The first case of hemorrhagic shock and encephalopathy syndrome with fulminant hypercytokinemia associated with pediatric COVID-19

BACKGROUND

Infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead not only to respiratory symptoms but also to neurologic symptoms with various levels of severity. After the worldwide prevalence of Omicron variant, severe neurological manifestations of coronavirus disease 2019 (COVID-19) such as febrile seizure, demyelinating disease, and cerebrovascular disease, have been reported. However, reports of acute encephalopathy in patients with COVID-19 are quite limited. Especially in terms of cytokine storm-inducing hemorrhagic shock and encephalopathy syndrome (HSES), there is no case reported related to COVID-19.

CASE PRESENTATION

We describe the case of an 8-year-old girl who presented with fatal HSES associated with pediatric SARS-CoV-2 infection. Status epilepticus occurs after the onset of fever and diarrhea and lasted for at least an hour. Unconsciousness was followed by circulatory failure and ultimately leading to death within 2 days after the fever onset. Analysis of forty-eight cytokines and chemokines measured in three consecutive serum samples revealed that interferon (IFN)-γ, interleukin (IL)-6, IL-10, IL-17A, tumor necrosis factor (TNF)-a, IL-8, Interferon gamma inducible protein (IP)-10, and Monocyte chemoattractant protein (MCP)-1, were increased within an hour after the onset of impaired consciousness.

CONCLUSION

Here, we describe a case of fatal fulminant encephalopathy with rapid progression because of HSES associated with COVID-19. High levels of cytokines and chemokines observed in this case may be because of the SARS-CoV-2-associated cytokine storm. This study is the first COVID-19-associated case of HSES.

Clinical significance of assessing cerebral blood volume by time-domain near-infrared spectroscopy in children with congenital heart disease

BACKGROUND

Despite providing cerebral tissue oxygen saturation (StO₂ ), the lack of quantitative information for continuous wave near-infrared spectroscopy (CW-NIRS) is an obstacle in evaluating cerebral hemodynamic conditions. Time-domain NIRS (TD-NIRS) provides both StO₂ and cerebral blood volume and has recently become clinically available.

AIM

To investigate if the additional monitoring of cerebral blood volume by TD-NIRS facilitates the understanding of cerebral hemodynamic conditions in patients with congenital heart disease.

METHODS

Preoperative TD-NIRS values were retrospectively reviewed in patients who underwent a cardiac surgery or catheter examination. We compared the values between patients with single and two ventricles. Moreover, we investigated the association of these values with the demographic and clinical variables.

RESULTS

There was no significant difference in StO2 between single ventricle and two ventricles groups (median: 59.9 vs. 54.4, median difference [95% CI]: -4.06 [-9.90 to 2.90], p = .37). However, cerebral blood volume was significantly higher in the single ventricle group (median: 4.68 vs. 2.84, median difference [95% CI]: -2.01 [-2.88 to -1.06], p < .001). Spearman's rank correlation analysis demonstrated an association between StO2 and postmenstrual age (r = 0.35, p = .03). In contrast, cerebral blood volume was correlated with single ventricle physiology (r = 0.62, p < .001), postmenstrual age (r = 0.74, p < .001), central venous pressure (r = 0.38, p = .02), and SaO2 (r = -0.38, p = .02). The multivariable regression analysis identified the postmenstrual age, single ventricle physiology, and SaO2 as independent factors associated with cerebral blood volume. In the logistic analysis, cerebral blood volume was identified as a significant predictor of unfavorable conditions.

CONCLUSION

Cerebral blood volume monitoring detected differences in cerebral hemodynamic conditions, related to the age and the type of ventricle physiologies. However, the differences were not apparent in StO₂ . The additional monitoring of cerebral blood volume by TD-NIRS would facilitate a better understanding of cerebral hemodynamic conditions in patients with congenital heart disease.

Bispectral Index™ variation during living donor liver transplantation in a child with hepatic encephalopathy: a case report

Background

It is unclear whether perioperative Bispectral Index™ (BIS) monitoring in pediatric cases with acute liver failure (ALF) is effective for evaluation of neurological function. We describe a pediatric patient with hepatic encephalopathy (HE) in whom the BIS value increased from low levels to the normal range during liver transplantation (LT).

Case presentation

Electroencephalography in a 6-year-old comatose girl diagnosed with ALF and HE who was unresponsive to pain and auditory stimuli revealed continuous slow waves, and hence, emergency LT was performed. Intraoperatively, BIS values remained low until reperfusion. However, BIS value variability increased after reperfusion. She was subsequently discharged without any neurological sequelae.

Conclusions

Low BIS values were considered to reflect the severity of HE. It is possible that improvement of the BIS value and waveform was a reflection of graft function. BIS monitoring might be a good indicator of neurological recovery after LT.

Dopaminergic restoration of prefrontal cortico-putaminal network in gene therapy for aromatic l-amino acid decarboxylase deficiency

Aromatic l-amino acid decarboxylase (AADC) is an essential dopamine-synthesizing enzyme. In children with AADC deficiency, the gene delivery of AADC into the putamen, which functionally interacts with cortical regions, was found to improve motor function and ameliorate dystonia. However, how the restoration of dopamine in the putamen in association with cortico-putaminal networks leads to therapeutic effects remains unclear. Here, we examined neuroimaging data of eight patients with AADC deficiency (five males and three females, age range 4-19 years) who received the AADC gene therapy of the bilateral putamen in an open-label phase 1/2 study. Using high-resolution positron emission tomography with a specific AADC tracer, 6-[¹⁸F]fluoro-l-m-tyrosine (FMT), we showed that FMT uptake increased in the broad area of the putamen over the years. Then, with the structural connectivity-based parcellation of the putaminal area, we found that motor improvement is associated with dopaminergic restoration of the putaminal area that belongs to the prefrontal cortico-putaminal network. The prefrontal area dominantly belongs to the frontoparietal control network, which contributes to cognitive-motor control function, including motor initiation and planning. The results suggest that putaminal dopamine promotes the development of an immature motor control system, particularly in the human prefrontal cortex that is primarily affected by AADC deficiency.

