoing non-cardiac surgery.

BACKGROUND

Physiology of neonates and infants is different from that of adults. Immaturity of their vital organ systems narrows a safety margin of perioperative management including anesthesia. Remifentanil has favorable characteristics for pediatrics such as short duration of action and rapid elimination. Although remifentanil was introduced into clinical practice since 1996, its application to neonatal anesthesia has not been validated yet.

METHODS

This is a 14-month retrospective case series of neonates receiving remifentanil during non-cardiac surgery at a tertiary care pediatric hospital in Japan. Patients' characteristics, intraoperative data, and complications were retrieved from medical records.

RESULTS

A total of 68 neonates underwent non-cardiac surgery under general anesthesia, of whom 48 received remifentanil. Infusion rate was 0.14 (0.04-0.35) mcg/kg/min (median, range). No intractable adverse events including postoperative apnea were detected.

CONCLUSION

Remifentanil is generally feasible to neonatal surgical population.

General anesthesia with a native airway for patients with mucopolysaccharidosis type III

BACKGROUND

Mucopolysaccharidosis type III is a progressive disease with worsening airway, pulmonary, and cardiac involvement that may complicate anesthetic care.

AIM

To prospectively evaluate the incidence of airway issues and complications during magnetic resonance imaging (MRI) and lumbar puncture (LP) during general anesthesia with a native airway for patients with mucopolysaccharidosis type III.

METHOD

The study was a part of the natural history study. Anesthesia was induced with sevoflurane, which was discontinued after intravenous access was obtained. General anesthesia with a native airway was provided by dexmedetomidine and propofol. Dexmedetomidine (0.5 μg·kg^-1 ) was administered over 5 min followed by a continuous infusion at 0.5 μg·kg^-1 ·h^-1 . A continuous infusion of propofol was started at 150 μg·kg^-1 ·min^-1 . A bolus dose of propofol (1 mg·kg^-1 ) was administered and the propofol infusion was increased as needed. Airway management and vital signs were recorded for the entire procedure until discharge.

RESULTS

Twenty-five patients (6.9 ± 3.1 years) received total of 43 MRI and LP procedures in the cohort. No patient failed sedation. Although mask induction with sevoflurane was not clinically problematic, upper airway obstruction was noted during 14 procedures (33%). This required the application of continuous positive airway pressure, temporary oral airway placement, jaw thrust, or shoulder roll. Airway dynamics improved once the anesthesia was transitioned to intravenous anesthetic agents. Although a small shoulder roll was needed to improve airway patency for 11 cases (26%), a large shoulder roll tended to make the upper airway obstruction worse. Oxygen desaturation (≤90%) was noted during MRI in three cases (7%).

CONCLUSION

A combination of dexmedetomidine and propofol provided effective general anesthesia with a native airway during the procedures. Although upper airway obstruction was noted, it resolved with simple airway maneuvers without further airway intervention.

Perioperative care in an adolescent patient with heparin-induced thrombocytopenia for placement of a cardiac assist device and heart transplantation: case report and literature review

Heparin-induced thrombocytopenia (HIT) can cause life-threatening complications following the administration of heparin. Discontinuation of all sources of heparin exposure and the use of alternative agents for anticoagulation are necessary when HIT is suspected or diagnosed. We present the successful use of bivalirudin anticoagulation in an adolescent patient during cardiopulmonary bypass who underwent both placement of a left ventricular assist device and subsequent heart transplantation within a 36-hour period. The pathophysiology and diagnosis of HIT are reviewed, previous reports of the use of direct thrombin inhibitors for cardiac surgery are presented, and potential dosing regimens for bivalirudin are discussed.

A Retrospective Analysis of the Influence of Ventricular Morphology on the Perioperative Outcomes After Fontan Surgery

OBJECTIVES

The objectives of this study were to evaluate the effect of ventricular morphology on perioperative outcomes during Fontan surgery.

DESIGN

Retrospective cohort study.

SETTING

Single standing, not-for-profit pediatric hospital.

