Possible mechanism for improving the endogenous immune system through the blockade of peripheral μ-opioid receptors by treatment with naldemedine

BACKGROUND

It has been considered that activation of peripheral μ-opioid receptors (MORs) induces side effects of opioids. In this study, we investigated the possible improvement of the immune system in tumour-bearing mice by systemic administration of the peripheral MOR antagonist naldemedine.

METHODS

The inhibitory effect of naldemedine on MOR-mediated signalling was tested by cAMP inhibition and β-arrestin recruitment assays using cultured cells. We assessed possible changes in tumour progression and the number of splenic lymphocytes in tumour-bearing mice under the repeated oral administration of naldemedine.

RESULTS

Treatment with naldemedine produced a dose-dependent inhibition of both the decrease in the cAMP level and the increase in β-arrestin recruitment induced by the MOR agonists. Repeated treatment with naldemedine at a dose that reversed the morphine-induced inhibition of gastrointestinal transport, but not antinociception, significantly decreased tumour volume and prolonged survival in tumour-transplanted mice. Naldemedine administration significantly decreased the increased expression of immune checkpoint-related genes and recovered the decreased level of toll-like receptor 4 in splenic lymphocytes in tumour-bearing mice.

CONCLUSIONS

The blockade of peripheral MOR may induce an anti-tumour effect through the recovery of T-cell exhaustion and promotion of the tumour-killing system.

Significant neonatal intraoperative cerebral and renal oxygen desaturation identified with near-infrared spectroscopy

INTRODUCTION

Near-infrared spectroscopy (NIRS) was used to monitor intraoperative regional oxygen saturation (rSO₂) during open (Op) and minimally invasive (MI) surgery performed in neonates (N) and children.

MATERIALS AND METHODS

NIRS sensors were applied to the forehead and flanks for cerebral rSO₂ (C-rSO₂) and renal rSO₂ (R-rSO₂), respectively. MI included laparoscopy (La), retroperitoneoscopy (Re) and thoracoscopy (Th). In children, Op and MI were major operations taking at least 3 h (MOp; MMI). Pathological desaturation (PD) was defined as > 20% deterioration in rSO₂.

RESULTS

Mean ages at surgery were N: 5.2 ± 8.2 days, MOp: 2.4 ± 2.9 years, and MMI: 3.8 ± 4.3 years. Despite significantly shorter operative times in N (169 ± 94 min; p < 0.0001), PD was significantly worse; PD(C-rSO₂): N = 14/35 (40.0%) versus MOp = 3/36 (8.3%) and MMI = 7/58 (12.1%); p = 0.0006, and PD(R-rSO₂): N = 27/35 (77.1%) versus MOp = 6/36 (16.7%) and MMI = 7/58 (12.1%); p < 0.0001, respectively. PD(R-rSO₂) occurred immediately with visceral reduction in NOp (Fig. 1) and PD was frequent during NMI(Th) (Fig. 2). rSO₂ was stable throughout MOp and MMI (Fig. 3). Fig. 1 Pathological desaturation in renal rSO₂ after visceral reduction for gastroschisis. Renal rSO₂ deteriorated immediately after viscera were returned to the abdominal cavity rSO₂ regional oxygen saturation Fig. 2 Fragility of tissue perfusion during thoracoscopic lung lobectomy in a neonate. Pathological desaturation occurred frequently during neonatal thoracoscopic surgery rSO₂ regional oxygen saturation Fig. 3 Changes in cerebral and renal rSO₂ according to operative time. Cerebral and renal rSO₂ did not appear to change according to operative time during major open and major minimally invasive surgery in children. rSO₂ regional oxygen saturation CONCLUSIONS: NIRS is a non-invasive technique for monitoring rSO₂ as an indicator of intraoperative stress and vascular perfusion. PD was so significant in neonates that intraoperative NIRS is highly recommended during thoracoscopy and procedures requiring visceral manipulation.

Histone modification of pain-related gene expression in spinal cord neurons under a persistent postsurgical pain-like state by electrocautery

Chronic postsurgical pain (CPSP) is a serious problem. We developed a mouse model of CPSP induced by electrocautery and examined the mechanism of CPSP. In this mouse model, while both incision and electrocautery each produced acute allodynia, persistent allodynia was only observed after electrocautery. Under these conditions, we found that the mRNA levels of Small proline rich protein 1A (Sprr1a) and Annexin A10 (Anxa10), which are the key modulators of neuropathic pain, in the spinal cord were more potently and persistently increased by electrocautery than by incision. Furthermore, these genes were overexpressed almost exclusively in chronic postsurgical pain-activated neurons. This event was associated with decreased levels of tri-methylated histone H3 at Lys27 and increased levels of acetylated histone H3 at Lys27 at their promoter regions. On the other hand, persistent allodynia and overexpression of Sprr1a and Anxa10 after electrocautery were dramatically suppressed by systemic administration of GSK-J4, which is a selective H3K27 demethylase inhibitor. These results suggest that the effects of electrocautery contribute to CPSP along with synaptic plasticity and epigenetic modification.

