Simulation training for medical emergencies: Evaluation of dentists' long-term learning skills and confidence

INTRODUCTION

As the population ages and more patients experience medical emergencies during dental treatments, dentists must competently and confidently manage these situations. We developed a simulation training course for medical emergencies in the dental setting using an inexpensive vital sign simulation app for smartphones/tablets without the need for an expensive simulator. However, the duration for which this effect is maintained is unclear. This study was performed to evaluate the long-term educational effect at 3, 6, and 12 months after taking the course.

MATERIALS AND METHODS

Thirty-nine dental residents participated in this course. Scenarios included vasovagal syncope, anaphylaxis, hyperventilation syndrome, and acute coronary syndrome, each of which the participants had to diagnose and treat. The participants were evaluated using a checklist for anaphylaxis diagnosis and treatment skills immediately after and 3, 6, and 12 months after the course. The participants were also surveyed about their confidence in diagnosing and treating these conditions by questionnaire before, immediately after, and 3, 6, and 12 months after the course.

RESULTS

The checklist scores for anaphylaxis were significantly lower at 3, 6, and 12 months after the course than immediately after the course. The percentage of participants who provided a correct diagnosis and appropriate treatment for vasovagal syncope, hyperventilation syndrome, and acute coronary syndrome was lower at all reassessments than immediately after the course.

CONCLUSION

Because medical emergency management skills and confidence declined within 3 months, it would be useful to introduce a refresher course approximately 3 months after the initial course to maintain skills and confidence.

Tracing Photoinduced Hydrogen Migration in Alcohol Dications from Time-Resolved Molecular-Frame Photoelectron Angular Distributions

The recent implementation of attosecond and few-femtosecond X-ray pump/X-ray probe schemes in large-scale free-electron laser facilities has opened the way to visualize fast nuclear dynamics in molecules with unprecedented temporal and spatial resolution. Here, we present the results of theoretical calculations showing how polarization-averaged molecular-frame photoelectron angular distributions (PA-MFPADs) can be used to visualize the dynamics of hydrogen migration in methanol, ethanol, propanol, and isopropyl alcohol dications generated by X-ray irradiation of the corresponding neutral species. We show that changes in the PA-MFPADs with the pump-probe delay as a result of intramolecular photoelectron diffraction carry information on the dynamics of hydrogen migration in real space. Although visualization of this dynamics is more straightforward in the smaller systems, methanol and ethanol, one can still recognize the signature of that motion in propanol and isopropyl alcohol and assign a tentative path to it. A possible pathway for a corresponding experiment requires an angularly resolved detection of photoelectrons in coincidence with molecular fragment ions used to define a molecular frame of reference. Such studies have become, in principle, possible since the first XFELs with sufficiently high repetition rates have emerged. To further support our findings, we provide experimental evidence of H migration in ethanol-OD from ion-ion coincidence measurements performed with synchrotron radiation.

Survey on the Awareness of the Use of Oropharyngeal Throat Packs in Dental Anesthesia: An International Online Survey

INTRODUCTION

Oropharyngeal throat packs (OPTPs) are frequently used to administer general anesthesia during oral surgery and dental procedures. However, the use of OPTPs has remained controversial, with concerns about their effectiveness, the potential for falling short of expectations, and the inherent risk of serious oversight in removing them. This study aimed to assess the awareness of dental anesthesiologists in the United States of America (USA) and Japan regarding the use of OPTPs.

METHODS

An online questionnaire was distributed to 41 dental anesthesia education facilities in May 2023 and responses were obtained from 32 facilities.

RESULTS

The responses to the questionnaire indicated that dental anesthesiologists in both the USA and Japan believe that using OPTPs during general anesthesia with airway securement is of significant importance, albeit with varying primary purposes for their application. In contrast, notable disparities were observed between the USA and Japan regarding the perceived importance and routine use of OPTPs during open-airway general anesthesia. In both countries, there is a common understanding that the residual risks of OPTPs are severe and that multiple preventive procedures are required.

CONCLUSIONS

 The present study showed that dental anesthesiologists in the USA and Japan believed that the use of OPTPs was generally necessary for dental anesthesia. However, there was a difference in awareness between Japan and the USA regarding the importance of OPTPs for open-airway general anesthesia. Therefore, there should be a consensus among dental anesthesiologists in Japan and the USA on using OPTPs during open-airway general anesthesia in the near future.

The Impact of COVID-19 on Dental Anesthesiologists: An Online Survey of Board-Certified Dental Anesthesiology Specialists of the Japanese Dental Society of Anesthesiology

OBJECTIVE

The impact of the COVID-19 pandemic on dental anesthesiologists has not been examined. This study aimed to determine how the COVID-19 pandemic affected Japanese dental anesthesiologists' professional lives.

METHODS

An online questionnaire related to the effects of COVID-19 on dental anesthesiologists' professional lives was emailed to 351 board-certified dental anesthesiology specialists from the Japanese Dental Society of Anesthesiology. The endpoints of this study were changes in income and job satisfaction as a dental anesthesiologist from 2019 prior to the COVID-19 pandemic.

RESULTS

A total of 141 dental anesthesiologists participated in the survey. Most respondents reported no change in income relative to 2019 for 2020 or 2021. Significantly more dental anesthesiologists reported income decreases relative to 2019 for 2020 (39%) vs 2021 (21.3%; P = .001). Very few dental anesthesiologists reported income increases relative to 2019 for 2020 (2.1%) vs 2021 (15.6%; P < .001). Job satisfaction as a dental anesthesiologist remained unchanged for all 3 years.