PARTICIPANTS

A total of 72 patients who underwent Fontan surgery using cardiopulmonary bypass without aortic cross-clamp between January 1, 2009 and December 31, 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The patients were divided into 3 categories depending on their single-ventricle lesions: (1) LV group (n = 20): left dominant and hypoplastic right ventricle; (2) RV group (n = 37): right dominant and hypoplastic left ventricle; and (3) BV group (n = 15): biventricular or indeterminate dominance. Perioperative major adverse events were collected based on the Society of Thoracic Surgeons database. The need for perioperative allogeneic blood transfusions also was determined. The mean age was 3.3±1.7 years and the mean weight was 13.6±4.0 kg. All patients had extracardiac lateral tunnel or conduit Fontan procedures. Sixty-nine of the patients (96%) underwent tracheal extubation in the operating room. Anesthesia, surgery, and CPB times were 326±68, 239±73, and 70±41 minutes, respectively. Eleven patients (15%) required allogeneic blood products intraoperatively, while 30 patients (42%) required allogeneic blood products during the perioperative period. Length of cardiac intensive care unit stay and hospital stay (median [IQR]) were 1 [1,2] and 12 [9,18] days, respectively. There was no mortality and no significant differences between groups in major postoperative complications, anesthetic or surgical variables.

CONCLUSIONS

No difference in the immediate perioperative outcomes was noted based on ventricular morphology.

[Laparoscopi Surgery and Anesthetic Management for Infants and Children]

The advantages of laparoscopic surgery resulting in quicker recovery from surgery, decreased postopera- tive pain, shorter hospital stay, and an: improved cos- metic outcome compared to open surgery have led to the expansion of its applications. This expansion includes its use for new surgical procedures as well as indications in younger patients even neonates. The majority of surgical procedures in children are at- tempted under laparoscopy, ranging from short pro- cedures such as day surgeries to even longer case such as congenital biliary atresia. The anesthetic man- agement of laparoscopic surgery in pediatric population has unique features and pitfalls. This chapter de- scribes : (i) the application of laparoscopic surgery for pediatrics ; (ii) the physiological effects of pneumo- peritoneum on respiratory, cardiovascular, renal sys- tems and intracranial pressure ; and (iii) actual anes- thesia management To accomplish safe anesthetic management of the pediatric patients for laparoscopic surgery, anesthesiologists should be familiar with the basic tenets of pediatric anesthesia as well as the potential physiological changes that result from in- creased intra-abdominal pressure due to insufflated CO2, the absorbed CO2, and patient positioning.

Clarifying the mechanism of effect of the Bionator for treatment of maxillary protrusion: A percentile growth study

AIM

The reported effects of Bionator treatment in patients with mandibular retrognathism are conflicting. This study evaluated the changes in craniofacial morphology resulting from treatment with a Bionator, based on measurement percentiles previously reported, to clarify the mechanism of the effect of this commonly used functional device.

MATERIALS AND METHODS

Study Design: Retrospective.

SETTING

A private orthodontic clinic.

PARTICIPANTS

Forty-two children (mean age, 10.13 years) requiring treatment with a Bionator for Class II malocclusion (mandibular retrognathism). Children were randomly assigned to a Bionator group with or without an expansion screw. Measurements on lateral cephalometric radiographs were taken before and upon completion of Bionator treatment. All parameters measured were characterised according to the measurement percentiles previously reported. Each parameter was compared before and after treatment for all patients and for each treatment group using Wilcoxon's test.

RESULTS

No significant differences in cranial length or mandibular body length were seen in any of the 3 groups, but anterior cranial base length and maxillary length were significantly decreased while mandibular ramus height and mandibular length were significantly increased after treatment in the Bionator with expansion screw group and in the all-patient group.

CONCLUSIONS

The findings suggest that treatment with a Bionator with expansion screw during the growth and development stage results in increased mandible length and ramus height and inhibits the growth of the maxilla and anterior cranial base bone.

Residual volume in the cuff of the endotracheal tube when the pilot balloon is torn off instead of deflated using a syringe

BACKGROUND

In recent years, there has been a shift in airway management with the use of cuffed endotracheal tubes (ETT) in pediatric patients. While the use of a syringe to deflate the cuff is generally recommended, anecdotal observations suggest that some healthcare practitioners tear off the pilot balloon from ETT to deflate the cuff. This study was conducted to estimate the residual volume in the cuff when the pilot balloon is torn off for deflation.