Perioperative management of Fontan operation for the child with panhypopituitarism: a case report

With the surgical improvement of congenital heart disease, Fontan operation has been applied to many complicated patients in recent years. This is the first report of a child with panhypopituitarism who underwent Fontan operation. A 5-year-old boy was scheduled for Fontan operation. He previously underwent Blalock-Taussig shunt and bidirectional Glenn operations for univentricular heart with double-outlet right ventricle and pulmonary atresia. He was receiving hydrocortisone and 1-desamino-8-D-arginine vasopressin (DDAVP) for panhypopituitarism secondary to removal of craniopharyngioma performed at the age of three years. Although urine output and serum sodium concentration were adequately controlled by adjustment of vasopressin infusion rate during surgery, massive pleural effusions and ascites developed postoperatively, which required several days for control by adjusting the dose of oral DDAVP and normalize the serum sodium level. Intraoperative management of Fontan operation for a patient with panhypopituitarism was controllable by appropriate hormone replacement. However, postoperative fluid management was complicated by the clinical features of panhypopituitarism and Fontan physiology.

Gene therapy improves motor and mental function of aromatic l-amino acid decarboxylase deficiency

In patients with aromatic l-amino acid decarboxylase (AADC) deficiency, a decrease in catecholamines and serotonin levels in the brain leads to developmental delay and movement disorders. The beneficial effects of gene therapy in patients from 1 to 8 years of age with homogeneous severity of disease have been reported from Taiwan. We conducted an open-label phase 1/2 study of population including adolescent patients with different degrees of severity. Six patients were enrolled: four males (ages 4, 10, 15 and 19 years) and one female (age 12 years) with a severe phenotype who were not capable of voluntary movement or speech, and one female (age 5 years) with a moderate phenotype who could walk with support. The patients received a total of 2 × 10¹¹ vector genomes of adeno-associated virus vector harbouring DDC via bilateral intraputaminal infusions. At up to 2 years after gene therapy, the motor function was remarkably improved in all patients. Three patients with the severe phenotype were able to stand with support, and one patient could walk with a walker, while the patient with the moderate phenotype could run and ride a bicycle. This moderate-phenotype patient also showed improvement in her mental function, being able to converse fluently and perform simple arithmetic. Dystonia disappeared and oculogyric crisis was markedly decreased in all patients. The patients exhibited transient choreic dyskinesia for a couple of months, but no adverse events caused by vector were observed. PET with 6-[¹⁸F]fluoro-l-m-tyrosine, a specific tracer for AADC, showed a persistently increased uptake in the broad areas of the putamen. In our study, older patients (>8 years of age) also showed improvement, although treatment was more effective in younger patients. The genetic background of our patients was heterogeneous, and some patients suspected of having remnant enzyme activity showed better improvement than the Taiwanese patients. In addition to the alleviation of motor symptoms, the cognitive and verbal functions were improved in a patient with the moderate phenotype. The restoration of dopamine synthesis in the putamen via gene transfer provides transformative medical benefit across all patient ages, genotypes, and disease severities included in this study, with the most pronounced improvements noted in moderate patients.

Influence of the aldehyde dehydrogenase 2 polymorphism on the vasodilatory effect of nitroglycerin in infants with congenital heart disease and pulmonary arterial hypertension

PURPOSE

The influence of the aldehyde dehydrogenase 2 (ALDH2) gene polymorphism on the pharmacokinetics and haemodynamics of nitroglycerin (GTN) was determined in human subjects.

METHODS

Eighteen infants (nine each with and without ALDH2 gene polymorphism) with congenital heart disease and pulmonary arterial hypertension participated in this study. GTN treatment started at a dose of 2 μg/kg/min, and the dose was escalated by 1-2 μg/kg/min until pulmonary vascular resistance (PVR) was reduced by more than 30%. The plasma GTN concentration and PVR were measured at the end of each infusion period.

RESULTS

Plasma GTN concentrations were significantly higher in patients with the ALDH2 gene polymorphism than in those without the polymorphism. Conversely, the reduction in PVR was smaller in patients with the ALDH2 gene polymorphism than in those without.

CONCLUSIONS

These data suggest that the ALDH2 gene polymorphism influences the pharmacokinetics and haemodynamics of GTN in human subjects.

[Use of RRa sensor in a pediatric patient with post-adenotonsillectomy]

Rad-87 and RRa are new acoustic monitoring devices which can monitor the respiratory rate. To our knowledge, no studies have reported the RRa sensor used in pediatric patients after surgery. We succeeded in measuring the respiratory rate with the RRa sensor in the Pediatric Intensive Care Unit(PICU). A 10-year-old boy, 14.5 kg in weight and 119.6 cm in height, with cerebral palsy, mental retardation, epilepsy, and obstructive sleep apnea due to adenoidal and tonsillar hypertrophy, was scheduled for adenotonsillectomy under general anesthesia. Anesthesia was maintained with oxygen, air, sevoflurane (1.5-2.0%), remifentanil (0.1 to 0.5 microg . kg-1. min-1), and fentanyl (4 microg . kg-1). The operating time was 55 minutes, and the duration of anesthesia was 133 minutes. After finishing the surgery, we attached the RRa sensor to his anterior neck and monitored his respiratory rate. Furthermore, RRa could count his respiratory rate, during transfer from the operating room to PICU. The patient was sedated with dexmedetomidine (0.28 microg . kg-1 . min-1) at PICU, and his respiratory rate was accurately measured with the RRa sensor. We hope that Rad-87 and RRa sensors will become useful for measuring the respiratory rate in pediatric patients in the future.