CONCLUSION

Even though many Japanese dental anesthesiologist specialists lost income because of COVID-19, they maintained their job satisfaction.

Simulation training for medical emergencies of dental patients: A review of the dental literature

In recent years, due to the aging of the population, the number of dental patients with comorbidities such as hypertension and diabetes has increased. Although it has been reported that these patients are increasingly developing medical emergencies during their dental treatments, many dental providers still do not possess the skills to manage medical emergencies appropriately. Simulation training is essential to improve this situation however, there is no report describing how to conduct an effective simulation in detail for dental office medical emergencies. The purpose of this review is to provide information on simulations that is effective and practical. The authors will highlight the key characteristics for providing effective simulation trainings, such as the selection of simulators, simulation locations, instructors, debriefings, methods for evaluating educational effectiveness, and the use of telesimulation as a method for simulation training due to the global COVID-19 pandemic. In addition, this review provides recommendations on tailoring an ideal simulation training course for those who wish to create one. The authors hope that this review will promote the spread of effective simulation training and in turn, contribute to improving the medical safety of dental patients.

Safety of COVID-19 vaccine delivery by dentists: An observational cohort study

Background/purpose

Although many coronavirus disease 2019 (COVID-19) vaccine injections have been administered worldwide, the safety of this practice remains unclear. This study aimed to compare the rates of complications associated with COVID-19 vaccines administered by dentists with those of vaccines administered by nurses. This study aimed to evaluate the safety of a vaccination program delivered by dentists.

Materials and methods

This observational cohort study included 537 recipients of the second dose of the Pfizer COVID-19 vaccine, delivered as an intramuscular injection to the upper arm deltoid muscle by dentists or nurses at the study site. Vaccine recipients were divided into two groups according to the vaccination administrator (dentist vs. nurse groups). The rates of complications associated with intramuscular injection technique (numbness in the hand or arm at the time of the injection, vasovagal reflex at the time of the injection, vaccine-related shoulder injury, and prolonged numbness) were examined.

Results

A total of 125 vaccine recipients were included (nurse group, n = 84; dentist group, n = 41). The overall incidence rate of complications was lower in the dentist group (2.4%; 1/41) than in the nurse group (8.3%; 7/84). However, this difference was not statistically significant (P = 0.3).

Conclusion

This study suggests that the safety of COVID-19 vaccine administration is comparable between dentists and nurses.

SARS-CoV-2 recombinant proteins-induced degeneration of taste buds in rat circumvallate papillae

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections cause loss or alteration of taste and smell as early symptoms and sequelae, but the detailed mechanism remains unclear. This study investigated whether coronavirus disease 2019-induced taste disorders are caused by direct effects on taste bud cells. SARS-CoV-2 recombinant spike and nucleocapsid proteins were applied to circumvallate papillae of male Sprague–Dawley rats. Immunohistochemistry and image analysis were used to compare the number of taste buds, and taste bud cells and area, together with confirmation of angiotensin-converting enzyme 2 (ACE2) expression. Immunohistochemical analysis revealed ACE2 expression in the taste buds of rat circumvallate papillae. Decreases in the number of taste buds, taste bud cells, and their area were observed at 12 days after application of SARS-CoV-2 recombinant spike and nucleocapsid proteins. These data suggest that SARS-CoV-2 proteins induce degeneration of taste buds.

Unexpected Anesthetic Circuit Leak Attributed to Improper Use of a Tube Holder: A Case Report

Leaks involving the anesthesia circuit can cause significant complications including hypoxia and hypoventilation. We present a case of a circuit leak caused by damage to the corrugated tubing attributed to improper use of the tube holder. A 58-year-old male was scheduled for resection of a palatal tumor under an intubated general anesthetic. After successful nasotracheal intubation, the anesthesiologist inserted the corrugated tubing of the anesthetic circuit into the tube holder. A leaking sound was heard and a tear in the corrugated tubing was promptly discovered. The corrugated tubing of the anesthetic circuit presumably tore because it was inserted into the groove of the tube holder at an inappropriate angle with excessive force. Anesthesiologists should be aware of potential leaks if the anesthesia circuit is damaged, which may be caused by improper use of tube holders.

A new option for education during surgical procedures and related clinical anatomy in a virtual reality workspace

The COVID-19 pandemic and mandatory social distancing has brought challenges to anatomy educators who generally need in-person classes. The purpose of this study is to share the experience of a distant online lecture on a surgical procedure and related anatomy in a three-dimensional (3D) virtual reality (VR) workspace and to compare it with reported teaching methods, that is, an in-person class and a Zoom online class. The lecture was delivered by three authors of this article in a VR workspace that enables people to meet through VR. The lectures were about combinations of dental surgical procedures and related clinical anatomy. Physically, the attendees could have been located anywhere in the world, so lecturers joined from the United States and the attendees were all from Japan. VR environment and its flexibility enabled attendees to join the lecture actively, helping them to gain understanding of the surgical procedure and anatomy more efficiently. The use of VR technology with a live communication tool demonstrated in this study has several advantages over previous education methods, although there are still technical issues or disadvantages that need to be addressed. Development of the technology and app/software is required so that more data can be processed at higher speed. Use of VR technology with a live communication tool could be an alternative teaching method. Its overall advantages are a closer look at the slides/monitor and concurrent observation of the multiple assets in various directions by multiple attendees. These advantages cannot be achieved by any other teaching method without VR assets with the workspace provided by Spatial. Even during the mandatory social distancing due to the COVID-19 pandemic, this could enable us to foster 3D understanding of surgery and related anatomy. Further study is now needed to evaluate the effectiveness of this newly proposed teaching method by comparing it with traditional in-person and online classes with a live communication tool.