METHOD

The in vitro study was conducted in three phases. In phases 1 and 2, various sized cuffed ETTs (3.0, 4.0, and 5.0 mm) were inflated to achieve an intracuff pressure of 20-30 cmH2O in open atmosphere (phase 1) or inside a tube to simulate external pressure from the tracheal wall (phase 2). The pilot balloons were ripped off and the residual volume in the cuff was measured. The process was repeated using 10 ETTs of each of the 3 sizes. In phase 3, the same process was repeated using ten, size 7.0 cuffed ETTs inflated in an intubating mannequin.

RESULTS

In phase 1, the percentage of the remaining residual volume was 60.7, 72.8, and 69.5% in 3.0, 4.0, and 5.0 mm ETTs respectively. Although the percentage of residual volume in phases 2 and 3 was less than phase 1, the residual volume in phases 2 and 3 still averaged approximately 60-70% of the volume required for cuff inflation. In one case, the pilot balloon tube was completely occluded and the residual volume in the cuff could not be expelled even with external pressure.

CONCLUSION

Since significant percentage of the volume remained in the cuff after tearing off the pilot balloon tube with one being completely occluded, we would not recommend this method for cuff deflation.

Perioperative care of infants with pyloric stenosis

Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.

An in vitro and in vivo validation of a novel color-coded syringe device for measuring the intracuff pressure in cuffed endotracheal tubes

BACKGROUND

The clinical practice of pediatric anesthesiology has changed with a transition to the use of cuffed endotracheal tubes (ETTs) in infants and children. The monitoring of intracuff pressure has been suggested as one means to limit the potential for damage to the tracheal mucosa. The current study evaluates the accuracy of a novel, color-coded syringe device which provides three zones (green, clear, and red) to estimate the intracuff pressure.

METHOD

The study was conducted in two phases. Phase 1 was an in vitro study where cuffed ETTs of sizes 4.0 mm, 5.0 mm and 6.0 mm ID were placed into polyvinylchloride tubing of appropriate sizes. A manometer and the syringe device were simultaneously attached to measure the intracuff pressure at the middle of the 3 different zones on the device (red, clear, and green). Phase 2 was an in vivo study where the syringe device and the manometer were simultaneously attached to the pilot balloon to measure the intracuff pressure and the corresponding zone on the color-coded syringe following endotracheal intubation. Statistical analysis included a descriptive reporting of the mean ± SD, median, range, and 95% confidence intervals (CI) of the actual intracuff pressure readings at the three zones of the syringe device during both its in vitro and in vivo use.

RESULTS

For phase 1 of the study, the 95% CI for the green, clear, and red zones were 21.5-21.8, 29.2-29.5, and 46.5-47.4 cmH2O respectively. This correlated well with the manufacturer reported values of 20-30, 30-40, and 40-60 cmH2O for the 3 zones (green, clear, and red respectively). Phase 2 of the study included 200 patients ranging in age from 0.1 to 21.8 years (6.7 ± 5.1 years) and in weight from 4.0 to 129.1 kilograms (29.4 ± 23.3 kgs). The size of the ETTs ranged from 3.0 to 7.0 mm ID. The intracuff pressure measured by the manometer ranged from 4 to 65 cmH2O (27.6 ± 9.7 cmH2O). The 95% CI for the green, clear, and red zones were 20.5-21.7, 27.7-29.1, and 41.2-46.5 cmH2O respectively. There was no significant differences noted when comparing different patient ages or sizes of ETT.

CONCLUSION

The current study demonstrates a clinically acceptable correlation between the zones on this novel, color-coded syringe device and the actual measurement of the intracuff pressure obtained by a manometer for both in vitro and in vivo use. This device is a simple, reliable, portable and affordable method to monitor intracuff pressure.