[General anesthesia for pediatric cardiac catheterization--effects of anesthetics on blood pressure, heart rate, oxygen saturation, and carbon dioxide]

BACKGROUND

There are limited data about the correlations between amount of anesthetics and variations in vital signs during pediatric cardiac catheterization.

METHODS

Data in 80 children with congenital heart disease undergoing cardiac catheterization with/without interventional cardiology in 2004 were examined in this retrospective cohort study. Data on blood pressure, heart rate, oxygen saturation, partial tension in end tidal carbon dioxide (PETCO2), and total amount of anesthetics given during general anesthesia were obtained from anesthetic charts. The correlations between amount of anesthetics and those vital signs were analyzed.

RESULTS

Median age of the patients was 14 months and median body weight was 8.8 kg. Median rates of variation in heart rate, blood pressure, oxygen saturation and PET(CO2) were 22.8%, 29.3%, 5.9% and 10.8%, respectively. Although there were no statistical correlations between those vital signs and amounts of anesthetics such as fentanyl, vecuronium and sevoflurane, rates of variation in heart rate was smaller in patients for whom the amount of fentanyl given was more than 4 microg x kg(-1) x hr(-1).

CONCLUSIONS

There were no associations between amount of anesthetics and variations in vital signs in pediatric cardiac catheterization.

[Airtraq optical laryngoscope: clinical assessment of its performance in 100 children]

BACKGROUND

The aim of the present study was to evaluate the suitability of Airtraq optical laryngoscope for the tracheal intubation in children.

METHODS

Endotracheal intubation was performed using the Airtraq optical laryngoscope in 100 pediatric patients undergoing general anesthesia. The time to complete tracheal intubation and optimizing procedures were recorded.

RESULTS

The Airtraq optical laryngoscope allowed visualization of the glottis and successful intubation in the 100 patients, including three patients with difficult airway. Utilization of a gum elastic bougie was helpful to introduce a tube tip to the trachea.

CONCLUSIONS

The Airtraq optical laryngoscope might be an alternative apparatus for endotracheal intubation in pediatric patients.

[Case report of endotracheal intubation using AirWay Scope (Pentax-AWS) in a Forestier's disease patient]

A Forestier's disease patient was scheduled for endoscopic mucosal resection under general anesthesia, because of his hypoxic episode during gastric endoscopy. Endotracheal intubation was planned while awake, because he was suspected as a case of difficult airway. By using AWS, we could easily confirm his larynx and aditus of trachea in spite of his narrow pharynx caused by Forestier's disease. The procedure was successful with no complications. AWS seems to be a useful device for endotracheal intubation in Forestier's disease.

Rudimentary right ventricle to pulmonary artery shunt in the Norwood procedure

We describe here successful palliative repair of tricuspid atresia, hypoplastic right ventricle, transposition of the great arteries, and hypoplastic aortic arch in a neonate. The repair consisted of the Norwood procedure with a rudimentary right ventricle to pulmonary artery shunt, which was located on the right side of a neo-aorta. This procedure could be a useful adjunct to avoid left ventriculotomy and its subsequent dysfunction.

[A case report of successful treatment of a child with respiratory distress using non-invasive continuous positive airway pressure via helmet]

Helmet is a new device of non-invasive continuous positive airway pressure (CPAP). Few cases have been described about usage of the helmet in children. We describe successful treatment of a child with respiratory distress using the helmet-delivered non-invasive CPAP. A 2-month-old male infant (3.1 kg) with multiple anomalies (cardiovascular, facial, and vertebral) developed respiratory distress after extubation. The helmet was well tolerated regardless of facial anomaly. Helmet CPAP started at initial settings of CPAP 8 cm H2O and FI(O2) 0.7, improved oxygenation. Pa(O2)/FI(O2) ratio increased from 106 to 316, and chest X-rays showed a marked improvement (15 hour after NPPV initiation). The helmet offers important advantage: the possibility of fitting to any children, regardless of any facial or external anomalies.

Distribution of aerobic bacteria which contain bacteriochlorophyll a

Sixteen strains of aerobic bacteria which contain bacteriochlorophyll a were isolated from the samples collected in aerobic marine environments: thalli of Enteromorpha linza, Porphyra sp., Sargussum horneri; beach sand; and the surface seawater from Aburatsubo Inlet. When they occurred, their proportions among the aerobic heterotrophic populations ranged from 0.9 to 1.1% in the seaweed samples and from 1.2 to 6.3% in the beach sand samples and were 0.9% in the seawater sample. The results suggested that the aerobic photopigmented bacteria widely inhabit aerobic marine environments.

Radial incision for ventricular septal defect with membranous septal aneurysm

Surgical exposure and accurate closure of a ventricular septal defect with a membranous septal aneurysm beneath the septal tricuspid leaflet carries a risk of tricuspid valve dehiscence and conduction disturbances when the septal leaflet is detached along the tricuspid annulus. To avoid these problems, we use a radial incision to expose and close perimembranous ventricular septal defects. We reviewed recent cases to determine the risks and benefits of this technique. From January 2005 through September 2008, 30 patients underwent closure of a perimembranous ventricular septal defect through a right atrial approach at our institution. The operation included radial incision of the membranous septal aneurysm to improve visualization of the perimembranous ventricular septal defect in 9 patients. There was no perioperative or late death. The operative and postoperative courses were uneventful in all cases. A residual leak was detected in only one patient. No patient had more than mild postoperative tricuspid valve insufficiency, none underwent reoperation, and no new arrhythmia or conduction disturbance was detected during follow-up. The radial incision for closure of a ventricular septal defect with a membranous septal aneurysm provides satisfactory exposure of the defect through the right atriotomy, for safe and accurate closure.