Potentiation of Rocuronium Bromide by Lithium Carbonate: A Case Report

Lithium carbonate is a medication used for the management of various mental disorders. The present report describes a case of prolongation of rocuronium bromide in a patient concurrently taking lithium carbonate. A 64-year-old woman was scheduled to undergo cystectomy under general anesthesia. The patient took lithium carbonate (600 mg/d) for treatment of bipolar affective disorder. General anesthesia was induced with propofol, fentanyl, remifentanil, and sevoflurane. After loss of consciousness, rocuronium bromide (50 mg) was administered, and the trachea was intubated. Approximately 1 hour after the administration of rocuronium, the degree of residual muscle relaxant was evaluated using a nerve stimulation device. No muscle contraction occurred with train-of-four (TOF) stimulation. Following administration of sugammadex (200 mg) the TOF ratio increased to 95%. The ionic size of lithium is similar to that of sodium; therefore, lithium is transported into the cell with sodium. The resting membrane potential decreases, leading to a reduction in the height of the action potential. Thus, the effect of the remaining lithium may have been superimposed on the rocuronium neuromuscular blockade. Evaluation with a nerve stimulation device in patients taking lithium is crucial before extubation because of the risk of rocuronium potentiation.

Compliance with infection control practices when taking dental x-rays: Survey of a Japanese dental school

The aim of this study was to assess knowledge, attitude, behavior, and compliance concerning infection control among dental practitioners in a dental university hospital in Japan. A 12-item questionnaire about infection control during radiographic procedures was distributed to 686 dental personnel working at Osaka Dental University. The questionnaire collected information on occupation and the use of gloves, holders, door handles, control panels, dental chairs, protectors, tube head, tube arms, tube cones, and keyboards for personal computers. To identify misunderstandings about, and thus noncompliance with, current infection control practices, the percentage of correct answers (PCA) was calculated. Understanding and compliance with the current practices was considered low when <75% and high when ≥75%. In addition, contaminated objects in the clinical setting were examined using black light. PCA was low for one question on using gloves in film positioning and high for three questions on using protective film barriers, regardless of the respondents' occupation. PCA was generally high for three questions on practicing hand hygiene before putting on gloves, methods to protect film holders, and methods to protect radiographic equipment, but was low among some subjects. PCA was generally low for four questions on using film protective barriers, developing images from unprotected films, practicing hand hygiene after removing gloves, and awareness of a procedures manual for taking intraoral x-rays, but was high among some subjects. Saliva contamination of radiographic equipment was confirmed by direct visualization using black light. Awareness was low of infection control measures to be used during intraoral projection. This study indicates the need for additional education and training to improve infection control practices, through, for example, using a standard procedures manual for all dental practitioners and visual evidence (visualization) of contamination.

Simulation training for medical emergencies in the dental setting using an inexpensive software application

INTRODUCTION

Every dental provider needs to be educated about medical emergencies to provide safe dental care. Simulation training is available with simulators such as advanced life support manikins and robot patients. However, the purchase and development costs of these simulators are high. We have developed a simulation training course on medical emergencies using an inexpensive software application. The purpose of this study was to evaluate the educational effectiveness of this course.

MATERIALS AND METHODS

Fifty-one dental providers participated in this study from December 2014 to March 2015. Medical simulation software was used to simulate a patient's vital signs. We evaluated participants' ability to diagnose and treat vasovagal syncope or anaphylaxis with an evaluation sheet and conducted a questionnaire before and after the scenario-based simulation training.

RESULTS

The median evaluation sheet score for vasovagal syncope increased significantly from 7/9 before to 9/9 after simulation training. The median score for anaphylaxis also increased significantly from 8/12 to 12/12 (P < .01). For the item "I can treat vasovagal syncope/anaphylaxis adequately," the percentage responding "Strongly agree" or "Agree" increased from 14% to 56% for vasovagal syncope and from 6% to 42% for anaphylaxis with simulation training.

CONCLUSIONS

This simulation course improved participants' ability to diagnose and treat medical emergencies and improved their confidence. This course can be offered inexpensively using a software application.

Dedifferentiated Fat (DFAT) cells: A cell source for oral and maxillofacial tissue engineering

Tissue engineering is a promising method for the regeneration of oral and maxillofacial tissues. Proper selection of a cell source is important for the desired application. This review describes the discovery and usefulness of dedifferentiated fat (DFAT) cells as a cell source for tissue engineering. Dedifferentiated Fat cells are a highly homogeneous cell population (high purity), highly proliferative, and possess a multilineage potential for differentiation into various cell types under proper in vitro inducing conditions and in vivo. Moreover, DFAT cells have a higher differentiation capability of becoming osteoblasts, chondrocytes, and adipocytes than do bone marrow-derived mesenchymal stem cells and/or adipose tissue-derived stem cells. The usefulness of DFAT cells in vivo for periodontal tissue, bone, peripheral nerve, muscle, cartilage, and fat tissue regeneration was reported. Dedifferentiated Fat cells obtained from the human buccal fat pad (BFP) are a minimally invasive procedure with limited esthetic complications for patients. The BFP is a convenient and accessible anatomical site to harvest DFAT cells for dentists and oral surgeons, and thus is a promising cell source for oral and maxillofacial tissue engineering.