Serum IL-33 levels are increased in patients with psoriasis

BACKGROUND

Interleukin (IL)-33 is a recently identified cytokine, which is a member of the IL-1 family and binds to a heterodimeric receptor comprising ST2 (suppression of tumorigenicity 2) and IL-1 receptor accessory protein. Serum levels of IL-33 have been reported to be upregulated in various T helper (Th)1/Th17-mediated diseases, such as rheumatoid arthritis and inflammatory bowel disease. IL-33 expression is increased in lesional skin in patients with psoriasis, but serum levels in patients with psoriasis have not yet been studied.

AIM

To study serum IL-33 levels in patients with psoriasis, a Th1/Th17-mediated skin disease, before and after anti-tumour necrosis factor (TNF)-α therapy.

METHODS

Serum IL-33 levels were measured in patients with psoriasis vulgaris (PV), psoriatic arthritis (PsA) or pustular psoriasis (PP), and compared with those of healthy controls. Associations between serum IL-33 levels and serum TNF-α, IL-6, vascular endothelial growth factor and C-reactive protein levels were also studied. In addition, the effect of IL-33 stimulation on IL-6, IL-8, TNF-α and VEGF secretion by human keratinocyte was analysed.

RESULTS

Serum IL-33 levels in patients with PV, PsA and PP were significantly higher than those in healthy controls. Serum IL-33 levels correlated with serum TNF-α levels in patients with psoriasis, and decreased after anti-TNF-α therapy. IL-33 stimulated IL-6 and IL-8 secretion by human keratinocytes.

CONCLUSIONS

These results suggest that serum IL-33 levels generally reflect increased inflammation in patients with psoriasis.

Predictive factors for pericardial effusion identified by heart dose-volume histogram analysis in oesophageal cancer patients treated with chemoradiotherapy

OBJECTIVE

To identify predictive factors for the development of pericardial effusion (PCE) in patients with oesophageal cancer treated with chemotherapy and radiotherapy (RT).

METHODS

From March 2006 to November 2012, patients with oesophageal cancer treated with chemoradiotherapy (CRT) using the following criteria were evaluated: radiation dose >50 Gy; heart included in the radiation field; dose-volume histogram (DVH) data available for analysis; no previous thoracic surgery; and no PCE before treatment. The diagnosis of PCE was independently determined by two radiologists. Clinical factors, the percentage of heart volume receiving >5-60 Gy in increments of 5 Gy (V5-60, respectively), maximum heart dose and mean heart dose were analysed.

RESULTS

A total of 143 patients with oesophageal cancer were reviewed retrospectively. The median follow-up by CT was 15 months (range, 2.1-72.6 months) after RT. PCE developed in 55 patients (38.5%) after RT, and the median time to develop PCE was 3.5 months (range, 0.2-9.9 months). On univariate analysis, DVH parameters except for V60 were significantly associated with the development of PCE (p < 0.001). No clinical factor was significantly related to the development of PCE. Recursive partitioning analysis including all DVH parameters as variables showed a V10 cut-off value of 72.8% to be the most influential factor.

CONCLUSION

The present results showed that DVH parameters are strong independent predictive factors for the development of PCE in patients with oesophageal cancer treated with CRT.

ADVANCES IN KNOWLEDGE

A heart dosage was associated with the development of PCE with radiation and without prophylactic nodal irradiation.

Thoracic epidural infusion with chloroprocaine for postoperative analgesia following epicardial pacemaker placement in an infant

In critically ill neonates and infants, major interventions, including thoracotomy, may result in significant postoperative respiratory insufficiency and pain leading to the need for postoperative mechanical ventilation. Although there are many potential options for providing postoperative analgesia, there continues to be expanding use of regional anesthesia in this population. One of the many reported advantages is the provision of postoperative analgesia while avoiding the deleterious effects on respiratory function that may be seen with systemic opioids. We report the use of thoracic epidural anesthesia using a continuous infusion of chloroprocaine to provide analgesia following thoracotomy and epicardial pacemaker placement in an infant. The perioperative plan was complicated by comorbid conditions including congenital complete heart block, recent rhinovirus infection with residual respiratory involvement, and prematurity.

Relationship between leukocyte telomere length and personality traits in healthy subjects

BACKGROUND

It has been shown that certain personality traits are related to mortality and disease morbidity, but the biological mechanism linking them remains unclear. Telomeres are tandem repeat DNA sequences located at the ends of chromosomes, and shorter telomere length is a predictor of mortality and late-life disease morbidity. Thus, it is possible that personality traits influence telomere length. In the present study, we examined the relationship of leukocyte telomere length with personality traits in healthy subjects.