[Use of the GlideScope video laryngoscope in 50 pediatric patients]

BACKGROUND

The GlideScope video laryngoscope (Verathon Inc. Bothell, Washington, USA) is a relatively new device for tracheal intubation, which provides a excellent glottic visualization. We here report the clinical experience of the GlideScope (small) in 50 pediatric patients.

METHODS

Tracheal intubation with GlideScope (small) was performed in 50 consecutive pediatric patients requiring orotracheal intubation for surgery. The view of glottic opening was scored according to the classification of Cormack-Lehane. The time required to intubate and the number of intubation attempts were recorded.

RESULTS

In all, 50 children included 4 neonates, 8 infants under 1 year and 38 children between 1 year and 9 years. Cormack-Lehane classification 1 or 2 was obtained in 74% and 22%, respectively, and successful intubation was achieved in 48 of 50 children (96%). In remaining two babies, GlideScope failed to intubate the trachea. The mean +/- SD time for instrumentation in successful intubation at first attempt was 56.6 +/- 34.2 seconds.

CONCLUSIONS

GlideScope seemed to be a novel device in pediatric patients. Further studies are required to evaluate the usefulness in neonates, small infants and children with a difficult airway.

[Work load of anesthesiologists at the Central Surgical Unit of the Jichi Medical University Hospital]

BACKGROUND

Since the diagnosis procedure combination (DPC) for health insurance plans in Japan was started in medical practice, the number of surgical procedures is increasing at teaching hospitals.

METHODS

We retrospectively surveyed 8,672 surgical procedures performed at the central surgical unit of the Jichi Medical University Hospital from April 1, 2007 to March 31, 2008.

RESULTS

Of the 8,672 surgical procedures, 6,922 operations were performed under the management of anesthesia staffs, and 1,904 procedures (27.5%) were done in emergency situation. Central surgical unit has 14 operating rooms and an estimated maximum number of surgical procedures is 7,700.

CONCLUSIONS

This survey revealed that the present status of manpower of anesthesiologists at our hospital was insufficient for the work. In particular, the demands for anesthesiologists have increased in emergency operations including major cardiovascular surgery, neurosurgery and liver transplantations.

[Crisis management in pediatric anesthesia]

We describe the risk management of pediatric anesthesia. The most important risk management of pediatric anesthesia is airway and temperature management. Neonates and infants easily become hypoxic due to their insufficient functional residual capacity. Therefore airway management is most important not only during induction of anesthesia but also during maintenance of anesthesia and extubation. The management of patients' temperature, including control of room temperature should be taken into consideration. In addition, careful attention should be paid not to introduce air bubbles in any lines, especially in patients with congenital heart diseases.

[Use of the airway scope for difficult airway]

The Airway Scope (AWS) is a new videolaryngoscope which consists of an optical system and a single-use blade. The blade of the device is designed according with the pharyngeal anatomy, and thus the AWS is expected to have a role in the management of difficult airway. We here report 15 patients with difficult airway in whom the AWS provided in successful intubation. The AWS provides a view of the glottis with Cormack-Lehane grade 1 and resulted in successful intubation in the 15 patients. The AWS is useful for the management of difficult airway.

[Study on the working conditions of rotating residents in the department of anesthesia under the new residency programs]

BACKGROUND

Jichi Medical University Hospital established a new residency program in 2004, which restricted the working time of junior residents to less than 80 hours for one week involving conferences and lectures.

METHODS

We evaluated the working conditions of non-anesthesia residents in the department of anesthesia from April 2005 to March 2006.

RESULTS

Non-anesthesia residents were engaged in anesthesia for 112 +/- 37 (mean +/-SD) hours for one month.

CONCLUSIONS

Non-anesthesia residents worked in the anesthesia department under the regulation of the new residency program. However, a significant increase in the number of anesthesia cases, observed in recent years, is a potential imperilment of the new residency program.

[GlideScope videolaryngoscope: a clinical assessment of its performance in 200 consecutive patients]

BACKGROUND

The GlideScope videolaryngoscope is a new device for endotracheal intubation, which provides a view of the glottis without alignment of the oral pharyngeal and tracheal axes. The purpose of this study was to evaluate the performance of the GlideScope in patients.

METHODS

We evaluated the performance of the GlideScope" in 200 consecutive patients requiring orotracheal intubation for surgery.

RESULTS

In the 200 patients, excellent (Cormack-Lehane [C-L] view 1) or good (C-L 2) laryngeal exposure was obtained in 68% and 31% respectively and successful orotracheal intubation was achieved in all the patients. The mean +/- SD time to intubate was 51 +/- 20 seconds in trainees, 52 +/- 25 seconds in junior anesthesia residents, 48 +/- 18 seconds in senior anesthesia residents, and 50 +/- 18 seconds in staff anesthetists.

CONCLUSIONS

The GlideScope was easily handled not only by experienced anesthetists but also by novice personnel. The GlideScope seems to be a novel device in routine and difficult airway management.