Functional recovery by application of human dedifferentiated fat cells on cerebral infarction mice model

Elderly people whose daily activities have declined due to a cerebrovascular disorder may suffer from dysphagia and may find oral hygiene difficult. Therefore, it is important to establish an effective therapy for the underlying cerebrovascular disorder. Dedifferentiated fat cells (DFAT) were obtained from mature adipocytes isolated from human buccal adipose pads in a ceiling culture. DFAT expressed the neural markers Nestin and SOX2. Flow cytometric analysis revealed that the cells had properties similar to mesenchymal stem cells. Although the transplantation of DFAT did not change the infarction area and volume ratios in a murine cerebral infarction model, functional recovery was observed in behavioral tests. Furthermore, DFAT administered to mice were later detected in cerebral infarctions. It therefore appears that transplanted DFAT affect the brain after infarction and contribute to the promotion of functional recovery. This finding may provide new cell replacement therapy options for treating disorders of the central nervous system.

Recurrent Coronary Artery Spasm Induced by Vasopressors During Two Operations in the Same Patient Under General Anesthesia

Variant angina is caused by coronary artery spasm (CAS) with ST-segment elevation. We herein report a case of recurrent CAS during 2 operations in the same patient. An 80-year-old woman was scheduled to undergo tracheostomy, submandibular dissection, left partial maxillectomy, and coronoidectomy. We administered ephedrine and phenylephrine to manage hypotension during general anesthesia. Immediately after the administration of these drugs, the ST segment elevated. We decided to cease the operation and transport the patient to the department of cardiology. Computed tomography angiography revealed pneumomediastinum. The cardiologists considered that the electrocardiography findings had changed secondary to pneumomediastinum. About 6 weeks later, a second operation was scheduled. We administered ephedrine and phenylephrine to manage hypotension during general anesthesia. Immediately after the administration of these drugs, ST-segment elevation occurred. We discontinued use of these drugs, and the ST-segment elevation did not recur. We considered that the cause of the ST-segment elevation was vasopressor-induced CAS because the vasopressors were administered immediately before the occurrence of CAS. Vasopressors such as ephedrine or phenylephrine are frequently used to manage hypotension during general anesthesia. Therefore, anesthesiologists should consider the occurrence of CAS before using vasopressors and know how to manage CAS well.

Junctional Rhythm Preoperatively and During General Anesthesia for Oral and Maxillofacial Surgery

We report a case of junctional rhythm that occurred both preoperatively and later during a portion of general anesthesia. A 19-year-old woman was scheduled to undergo bilateral sagittal split ramus osteotomy after being diagnosed with a jaw deformity. Preoperative electrocardiography (ECG) revealed a junctional rhythm with a slow heart rate (HR). At 90 minutes after anesthesia induction, local anesthesia with 10 mL of 1% lidocaine and 1:100,000 adrenaline was administered. A junctional rhythm appeared 15 minutes after the local anesthesia. We believe that the atrioventricular nodal pacemaker cells accelerated because of the increased sympathetic activity due to the adrenaline. On the preoperative ECG, the junctional rhythm with slow HR appeared as an escaped beat caused by slowing of the primary pacemaker. Therefore, we think that the preoperative junctional rhythm and the junctional rhythm that appeared during general anesthesia were due to different causes. Understanding the cause of a junctional rhythm could lead to more appropriate treatment. We therefore believe that identifying the cause of the junctional rhythm is important in anesthetic management.

Tension Pneumothorax After Percutaneous Tracheostomy

A 76-year-old woman with right mandibular gingival cancer was scheduled for surgery. A percutaneous tracheostomy kit was used for tracheostomy under intravenous sedation. After puncturing the cricothyroid membrane, a dilator was inserted along a guidewire. Bucking was observed at the time of insertion of the dilator, despite intratracheal lidocaine spray applied before insertion. After that, the tracheostomy tube was inserted, but no capnographic waveforms appeared when the tube was connected to the anesthesia circuit. Direct macroscopic observation revealed a perforation extending from the posterior wall of the trachea to the anterior wall of the esophagus, which prompted us to request assistance from a thoracic surgeon for treatment before reinserting the tracheostomy tube. After verifying capnographic waveforms on the monitor, anesthesia was induced. Because arterial oxygen saturation was 96% under the administration of pure oxygen, chest radiography was conducted revealing a right pneumothorax. A chest tube was inserted and the patient transported to a nearby general hospital. We suspect that pneumothorax was induced when the integrity of the mediastinal pleura was compromised by mediastinal emphysema because of the injury to the posterior tracheal wall complicated by bucking at the time of insertion of the dilator.

Management of infusion reactions associated with cetuximab treatment: A case report

Cetuximab is a drug targeting the epidermal growth factor receptor, which is indicated for the treatment of unresectable advanced or recurrent head and neck or colorectal cancer. Cetuximab also enhances the cytotoxic effects of radiation in squamous cell carcinoma. The severity of infusion reactions (IR) is categorized from grade 1 to 5; grades 3 and 4 are associated with life-threatening reactions (anaphylaxis), whereas grade 5 indicates death. The incidence of grade 3–4 IR with premedication is reported to be 1.1%. We herein describe a case of a 77-year-old man who developed IR during intravenous administration of cetuximab. The patient developed grade 3–4 anaphylaxis with pruritus, rash and urticaria, followed by hypotension and bradycardia. The timely diagnosis and treatment with intravenous infusion of a vasopressor drug and Ringer's acetate solution proved to be effective. The case presented herein demonstrated an unfeatured aspect of cetuximab-related IR as dermatological reactions over the entire body followed by circulatory collapse.