SUBJECTS AND METHODS

The subjects were 209 unrelated healthy Japanese who were recruited from medical students at 4th-5th grade. Assessment of personality traits was performed by the Revised NEO Personality Inventory (NEO-PI-R) and the Temperament and Character Inventory (TCI). Leukocyte relative telomere length was determined by a quantitative real-time PCR method for a ratio of telomere/single copy gene.

RESULTS

In the stepwise multiple regression analysis, shorter telomere length was related to lower scores of neuroticism (P<0.01) and conscientiousness (P<0.05) of the NEO-PI-R, and lower scores of harm avoidance (P<0.05) and reward dependence (P<0.05) of the TCI.

CONCLUSIONS

The present study suggests that leukocyte telomere length is associated with some personality traits, and this association may be implicated in the relationship between personality traits and mortality.

[Anesthetic management of a patient with Fontan circulation with pacemaker failure]

We describe the anesthetic management of a 23-year-old female patient with severe bradycardia due to pacemaker lead disconnection. The pacemaker had been placed due to complete AV block following an extracardiac Fontan operation. She was scheduled for lead repair under general anesthesia. The preoperative HR was only 37 beats x min(-1) of idioventricular rhythm. As further bradycardia was a major concern, we prepared a percutaneous cardiac pacemaker and the catheterization laboratory for transatrial cardiac pacing. After placement of transcutaneous cardiac pacing pads on the chest, we administered isoproterenol at 0.01 microg x kg(-1) x min(-1). We confirmed an increase in HR to 50 beats x min(-1) and induced anesthesia, after which isoproterenol was administered at 0.015 microg x kg(-1) x min(-1). No bradycardia was observed perioperatively. Transvenous cardiac pacing, part of the last step in the ACLS bradycardia algorithm, is inappropriate except in patients with anatomic Fontan circulation. Furthermore, in the case of bradycardia, percutaneous or transesophageal cardiac pacing can be used; however, these are not always effective. Transatrial cardiac pacemakers are probably most effective for bradycardia with Fontan circulation but they should be placed by a catheter specialist, and emergency placement can be difficult. As described here, a special management protocol is necessary to control bradycardia in the face of Fontan circulation.

[Anesthetic management of Jehovah's Witnesses patients undergoing open heart surgery with cardiopulmonary bypass]

BACKGROUND

The anesthetic management of Jehovah's Witnesses (JW) patients undergoing open heart surgery with cardiopulmonary bypass (CPB) is associated with a major risk of anemic hypoxia.

METHODS

Fifteen patients from the community of JW underwent open heart surgery. The surgical procedures undertaken were aortic valve replacement in 7 patients, mitral valve plasty or replacement in 5 patients, repair of congenital heart diseases in 2 patients, and removal of left atrial myxoma in one patient. Hemoglobin values, cardiac output, and oxygen delivery (Do2) as well as consumption (Vo2) were evaluated during and after surgery.

RESULTS

After CPB, the mean hemoglobin (Hb) value decreased to 8.2 g x dl(-1) from the baseline level of 11.6 g x dl(-1) (P = 0.0007); however, it increased to 10.5 g x dl(-1) at the end of surgery Cardiac index remained unchanged. Oxygen delivery (Do2) decreased after CPB from its baseline level, whereas oxygen consumption remained unchanged. Twenty-four hours after surgery, Do2 recovered to its baseline level because of an increase in cardiac output with the Hb value of 10.7 g x dl(-1) .

CONCLUSIONS

The decrease in Hb level is unavoidable in cardiac surgery with CPB in these JW patients. This survey showed that the decrease in Hb level may be compensated by conserved cardiac output avoiding the decrease of Do2 to its critical level when hypoxia occurs.

Interaction effects between the brain-derived neurotrophic factor Val66Met polymorphism and parental rearing on personality traits in healthy subjects

Aims

There is a growing body of data suggesting the gene-environment interaction in the characterization of personality traits, but variation in ordinary parental rearing among environmental factors has not been focused yet. We examined the effects of the interaction between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism and parental rearing on personality traits.