[General anesthesia outside the operating room in patients with Pierre-Robin syndrome]

Anesthesiologists are increasingly asked to involve in administering general anesthesia outside the operating room for such procedures as computed tomography, magnetic resonance imaging or angiography. Especially, pediatric patients require some kind of sedation or general anesthesia during these procedures. We report general anesthesia outside the operating room in patients with Pierre-Robin syndrome, who are expected to have possible difficult airway. A one-year-old girl and a 16-year-old boy were anesthetized for cardiac catheterization. General anesthesia was given at the angiography room which was located outside the operating room. Anesthesia was induced with oxygen, nitrous oxide and sevoflurane while portable storage unit for difficult airway was prepared including various types and size of laryngoscopes, laryngeal mask airway, fiberoptic intubation equipment and surgical airway access. Fortunately, tracheas were successfully intubated without using special devices, although cautious care during induction was taken. According to development of medical and surgical procedures, it is readily presumed that anesthesiologists will be more often involved in the sedation or anesthesia conducted outside the operating room in future. Anesthesiologists should always ensure enough staffing, proper monitoring and equipment when sedation or anesthesia is conducted outside the operating room, particularly if patients have anesthetic risks.

Anesthetic management of a patient with severe dilated cardiomyopathy and an automatic implantable cardioverter-defibrillator (AICD) during total gastrectomy

We report a case of severe dilated cardiomyopathy with an automatic implantable cardioverter-defibrillator (ICD) undergoing total gastrectomy. During the operation, the defibrillation function of the ICD was suspended and its pacing function was used solely in VOO mode. Electrodes of an external defibrillator were attached on the chest wall, and a pulmonary arterial (PA) catheter with a ventricle pacing port was inserted into the pulmonary artery. Proper perioperative management, including measures that the patient underwent the surgery uneventfully and could attain a rapid and successful discharge from the intensive care unit.

[Postoperative course after first-stage palliation of hypoplastic left heart syndrome with right ventricle-to-pulmonary artery shunt; compared with classic Norwood procedure]

BACKGROUND

A recent modification of the Norwood procedure involves the use of a right ventricle-to-pulmonary artery (RV-PA) shunt to provide pulmonary blood flow for patients with hypoplastic left heart syndrome (HLHS). We investigated the hemodynamics after first-stage palliation of HLHS with RV-PA shunt compared with classic Norwood procedure with subclavian-to-pulmonary artery (BT) shunt.

METHODS

The postoperative course of 12 infants who had undergone first-stage palliation for HLHS using BT shunt (group BT: n=6) and RV-PA shunt (group RV-PA: n=6) were retrospectively reviewed and we obtained the following data: blood pressure, heart rate, inotropic support, atrial pressure, lactate, base excess, PaO2, FIO2.

RESULTS

The RV-PA shunt using a non-valved conduit provided higher diastolic blood pressure than the BT shunt, but no significant difference in heart rate, systemic blood pressure, inotropic support and atrial pressure was observed between the two groups. Although the infants in the group RV-PA required significantly more myocardial ischemic time for operative procedure than those in the group BT, the serum lactate level in the group RV-PA was significantly lower than those in the group BT.

CONCLUSIONS

These results show that the RV-PA shunt provides a stable systemic circulation and abundant tissue oxygen supply. Excellent hemodynamics provided by RV-PA shunt is beneficial for infants undergoing stage I palliation for HLHS.

Increased carbon monoxide concentration in exhaled air after surgery and anesthesia

Heme oxygenase-1 (HO-1) is induced by oxidative stress and is thought to confer protection against oxidative tissue injuries. HO-1 catalyzes the conversion of the heme moiety of hemeproteins, such as hemoglobin, myoglobin, and cytochrome P450, to biliverdin, liberating carbon monoxide (CO) in the process. CO reacts with hemoglobin to form carboxyhemoglobin. In this study, to examine the effect of anesthesia and/or surgery on endogenous CO production, we measured the amount of exhaled CO and the arterial carboxyhemoglobin concentration of patients who underwent surgery under general or spinal anesthesia. Both CO and carboxyhemoglobin concentrations were significantly larger on the day after surgery than during the preoperative period (P < 0.05) and in the recovery room (P < 0.05), regardless of anesthesia. However, neither index differed between general and spinal anesthesia. These results suggest that oxidative stress caused by anesthesia and/or surgery may induce HO-1, which catalyzes heme to produce CO, leading to increased exhaled CO concentration.

Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain

The long-term effect of percutaneous electrical nerve stimulation (PENS) on chronic low back pain (LBP) is unclear. We evaluated the number of sessions for which PENS should be performed to alleviate chronic LBP and how long analgesia is sustained. Patients underwent treatment on a twice-weekly schedule for 8 wk. Group A (n = 18) received PENS for 8 wk, group B (n = 17) received PENS for the first 4 wk and transcutaneous electrical nerve stimulation (TENS) for the second 4 wk, and group C (n = 18) received TENS for 8 wk. Pain level, degree of physical impairment, and the daily intake of nonsteroidal antiinflammatory drugs (NSAIDs) were assessed before the first treatment, 3 days after Week 2, Week 4, and Week 8 treatments, and at 1 and 2 mo after the sessions. During PENS therapy, the pain level decreased significantly from Week 2 in Groups A and B (P < 0.05 or 0.01), and physical impairment and required NSAIDs decreased significantly from Week 4 (P < 0.05 or 0.01) in Group A but only at Week 4 in Group B (P < 0.05 or 0.01). These effects were sustained until 1-mo follow-up (P < 0.01) in Group A but not in Group B; these effects were not observed at 2-mo follow-up even in Group A. In Group C, pain level decreased significantly only at Week 8 (P < 0.05). Our results indicate that repeated PENS is more effective than TENS for chronic LBP but must be continued to sustain the analgesic effect.

IMPLICATIONS

A cumulative analgesic effect was observed in patients with chronic low back pain (LBP) after repeated percutaneous electrical nerve stimulation (PENS), but this effect gradually faded after the treatment was terminated. Results indicate that although PENS is effective for chronic LBP, treatments need to be continued to sustain analgesia.