Second-degree atrioventricular block type II and third-degree atrioventricular block requiring cardiac pacing after tooth extraction

Because atrioventricular block can cause cardiovascular collapse, the rapid management of this condition is necessary. An 82-year-old man complained of discomfort after tooth extraction, and electrocardiography showed second- and third-degree atrioventricular blocks. Dentists should monitor patients who report discomfort using electrocardiography because of the possibility of life-threatening arrhythmia.

Antimicrobial properties and mechanism of volatile isoamyl acetate, a main flavour component of Japanese sake (Ginjo-shu)

AIMS

To evaluate the antimicrobial properties of the main Ginjo-flavour components of sake, volatile isoamyl acetate and isoamyl alcohol.

METHODS AND RESULTS

Volatile isoamyl acetate and isoamyl alcohol both inhibited growth of the five yeast and 10 bacterial test strains. The minimum inhibitory dose and minimum bactericidal (fungicidal) dose of isoamyl acetate were higher than those of isoamyl alcohol. Escherichia coli and Acetobacter aceti were markedly sensitive to isoamyl acetate and isoamyl alcohol. In E. coli exposed to isoamyl acetate for 5 h, changes in expression were noted in proteins involved in sugar metabolism (MalE, MglB, TalB and PtsI), tricarboxylic acid cycle (AceA, Pfl and AcnB) and protein synthesis (EF-Tu, EF-G, and GlyS). Expression of acid and alcohol stress-response proteins was altered in E. coli exposed to isoamyl acetate. Esterase activity was detected in E. coli, suggesting that isoamyl acetate was hydrolyzed to acetic acid and isoamyl alcohol. Acetic acid and isoamyl alcohol damaged E. coli cell membranes and inactivated membrane proteins, impairing respiration.

CONCLUSIONS

Volatile isoamyl acetate and isoamyl alcohol were effective in inactivating various micro-organisms, and antimicrobial mechanism of volatile isoamyl acetate against E. coli was clarified based on proteome analysis.

SIGNIFICANCE AND IMPACT OF THE STUDY

To the best of our knowledge, this is the first report to examine the antimicrobial mechanism of volatile organic compound using proteome analysis combining two-dimensional difference gel electrophoresis with peptide mass fingerprinting.

The osteoblastic differentiation ability of human dedifferentiated fat cells is higher than that of adipose stem cells from the buccal fat pad

Objectives

The purpose of this study was to evaluate and compare the osteoblastic differentiation ability of dedifferentiated fat (DFAT) cells and adipose stem cells (ASCs) from the buccal fat pad (BFP).

Materials and methods

We isolated human DFAT cells and ASCs from the BFP of a patient who underwent oral and maxillofacial surgery and then analyzed their cell surface antigens by flow cytometry. Then, the cells were cultured in osteogenic medium for 14 days. Measurement of bone-specific alkaline phosphatase (BAP), osteocalcin (OCN), and calcium deposition and alizarin red staining were performed to evaluate the osteoblastic differentiation ability of both cell types.

Results

ASCs and DFAT cells were positive for CD90 and CD105 and negative for CD11b, CD34, and CD45. BAP (days 3 and 7), OCN (day 14), and calcium deposition (days 7 and 14) within DFAT cell cultures were significantly higher than those in ASC cultures. The alizarin red-stained area in DFAT cell cultures, which indicates mineralized matrix deposition, was stained more strongly than that in ASC cultures.

Conclusions

The cell surface antigens of ASCs and DFAT cells tend to be similar. Furthermore, the osteoblastic differentiation ability of human DFAT cells is higher than that of ASCs from the BFP.

Clinical relevance

Isolation of DFAT cells from the BFP has an esthetic advantage because the BFP can be obtained via the oral cavity without injury to the external body surface. Therefore, we consider that DFAT cells from the BFP are an ideal cell source for bone tissue engineering.

The utility of human dedifferentiated fat cells in bone tissue engineering in vitro

We compared the osteoblastic differentiation abilities of dedifferentiated fat cells (DFATs) and human bone marrow mesenchymal stem cells (hMSCs) as a cell source for bone regeneration therapies. In addition, the utility of DFATs in bone tissue engineering in vitro was assessed by an alpha-tricalcium phosphate (α-TCP)/collagen sponge (CS). Human DFATs were isolated from the submandibular of a patient by ceiling culture. DFATs and hMSCs at passage 3 were cultured in control medium or osteogenic medium (OM) for 14 days. Runx2 gene expression, alkaline phosphatase (ALP) activity, as well as osteocalcin (OCN) and calcium contents were analyzed to evaluate the osteoblastic differentiation ability of both cell types. DFATs seeded in a α-TCP/CS and cultured in OM for 14 days were analyzed by scanning electron microscopy (SEM) and histologically. Compared with hMSCs, DFATs cultured in OM generally underwent superior osteoblastogenesis by higher Runx2 gene expression at all days tested, as well as higher ALP activity at day 3 and 7, OCN expression at day 14, and calcium content at day 7. In SEM analyses, DFATs seeded in a α-TCP/CS were well spread and covered the α-TCP/CS by day 7. In addition, numerous spherical deposits were found to almost completely cover the α-TCP/CS on day 14. Von Kossa staining showed that DFATs differentiated into osteoblasts in the α-TCP/CS and formed cultured bone by deposition of a mineralized extracellular matrix. The combined use of DFATs and an α-TCP/CS may be an attractive option for bone tissue engineering.