Yokukansan, a Japanese Herbal Medicine, Suppresses Substance PInduced Production of Interleukin-6 and Interleukin-8 by Human U373 MG Glioblastoma Astrocytoma Cells

BACKGROUND

Yokukansan is a traditional Japanese herbal medicine that has an antiallodynic effect in patients with chronic pain. However, the mechanisms by which yokukansan inhibits neuropathic pain are unclear.

OBJECTIVE

This study aimed to investigate the molecular effects of yokukansan on neuroinflammation in U373 MG glioblastoma astrocytoma cells, which express a functional high-affinity neurokinin 1 receptor (substance P receptor), and produce interleukin (IL)-6 and IL-8 in response to stimulation by substance P (SP).

METHODS

We assessed the effect of yokukansan on the expression of ERK1/2, P38 MAPK, nuclear factor (NF)-κB, and cyclooxygenase-2 (COX-2) in U373 cells by western blot assay. Levels of IL-6 and IL-8 in conditioned medium obtained after stimulation of cells with SP for 24 h were measured by enzyme-linked immunosorbent assay. All experiments were conducted in triplicate. Results were analyzed by one-way ANOVA, and significance was accepted at p < 0.05.

RESULTS

Yokukansan suppressed SP-induced production of IL-6 and IL-8 by U373 MG cells, and downregulated SP-induced COX-2 expression. Yokukansan also inhibited phosphorylation of ERK1/2 and p38 MAPK, as well as nuclear translocation of NF-κB, induced by SP stimulation of U373 MG cells.

CONCLUSION

Yokukansan exhibits anti-inflammatory activity by suppressing SP-induced production of IL-6 and IL-8 and downregulating COX-2 expression in U373 MG cells, possibly via inhibition of the activation of signaling molecules, such as ERK1/2, p38 MAPK, and NF-κB.

Direct evidence that the brain reward system is involved in the control of scratching behaviors induced by acute and chronic itch

In the present study, we demonstrated that there is a direct relationship between scratching behaviors induced by itch and functional changes in the brain reward system. Using a conditional place preference test, the rewarding effect was clearly evoked by scratching under both acute and chronic itch stimuli. The induction of ΔFosB, a member of the Fos family of transcription factors, was observed in dopamine transporter (DAT)-positive dopamine neurons in the ventral tegmental area (VTA) of mice suffering from a chronic itch sensation. Based on a cellular analysis of scratching-activated neurons, these neurons highly expressed tyrosine hydroxylase (TH) and DAT genes in the VTA. Furthermore, in an in vivo microdialysis study, the levels of extracellular dopamine in the nucleus accumbens (NAcc) were significantly increased by transient scratching behaviors. To specifically suppress the mesolimbic dopaminergic pathway using pharmacogenetics, we used the TH-cre/hM4Di mice. Pharmacogenetic suppression of mesolimbic dopaminergic neurons significantly decreased scratching behaviors. Under the itch condition with scratching behaviors restricted by an Elizabethan collar, the induction of ΔFosB was found mostly in corticotropin-releasing hormone (CRH)-containing neurons of the hypothalamic paraventricular nucleus (PVN). These findings suggest that repetitive abnormal scratching behaviors under acute and chronic itch stimuli may activate mesolimbic dopamine neurons along with pleasant emotions, while the restriction of such scratching behaviors may initially induce the activation of PVN-CRH neurons associated with stress.

The dynamic collapse of the trachea during anesthesia for a pediatric patient with a large anterior mediastinal mass: A case report

Anesthesia for patient with large anterior mediastinal mass might induce life-threatening complication. Maintaining the spontaneous breathing throughout the procedure and finding rescue position are the cornerstones of anesthetic management.

Insomnia and caregiver burden in chronic pain patients: A cross-sectional clinical study

Insomnia is a major comorbid symptom of chronic pain and is likely to affect caregiver burden. This cross-sectional study investigated the association between insomnia in chronic pain patients and family caregiver burden. Participants were 60 patients with chronic pain of ≥3 months duration. Demographic and clinical information were collected using the Athens Insomnia Scale (AIS), the Pain Disability Assessment Scale (PDAS), the Hospital Anxiety and Depression Scale (HADS), and a pain intensity numerical rating scale (NRS). Family members who accompanied chronic pain patients to hospital completed the Zarit Burden Interview (ZBI). Univariate regression analysis and multiple regression analysis were conducted to clarify the associations between ZBI scores and total/subscale AIS scores. Covariates were age; sex; pain duration; and scores on the PDAS, HADS anxiety subscale, HADS depression subscale, and NRS. Insomnia was independently associated with ZBI scores [β: 0.27, 95% confidence interval (CI): 0.07–0.52, p = 0.001]. Scores on the AIS subscale of physical and mental functioning during the day were significantly associated with ZBI scores (β: 0.32, 95% CI: 0.05–0.59, p = 0.007). In conclusion, the findings suggest that in chronic pain patients, comorbid insomnia and physical and mental daytime functioning is associated with family caregiver burden independently of pain duration, pain-related disability, and pain intensity.