[Usefulness of intraoperative transesophageal echocardiography for pediatric patients with congenital heart disease]

This report describes usefulness of intraoperative transesophageal echocardiograpy (TEE) based on 773 cases we experienced in 7 years. We assessed residual lesions, ventricular function and preload with TEE. We found a case with stenotic lesion in her lateral tunnel which TEE revealed after Fontan procedure. We also ensured that no micro air bubble was in the left ventricle and the left atrium before weaning from cardiopulmonary bypass. No patient suffered from convulsion during postoperative management after induction of intraoperative TEE examination though we had had some cases in the previous year. Respiratory compromise was observed in 3 cases (0.5%) and significant hemodynamic change occurred in 9 cases (1.3%). The conditions improved just after withdrawing TEE probe. Neither inadvertent tracheal extubation, nor serious complication occurred during TEE examinations. The incidence of complications during pediatric TEE is low and TEE examination is useful for pediatric patients with congenital heart disease.

Right Ventricle of Patients Undergoing Congenital Cardiac Surgery Differentially Expresses Haem Oxygenase-1 and Heat Shock Protein 70 Genes

Reactive oxygen species are implicated in the pathogenesis of cardiac hypertrophy. Haem oxygenase-1 (HO-1), the rate-limiting enzyme in haem catabolism, is induced by oxidative stress and confers protection against oxidative tissue injuries. We used Northern blotting to examine expression of HO-1 and heat shock protein 70 (HSP70) in the hypertrophic cardiac muscle of eight patients (one infant and seven children) who underwent surgery for congenital heart disease. Levels of HO-1 and HSP70 mRNA were significantly increased in all specimens, but the orders of magnitude of the increases were different, suggesting that the genes expressing HO-1 and HSP70 are regulated separately.

Induction of renal metallothionein in rats with ischemic renal failure

Metallothionein (MT) is induced by various types of oxidative stress. However, whether or not MT is induced in renal ischemia/reperfusion injury, in which oxidative stress is believed to play a major role, remains unknown. The present study investigated MT expression in the kidneys of rats with ischmic acute renal failure (IARF). Rats were subjected to 60 min of bilateral renal ischemia followed by reperfusion. Renal MT mRNA expression was then analyzed by Northern blotting. MT expression in ischemic kidney was also localized by in situ hybridization and immunohistochemistry. Renal MT mRNA expression, which was barely detectable in the sham-operated control kidney, increased significantly at 3 h afer reperfsion, continued to increase to a maximal level at 24 h that was maintained for 48 h. The level of MT mRNA expression returned to that of the control by day 4. A morphological study revealed that MT was expressed exclusively in the renal tubular epithelial cells, which are the targets of ischemia/reperfusion injury, and that MT predominated in the outer medulla in the IARF rat kidney at transcriptional and translational levels. These results suggest that MT induced in the IARF rat kidney plays an important role in protecting renal cells against oxidative stress induced by ischemia/reperfusion.

Microbial production of poly-D-3-hydroxybutyrate from CO2

This short review covers the biotechnological aspects of the production of poly-D-3-hydroxybutyric acid, P(3HB), from H2, O2 and CO2 by autotrophic culture of the hydrogen-oxidizing bacterium, Ralstonia eutropha. Considering the efficiency of utilization of a gas mixture as substrate, a practical fermentation process using R. eutropha for the mass production of P(3HB) from CO2 should be designed on the basis of a recycled-gas, closed-circuit culture system. Also, maintaining the O2 concentration in a gas phase lower than 6.9% (v/v) is essential to prevent the gas mixture from exploding. Our study, using an explosion-proof fermentation bench plant and a two-stage culture system with a newly designed air-lift fermenter, demonstrated that very high P(3HB) yield and productivity could be obtained while the O2 concentration was maintained below 6.9%. However, a study on the continuous production of P(3HB) from CO2 by chemostat culture of R. eutropha revealed that the productivity and content of P(3HB) in the cells was considerably lower than by fed-batch culture. It is deduced that the use of the hydrogen-oxidizing bacterium, Alcaligenes latus, which accumulates P(3HB) even in the exponential growth phase, will be useful for the effective production of P(3HB) from CO2.

[A case of central retinal artery occlusion after anterior posterior fusion of the lumbar spine]

We report a case of central retinal artery occlusion after anterior-posterior fusion of the lumbar spine. The patient suddenly lost his vision of the right eye in the ICU just after the end of long procedure for anterior-posterior fusion of the lumbar spine. The patient was diagnosed as having central retinal artery occlusion, and treated successfully with treatments including immediate administration of urokinase and PGE1, stellate ganglion block, and hyperbaric oxygen therapy. The patient was discharged from the hospital on the 54th postoperative day with adequate vision to drive a car. Central retinal artery occlusion is a rare but very serious complication during and after supine surgery with prone position. It is very important for us to be aware of its possible occurrence. We have to diagnose and treat, as soon as possible, the vision loss after the spine surgery.

Significance of adrenomedullin under cardiopulmonary bypass in children during surgery for congenital heart disease

To elucidate the effect of adrenomedullin (AM) on fluid homeostasis under cardiopulmonary bypass (CPB), we investigated the serial changes in plasma AM and other parameters related to fluid homeostasis in 13 children (average age, 28.2 months) with congenital heart disease during cardiac surgery under CPB. Arterial blood and urine samples were collected just after initiation of anesthesia, just before commencement of CPB, 10 min before the end of CPB, 60 min after CPB, and 24 h after operation. Plasma AM levels increased significantly 10 min before the end of CPB and decreased 24 h after operation. Urine volume increased transiently during CPB, which paralleled changes in AM. Simple regression analysis showed that plasma AM level correlated significantly with urinary vasopressin, urine volume, urinary sodium excretion, and plasma osmolarity. Stepwise regression analysis indicated that urine volume was the most significant determinant of plasma AM levels. Percent rise in AM during CPB relative to control period correlated with that of plasma brain natriuretic peptide (r = 0.57, P < 0.01). Our results suggest that AM plays an important role in fluid homeostasis under CPB in cooperation with other hormones involved in fluid homeostasis.