Dedifferentiated fat cells differentiate into osteoblasts in titanium fiber mesh

Mature adipocyte-derived dedifferentiated fat (DFAT) cells rapidly differentiate into osteoblasts under three-dimensional culture conditions. However, it has not been demonstrated that DFAT cells can differentiate into osteoblasts in a rigid scaffold consisting of titanium fiber mesh (TFM). We examined the proliferation and osteogenic differentiation ability of DFAT cells using TFM as a scaffold. DFAT cells derived from rabbit subcutaneous fat were seeded into TFM and cultured in osteogenic medium containing dexamethasone, L-ascorbic acid 2-phosphate and β-glycerophosphate for 14 days. In scanning electron microscopy (SEM) analysis, well-spread cells covered the titanium fibers on day 3, and appeared to increase in number from day 3 to 7. Numerous globular accretions were found and almost completely covered the fibers on day 14. Cell proliferation, as measured by DNA content in the TFM, was significantly higher on day 7 compared with that of day 1. Osteocalcin and calcium content in the TFM were significantly higher on day 14 compared to those of days 1, 3, and 7, indicating DFAT cells differentiated into osteoblasts. We theorize that globular accretions observed in SEM analysis may be calcified matrix resulting from osteocalcin secreted by osteoblasts binding calcium contained in fetal bovine serum. In this study, we demonstrated that DFAT cells differentiate into osteoblasts and deposit mineralized matrices in TFM. Therefore, the combination of DFAT cells and TFM may be an attractive option for bone tissue engineering.

[Examination of the optimal midazolam dose required for loss of puncture memory at the time of spinal anesthesia]

BACKGROUND

We examined midazolam ED50 according to age that was necessary for loss of puncture memory at the time of spinal anesthesia and determined whether we could estimate the presence of puncture memory from the degree of sedation after midazolam administration.

METHODS

We enrolled patients with ASA PS 1 or 2 and patients from 50 to 80 years of age who had been planned for surgery with spinal anesthesia. We divided the patients into groups according to their age--50s, 60s, and 70s as L, M, and H groups, respectively. We evaluated the degree of sedation with six phases of scores after intravenous administration of midazolam and spinal anesthesia was performed. The midazolam dose was based on the ups and downs method.

RESULTS

The midazolam ED50s required for the loss of puncture memory in groups L, M, and H were 0.043, 0.035, and 0.026 mg x kg(-1), respectively. We estimated the association between the sedation degree score after midazolam administration and the puncture memory from ROC curve, but AUC was 0.56 for all cases.

CONCLUSIONS

The midazolam ED50 required for the loss of puncture memory decreased with age but it was difficult to estimate puncture memory from the degree of sedation.

A case of Goodpasture syndrome positive for anti-GBM antibody and MPO-ANCA complicated by a variety of serious infections

A 62-year-old female was admitted to our hospital for investigation of acute progressive renal insufficiency and a systemic inflammatory reaction, despite treatment with several antibiotics. Laboratory data revealed severe renal insufficiency and positive titers for the myeloperoxidase anti-neutrophil cytoplasmic and anti-glomerular basement membrane antibodies. The deterioration of her general status did not allow us to perform the renal biopsy. Although corticosteroid therapy, hemodialysis, and plasma exchange were concomitantly initiated, pulmonary hemorrhage occurred several days after admission. Mechanical ventilation support was provided and continuous hemodiafiltration was carried out, following which the respiratory failure improved immediately. However, she developed clinical depression and suicidal behavior under the intensive therapy. Therefore, plasma exchange was discontinued and corticosteroid was tapered as quickly as possible. Four months after admission, platelet transfusion and short-term mechanical ventilation support improved the pulmonary hemorrhage; however, her mental status deteriorated despite psychiatric consultation and treatment with a tranquilizer. Thereafter, severe and serious systemic infection due to various pathogens including Staphylococcus aureus, Cytomegalovirus, Pneumocystis jiroveci, Pseudomonas aeruginosa, and Bacteroides recurred, and she died from systemic invasive aspergillosis (IA). We suspected severe immunosuppression caused by various factors, such as predonisolone administration, chronic renal failure on maintenance hemodialysis, depression, and malnutrition due to chronic inflammation and granulocytopenia as a side effect of ganciclovir. When treating rapidly progressive glomerulonephritis, immunosuppressive status should be carefully monitored regarding not only the dosage of therapeutic regimen but also the mental health status and nutrition of the patient.

Changes in blood pressure during induction of anesthesia and oral and maxillofacial surgery by type and timing of discontinuation of antihypertensive drugs

The purpose of this study was to evaluate the effects of an antihypertensive drug class and the timing of discontinuation of antihypertensive therapy on blood pressure during oral and maxillofacial surgery for 129 patients on antihypertensive therapy receiving general anesthesia. Blood pressures at loss of response to stimulation and 5-15 minutes after intubation were significantly lower than those before induction, although the type of antihypertensive therapy did not affect changes in blood pressure. No significant correlation was observed between systolic blood pressure (SBP) on the ward and change in SBP during surgery, though patients with higher blood pressure on the ward tended to exhibit larger differences between SBP on the ward and the lowest SBP during surgery. Frequency of use of vasopressors during surgery was significantly higher in patients who discontinued antihypertensive therapy on the day before surgery than in those who continued antihypertensive therapy on the day of surgery. These findings suggest that appropriate preoperative antihypertensive therapy is important for minimizing change in blood pressure during surgery and preventing perioperative complications. Patients undergoing antihypertensive therapy should be carefully monitored perioperatively by observation for interactions between antihypertensive and anesthetic agents and minimizing interruption schedules for antihypertensive therapy.