Methods

Subjects were 710 Japanese healthy volunteers. Perceived parental rearing was assessed by the Parental Bonding Instrument (PBI), which consists of the care and protection factors. Personality assessment was performed by the Temperament and Character Inventory (TCI), which has 7 dimensions, i.e., novelty seeking, harm avoidance, reward dependence, persistence, self-directedness, cooperativeness, and self-transcendence. The BDNF Val66Met polymorphism was detected by the PCR-RFLP method.

Results

Parental rearing has significant main effects on all TCI dimensions except novelty seeking, while no significant main effects of the BDNF genotype on the TCI scores were found. The interaction between the BDNF genotype and maternal care of the PBI had significant effects on harm avoidance and self-directedness of the TCI. Post-hoc analyses showed that decreased maternal care was correlated with increased harm avoidance and decreased self-directedness in most of the genotype groups, and for both personality traits the correlation was highest in the Met/Met genotype and lowest in the Val/Val genotype and that for the Val/Met genotype was in between the two values.

Conclusion

The present study suggests that the BDNF Val66Met polymorphism moderates the effects of parenting rearing, especially maternal care, on harm avoidance and self-directedness in healthy subjects.

THE -1021C/T polymorphism of the dopamine-B-hydroxylase (DBH) gene promoter affects personality traits in healthy subjects

Introduction

Dopamine and norepinephrine are implicated in the characterization of personality traits. Dopamine-β-hydroxylase (DBH) is the enzyme responsible for conversion of dopamine to norepinephrine. Previous studies have shown that the -1021C/T polymorphism of the DBH gene promoter influences plasma DBH activity. Few studies investigated the association between this polymorphism and personality traits.

Aim

To examine the association between the -1021C/T DBH polymorphism and personality traits in healthy volunteers.

Methods

The participants were 627 Japanese unrelated volunteers. The subjects with present psychiatric disorders or past history of psychiatric disorders according to the DSM-IV were excluded. The DBH genotypes were identified by a PCR-RFLP method, and personality traits were assessed by the Temperament and Character Inventory (TCI). The study protocol was approved by the Ethics Committee of Yamagata University School of Medicine, and all subjects provided written informed consent to participate.

Results

In the two-factor analysis of covariance with the DBH genotype and sex as factors and with age as a covariate, there was no main effect of the DBH genotype on any TCI score, while the interaction between the factors was significant in harm avoidance. In the post-hoc analysis, the group with the T allele predictive of lower DBH activity had higher scores of harm avoidance than that without the T allele in females (p=0.006), but not in males.

Conclusion

The present study suggests that the -1021C/T DBH polymorphism affects the personality trait of harm avoidance in healthy females.

The brain-derived neurotrophic factor Val66Met polymorphism modulates the effects of parental rearing on personality traits in healthy subjects

There is a growing body of data suggesting that gene-environment interaction is critical in the characterization of personality traits; however, previous studies have not taken into consideration variability in parental rearing as an environmental factor. In this study, we examined the effects of the interaction between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism and parental rearing on personality traits in 710 healthy Japanese subjects. Perceived parental rearing was assessed by the Parental Bonding Instrument (PBI), which consists of the care and protection factors. Assessment of personality traits was performed by the temperament and character inventory (TCI), which has seven dimensions, i.e. novelty seeking, harm avoidance, reward dependence, persistence, self-directedness, cooperativeness and self-transcendence. Parental rearing has significant main effects on some TCI dimensions, but no significant main effects of the BDNF genotype on the TCI scores were found. The interaction between the BDNF genotype and maternal care of the PBI had significant effects on harm avoidance and self-directedness of the TCI. Post hoc analyses showed that decreased maternal care was correlated with increased harm avoidance and decreased self-directedness, and for both personality traits the partial correlation coefficient was highest in the Met/Met genotype group and lowest in the Val/Val genotype group and the value of the Val/Met genotype group was in the middle. Data from this study suggest that the BDNF Val66Met polymorphism modulates the effects of parental rearing, especially maternal care, on harm avoidance and self-directedness in healthy subjects.