[Four cases of the anomalous origin of the left coronary artery from the pulmonary artery]

We report perioperative management of 4 patients with anomalous origin of the left coronary artery from the pulmonary artery. This report involves with 3 infant cases and an adult. Two infants underwent coronary reimplantation procedure and Takeuchi's method was performed on the other infant. In all infant cases, mitral valve plasty was performed to correct mitral regurgitation secondary to papillary muscle dysfunction. The adult patient underwent CABG with ligation of LCA. General anesthesia was performed with high doses of fentanyl in all cases. We employed a relatively high PaCO2 and low FIO2 in order to maintain a high pulmonary vascular resistance. It aims to decrease the incidence of left to right shunt. We used epinephrine to wean one infant and the adult from cardiopulmonary bypass. Perioperative course was uneventful with the use of catecholamines and high doses of vasodilators for left ventricular dysfunction and coronary perfusion under mechanical ventilation.

[Anesthetic and perioperative management of 1000 cases of congenital heart surgery--massive vasodilator therapy and early extubation]

We report our anesthetic and perioperative management of 1000 cases of congenital heart surgery in Okayama University Medical School over the last six and a half years. Most of these patients were anesthetized by fentanyl and all patients were managed in our ICU postoperatively. Although hospital death rate in all patients was 4.5%, almost half of dead patients were patients with hypoplastic left heart syndrome. Neonatal mortality rate has been still high, 18.9%, which has been our main problem. We tried to extubate patients with complex congenital heart diseases earlier postoperatively for the last three years, using massive dose of vasodilators without nitric oxide.

Bacterial endotoxin-induced expression of metallothionein genes in rat brain, as revealed by in situ hybridization

In order to clarify acute-phase response in brain, we investigated induction of metallothionein (MT) genes by administrating an endotoxin (lipopolysaccharide) in rat intraperitoneum. We performed in situ hybridization on the serial brain sections to identify the cells expressing the MT genes in acute-phase. After endotoxin administration, transcripts of MT genes were detected in the arachnoideal, ependymal cells and glial cells around the Purkinje cells of the cerebellum, while no significant induction of the MT genes by zinc ion was observed in brain. These results suggest that the acute-phase response occurs specifically in at least these 3 non-neuronal cells.

[Usefulness of midazolam in a modified NLA--study on plasma concentrations]

Midazolam 0.2mg.kg-1 or diazepam 0.2mg.kg-1 was used as an induction agent in a modified NLA. Plasma concentrations of midazolam or diazepam were measured with benzodiazepines screen method, which was based on enzyme immunoassay. Pharmacokinetic analysis is based on the plasma concentration-time courses after a bolus injection. The distribution half-life (T alpha 1/2) of midazolam, 1.24 minutes, was shorter than that of diazepam, 3.85 minutes. The elimination half-life (T beta 1/2) of midazolam, 5.44 hours, was similar to that of diazepam, 5.02 hours. The initial fall-off in the alpha-phase was due to the distribution of the drug from plasma to the peripheral compartment, while the drop in the beta-phase was caused by redistribution from the peripheral compartment and total elimination of the drug. Midazolam was thought to be useful as an induction agent in a modified NLA, because midazolam is distributed to the peripheral compartment faster than diazepam. As midazolam has a long elimination half-life as that of diazepam, prolongation of its effects has to be considered when a large dose or continuous infusion is employed.

Correlation of Direct Viable Counts with Heterotrophic Activity for Marine Bacteria

Viable-bacteria counts, heterotrophic activity, and substrate responsiveness of viable bacteria have been used to measure microbial activity. However, the relationship between these parameters is not clear. Thus, the direct viable count (DVC) method was used to analyze seawater samples collected from several different geographical locations. Samples collected from offshore waters of the South China Sea and western Pacific Ocean yielded DVC that indicated the presence of surface and subsurface peaks of viable, substrate-responsive bacteria which could be correlated with turnover rates of amino acids obtained by using uniformly 14 C-labeled amino acids. DVC were always less than total viable counts (acridine orange direct counts), and the DVC subsurface peak occurred close to and within the chlorophyll a zone, suggesting algal-bacterial interactions within the layer. For comparison with the open-ocean samples, selected substrates were used to determine the response of viable bacteria present in seawater samples collected near an ocean outfall of the Barceloneta Regional Waste Treatment Plant, Barceloneta, Puerto Rico. The number of specific substrate-responsive bacteria at the outfall stations varied depending on the substrate used and the sampling location. Changes in the population size or physiological condition of the bacteria were detected and found to be associated with the presence of pharmaceutical waste.

3-Amino-3-deoxy-D-glucose: an antibiotic produced by a deep-sea bacterium

Gram-positive bacteria isolated from deep-sea sediments of the Pacific basin showed considerable antibacterial activity. A Bacillus strain, isolated from a sediment sample collected at a depth of 4310 m, was shown to produce 3-amino-3-deoxy-D-glucose, a known antibiotic.