Feasibility of an electrochemically assisted Fenton method using Fe(2 +)/HOCl system as an advanced oxidation process

The feasibility of an electrochemically assisted Fenton treatment using a Fenton-type reaction of ferrous iron (Fe(2 + )) and hypochlorous acid (HOCl) is discussed in this research. The reactor used was composed of an undivided single cell with a ruthenium dioxide-coated titanium anode and a stainless steel cathode, in which Fe(2 + ) and HOCl were catalytically regenerated from ferric iron at the cathode and chloride ion at the anode, respectively. Although the reactor functioned well, the degradation rate of 1,4-dioxane as a hydroxyl radical probe decreased at the current density more than 6.92 mA cm(-2). The decrease in degradation rate was inferred to be caused by the vain consumption of hydroxyl radicals by excess HOCl and the deposition of ferric hydroxide on the cathode at relatively high current density. The current efficiency of 1,4-dioxane removal remained more than 90% at the current density less than 6.92 mA cm(-2) and the iron concentration not less than 1.0 mmol L(-1). Consequently, this technique is thought to be applicable to the treatment of wastewater containing high concentration of chloride ion such as landfill leachate, scrubber wastewater from incineration plants, etc.

Effect of active control of electric potential of filter medium on depth filtration

The effect of active control of electric potential of filter medium on depth filtration was explored experimentally. Activated carbon particles were selected as the conductive filter medium. The filter medium potential was controlled with an external DC power supply. Kaolin particles were used as the model suspended solid. The activated carbon and kaolin had negative zeta potential around neutral pH. When the filter medium potential against a counter electrode was greater than or equal to + 0.2 V, rejection rate of particles was 1.8 times higher than that when the potential was less than + 0.2 V. Thus adsorption of particles by interaction of electric double layers was enhanced by maintaining a positive charge on the filter media. Desorption of kaolin trapped on the filter media was also confirmed by changing the filter medium potential from positive to negative. The percentage of kaolin particles desorbed was 11% of the kaolin trapped on the filter media. The desorption rate was not high, but this technique will enhance refreshment of the filter media when combined with back washing.

Comparison of Parker-tipped and Murphy-tipped tracheal tubes in Airway Scope-assisted intubation in a manikin

PURPOSE

We tested our hypothesis that a Parker-tipped tracheal tube could improve the reliability of tracheal tube passage as compared to a Murphy-tipped tracheal tube during Airway Scope-assisted intubation in a manikin.

METHODS

Twenty-seven resident doctors performed Airway Scope-assisted intubations using both tracheal tubes, and the number of times the tracheal tube tip touched the glottis or other laryngeal structures was counted on the Airway Scope monitor.

RESULTS

The incidence of the tracheal tube tip touching the glottis during Airway Scope-assisted intubation using the Parker-tipped tracheal tube (7.4%; 2 of 27 attempts) was significantly less than that obtained using the Murphy-tipped tracheal tube (33.3%; 9 of 27 attempts; P = 0.039).

CONCLUSION

When the advancement of a conventional tracheal tube during Airway Scope-assisted intubation is likely to result in collision with the glottis or other laryngeal structures, the selection of a Parker-tipped tracheal tube is a better option.

Microstrip structures of ZnO nanoparticle aggregates of millimetric length formed by selected-area ion implantation and thermal oxidation

Regularly arrayed microstrip regions of width approximately 1.4 microm and length extending up to approximately 5 mm, consisting of ZnO nanoparticles (NPs) of diameter approximately 50 nm, were fabricated on silica substrates by a two-step process: i.e., selected-area ion implantation and thermal oxidation. The implantation of 60 keV Zn ions in periodic microstrip regions via a resist mask generated periodic grooves with large wings on the surface of silica glass, which can be ascribed to the radiation-induced plastic deformation of silica and sputtering loss. This is the lowest record of the electronic energy loss (S(e)) value to induce the radiation-induced plastic deformation of silica, while no or very low threshold energy has been predicted from a recent study. After thermal oxidation at 700 degrees C for 1 h, the groove structures with the wings disappeared, and periodic microstrips of ZnO nanoparticle aggregates up to 5 mm long appeared on the surface of the substrate. A clear free-exciton peak due to ZnO NPs is observed from these microstrip structures both in optical absorption and photoluminescence spectra.

Nanogroove formation by ion irradiation on indentation-modified amorphous SiO(2)

Ion beams are widely used for micro/nanostructure fabrication with unique features of the energetic processes. In this work, we present a self-assembled nanostructure fabrication by ion irradiation with a patterned strain/stress field. The patterned strain/stress field is introduced by micro-Vickers indentation to amorphous SiO(2) (load = 100 mN). After irradiation of 60 keV Cu(-) ions, nanogrooves (width from 150 to 250 nm) were created at the indentation edge. Under the ion irradiation of a constant ion flux, the nanogroove size linearly increased with ion fluence from 2 × 10(16) to 1.2 × 10(17) ions cm(-2). Comparison of indented samples after irradiation and thermal annealing suggests that the nanogrooving originates from ion beam interactions with residual stress/strain by indentation and that a non-thermal effect results from the ion irradiation processes. Cross-sectional TEM analysis showed that the grooves extend over 200 nm below the surface, implying that the groove growth is not caused by surface diffusion. It is concluded from the results that the grooving is due to irradiation-induced mass transport accompanied by vacancy aggregation at the interface between the indented and non-indented areas.

Dual surface plasmon resonances in Zn nanoparticles in SiO(2): an experimental study based on optical absorption and thermal stability

Metallic zinc nanoparticles (NPs) of 5-15 nm in diameter, formed in silica glass (SiO(2)) by Zn ion implantation of 60 keV, showed a strong ultraviolet absorption peak at around 4.8 eV, which has been assigned as the surface plasmon resonance (SPR) of Zn NPs, and another small peak at 1.2 eV, which has never been reported before. To identify the origin of the 1.2 eV peak, the correlations of thermal stability between the two peaks and Zn NPs were evaluated under annealing both in a vacuum (pure thermal stability) and in oxygen gas (thermal oxidation stability). The well-correlated stability between the 1.2 eV peak, the 4.8 eV peak and Zn NPs indicates that the 1.2 eV peak is not ascribed to radiation-induced defects but to the Zn NPs. The 1.2 eV peak can be ascribed to an SPR of Zn NPs in SiO(2), because the peak satisfies the criterion of the SPR of metallic NPs. Since the 4.8 eV peak is also expected to satisfy the criterion, Zn NPs in SiO(2) have two SPRs at 1.2 and 4.8 eV.

Histamine ameliorates anti-glomerular basement membrane antibody-induced glomerulonephritis in rats

Anti-glomerular basement membrane (anti-GBM)-induced glomerulonephritis involves T-helper type 1 (Th1) responses leading to rapid crescent formation. As many inflammatory and immune responses in general are affected by histamine, we examined the effects of histaminergic ligands on immune renal injury in the rat. Female Wistar-Kyoto rats were injected intraperitoneally with an antibody against the GBMs. Histaminergic ligands were then injected twice daily for 5 days after which renal function was assessed by proteinuria. Treatment with histamine led to significant dose-dependent reductions in proteinuria compared to the control antibody-injected group and markedly decreased the number of crescentic glomeruli and macrophage infiltration of the glomeruli. Furthermore, histamine significantly decreased the plasma concentration of interleukin-12, a Th1-type cytokine compared to the antibody-injected control animals. Dimaprit, an H(2)/H(4) agonist, mimicked the effects of histamine on proteinuria and crescent formation. Clozapine, an H(4) agonist, tended to mimic the effects of histamine, whereas an H(1), mepyramine, or an H(2) antagonist, ranitidine, did not reverse the protective effect of histamine. We suggest that histamine may alleviate renal injury in anti-GBM glomerulonephritis by suppressing the immune response.

Renal involvement in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary systemic arteriopathy presenting with migraines, mood disorders, focal neurologic deficits, recurrent ischemic attacks and dementia in young adults. The genesis of this disease relates to missense mutation of the Notch3 gene. We report here a newly identified CADASIL patient and discuss unique vascular lesions observed in the kidney. A 64-year-old female was admitted to our hospital for the investigation of proteinuria, hematuria and progressive neurological abnormalities. Her mother and brother died of cerebral infarction at a relatively young age despite a lack of apparent risk factors for arteriosclerosis. Over the past 4 months before admission, she had suffered from frequent transient ischemic attacks despite appropriate antiplatelet therapy. Blood examination revealed mild renal insufficiency and urinalysis revealed moderate protein excretion and dysmorphic hematuria. Magnetic resonance imaging of the brain revealed multiple infarcts and leukoencephalopathy. Histopathological analysis of the kidney revealed focal segmental mesangial proliferation, the loss and degeneration of arterial medial smooth muscle cells and arterial intimal thickening. Immunofluorescence analysis of glomeruli revealed IgA deposition in the mesangial area. Electron microscope analysis revealed electron-dense deposition also in the mesangial area. In addition, granular osmophilic material (GOM) was observed in the extraglomerular mesangial area and around the vascular smooth muscle cells. Genetic analysis of Notch3 revealed an R141C missense mutation and she was diagnosed with CADASIL complicated with IgA nephropathy. In immunohistological analysis, Notch3 stains were positive in vascular smooth muscle cells of the interlobular arteries and both afferent and efferent arterioles, and weak in the glomerular mesangial area. Antihypertensive treatment using angiotensin II receptor blocker and a low protein diet were initiated, and her urinary protein excretion decreased to 0.2 g/day. However, due to the progression of her neurological abnormalities, she became socially withdrawn. In CADASIL, GOM, abnormal accumulation of Notch3 ectodomain, is thought to induce the degeneration and loss of vascular smooth muscle cells and subsequent intimal thickening. Analysis of our cases provided that these morphological abnormalities were also observed in the CADASIL patient kidney.

Cytoplasmic antineutrophil cytoplasmic antibody positive pauci-immune glomerulonephritis associated with infectious endocarditis

Renal deterioration often occurs in cases of infectious endocarditis (IE), but, IE- associated nephritis with rapidly progressive glomerulonephritis (RPGN) is rare. Patients with severe infection (e.g., IE) sometimes show positivity for cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA). Therefore, diagnosis and treatment are very difficult in cases of RPGN with IE and positivity for C-ANCA. Such cases are rare, only 12 have been reported in the English literature. Herein, we describe the case of a 50-year-old man who presented with RPGN with IE and tested positively for C-ANCA. He was referred to our hospital because of leg edema, purpura and renal dysfunction. Laboratory tests revealed serum creatinine elevation and positivity for C-ANCA and proteinase 3-specific (PR3)-ANCA. RPGN and acute renal failure were diagnosed. Hemodialysis and steroid therapy were started. Streptococcus oralis was isolated by blood culture. Transthoracic echocardiography revealed grade III mitral valve insufficiency with two vegetations. Therefore, IE was diagnosed. The steroid therapy was stopped, and antibiotic therapy was begun. Because there was no improvement, surgical therapy was performed. The operation was successful, but the patient died of brain hemorrhage. Our experience in this case indicates C/PR3-ANCA positive RPGN must be ruled out in patients with infectious disease, particularly IE, together with renal symptoms, and renal biopsy should be performed.