Purification and some properties of halophilic protease produced by a moderately halophilic marine Pseudomonas sp

Halophilic protease in culture fluids of a moderately halophilic marine Pseudomonas sp. (A-14) was purified by ammonium sulfate precipitation, DEAE-cellulose chromatography, and gel filtration through Sephadex G-200. The enzyme was purified to homogeneity, as judged by polyacrylamide gel electrophoresis. The molecular weight of the enzyme was estimated to be 120 000. The optimum pH for activity was 8.0. The enzyme had maximal activity at 18% NaCl concentration. The enzyme was activated by Mg2+, Co2+, and Ca2+. Ca2+ increased the heat stability, and heavy metal ions such as Fe2+, Cu2+, and Hg2+ inactivated the enzyme. Thiol reagents and diisopropyl fluorophosphate did not affect the enzymatic activity of the protease. Metal-complexing reagents, such as ethylenediaminetetraacetic acid and o-phenanthroline, inhibited enzymatic activity, although citrate and oxalate did not affect it.

Growth responses of oligotrophic and heterotrophic marine bacteria in various substrate concentrations, and taxonomic studies on them

Growth responses of oligotrophic bacteria to substrate concentrations have been investigated in comparison with those of heterotrophic bacteria. The results suggested that oligotrophs were the group which could grow and produce a perceptible turbidity in the media containing less than 10 mg peptone C/L of medium.Taxonomic studies indicated that the most abundant group in the oligotrophic bacterial flora was consistent with that in the heterotrophic bacterial flora at each sampling station. However, the relative proportion of pseudomonads in the oligotrophs was higher than that in the heterotrophs (at stations H-24, H-28, H-29, Ab-1, Ab-2, and O-4), while the relative proportion of Vibrio in the former was lower than that in the latter (at stations H-24, H-28, H-29, O-4, and O-9).

Uptake of D-glucose and L-proline by oligotrophic and heterotrophic marine bacteria

The transport systems of the oligotrophic bacterium 486 for D-glucose and L-proline have been compared with those of the heterotrophic bacterium RP-303. Kinetic studies demonstrated that the rates of D-glucose and L-proline uptake by the two organisms were saturable processes. The apparent Km values of strain 486 for D-glucose and L-proline were 13.0 microM and 0.2 microM, respectively, whereas those of strain RP-303 were 3.2 microM for D-glucose and 1.8 microM for L-proline. Competition studies indicated that the D-glucose transport system of each bacterium was highly specific for D-glucose. The L-proline transport system of the oligotrophic bacterium 486 had a broad specificity, whereas that of the heterotrophic bacterium RP-303 had a narrow one.

Distribution of viable marine bacteria in neritic seawater around Japan

The direct viable court (DVC) method of determining the number of living bacteria in natural seawater was applied to samples collected from areas around Japan ranging from polluted to oligotrophic. In summer, the DVC comprised 1.5-39.8% (mean, 11.2%) of the total direct count (TDC) in Tokyo Bay, which was highly eutrophic. In offshore areas (Sagami Bay and the Kuroshio region), the percentages ranged from 0.7 to 7.9 (mean 2.8%). In winter, slightly higher percentages were observed in Sagami Bay. The majority of DVC cells were free-living. The distruction of bacteria correlated closely with particulate or dissolved organic matter.

Comparative study of the aerobic, heterotrophic bacterial flora of Chesapeake Bay and Tokyo Bay

A comparative study of the bacterial flora of the water of Chesapeake Bay and Tokyo Bay was undertaken to assess similarities and differences between the autochthonous flora of the two geographical sites and to test the hypothesis that, given similarities in environmental parameters, similar bacterial populations will be found, despite extreme geographic distance between locations. A total of 195 aerobic, heterotrophic bacterial strains isolated from Chesapeake Bay and Tokyo Bay water were examined for 115 biochemical, cultural, morphological, nutritional, and physiological characters. The data were analyzed by the methods of numerical taxonomy. From sorted similarity matrices, 77% of the isolates could be grouped into 30 phena and presumptively identified as Acinetobacter-Moraxella, Caulobacter, coryneforms, Pseudomonas, and Vibrio spp. Vibrio and Acinetobacter species were found to be common in the estuarine waters of Chesapeake Bay, whereas Acinetobacter-Moraxella and Caulobacter predominated in Tokyo Bay waters, at the sites sampled in the study.

A tentative direct microscopic method for counting living marine bacteria

Yeast extract (0.025%) and nalidixic acid (0.002%) were added to seawater samples and the samples were incubated for 6 h at 20 degrees C in the dark. Under these conditions, bacterial cells did not divide but grew to form elongated cells that are easily recognized by a direct microscopic method and epifluorescent microscopic technique. The number of cells thus obtained is proposed as a direct cound of viable bacterial cells (DVC). With open ocean samples, DVC was higher than 'viable' plate counts by up to three orders of magnitude and lower than the direct counts by about one order.

Microbiological studies of Tokyo Bay

The generic composition of the heterotrophic bacterial population of Tokyo Bay, which is now highly polluted and eutrophic, was compared with that of the adjacent, less polluted regions of Sagami Bay and Suruga Bay. Members of Vibrionaceae predominated in the bacterial flora of seawater and zooplankton samples from Sagami Bay, Suruga Bay, and the mouth of Tokyo Bay. However,Vibrio spp. formed only a small proportion of the bacterial population of the water and sediment samples from the inner Tokyo Bay; there the Gram-negative, nonmotile, nonpigmented bacteria, which were tentatively identified asAcinetobacter, were predominant. The result of experiments, in which seawater samples from Tokyo Bay were incubated under various experimental conditions, indicated that two significant factors apparently control the growth ofVibrio spp. in seawater; (1) a direct antagonism betweenVibrios and phytoplankton undergoing rapid growth, and (2) a limiting organic nutrient forvibrios.