The effects of a recruitment manoeuvre with positive end-expiratory pressure on lung compliance in patients undergoing robot-assisted laparoscopic radical prostatectomy

The effects of a recruitment manoeuvre (RM) with positive end-expiratory pressure (PEEP) on lung compliance (C_LUNG) are not well characterised in robot-assisted laparoscopic radical prostatectomy (RARP). Patients were allocated to group R (n = 10; with an RM) or C (n = 9; without an RM). An RM involved sustained inflation of 30 cmH₂O for 30 s. The lungs were ventilated with volume-controlled ventilation with tidal volume of 7 mL kg^-1 of predicted body weight and fraction of inspired oxygen of 0.5. End-tidal carbon dioxide pressure was maintained at normocapnia. Patients were in the horizontal lithotomy position (pre-op). After pneumoperitoneum, patients underwent RARP in a steep Trendelenburg lithotomy position at a PEEP level of 0 cmH₂O (RARP0). An RM was used in the R group but not in the C group. Patients were then ventilated with 5 cmH₂O PEEP for 1 h after RARP0 (RARP5.1) and 2 h after RARP0 (RARP5.2). Oesophageal pressure and airway pressure were measured for calculating C_LUNG and chest wall compliance. C_LUNG significantly decreased from pre-op to RARP0 and did not significantly increase from RARP0 to RARP5.1 and RARP5.2 in either group. C_LUNG differed significantly between groups at RARP5.1 and RARP5.2 (103 ± 30 vs. 68 ± 11 mL cm^-1 H₂O and 106 ± 35 vs. 72 ± 9 mL cm^-1 H₂O; P < 0.05). In patients undergoing RARP, with the addition of RM, the C_LUNG was effectively increased from the horizontal lithotomy position to the steep Trendelenburg lithotomy position under pneumoperitoneum.

Correlation between urinary biomarker and organ failure in patients with sepsis and patients after esophagectomy: a prospective observational study

Background

Neutrophil gelatinase-associated lipocalin (NGAL) is a diagnostic marker for acute kidney injury (AKI). NGAL expression is highly induced not only in kidney injury but also in bacterial infection, inflammation, and cancer. The factors regulating NGAL expression are proinflammatory cytokines, and plasma NGAL levels have been increased in septic shock. However, there are no reports of urine neutrophil gelatinase-associated lipocalin (uNGAL) levels after open esophagectomy.

Methods

We prospectively enrolled critically ill patients, including patients with sepsis (n = 45) and patients who underwent open esophagectomy (n = 40). We compared vital signs, PaO₂/F_IO₂, serum C-reactive protein (CRP) levels, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, and uNGAL levels between the sepsis group and the esophagectomy group. Then, we investigated whether uNGAL is associated with the severity of illness and organ failure, and whether uNGAL is a reliable screening test for AKI.

Results

The median uNGAL levels, APACHE II score, SOFA score, and serum CRP levels were significantly (p < 0.001) higher in the sepsis group than in the esophagectomy group on ICU day 1. In the sepsis group, uNGAL levels were significantly (p < 0.05) correlated with APACHE II score and SOFA score on intensive care unit (ICU) day 1, 2, and 3. In the esophagectomy group, uNGAL levels were significantly (p < 0.05) correlated with SOFA score on ICU day 3 and 4. In the sepsis group, 1 patient developed AKI stage 2 and 6 patients developed AKI stage 3. No patients developed AKI in the esophagectomy group. In a total of 85 patients of this study, 80 patients had an abnormal value of uNGAL and only 7 patients (8.7%) of those 80 patients developed AKI.

Conclusions

uNGAL levels were correlated with the severity of illness and organ failure in critically ill patients. The value of uNGAL increases under the surgical and inflammatory responses, thereby losing a significance of a screening test of AKI in critically ill patients.

NF-kB signaling in cardiomyocytes is inhibited by sevoflurane and promoted by propofol

Both inhalational and intravenous anesthetics affect myocardial remodeling, but the precise effect of each anesthetic on molecular signaling in myocardial remodeling is unknown. Here, we performed in silico analysis to investigate signaling alterations in cardiomyocytes induced by inhalational [sevoflurane (Sevo)] and intravenous [propofol (Prop)] anesthetics. Bioinformatics analysis revealed that nuclear factor‐kappa B (NF‐kB) signaling was inhibited by Sevo and promoted by Prop. Moreover, nuclear accumulation of p65 and transcription of NF‐kB‐regulated genes were suppressed in Sevo‐administered mice, suggesting that Sevo inhibits the NF‐kB signaling pathway. Our data demonstrate that NF‐kB signaling is inhibited by Sevo and promoted by Prop. As NF‐kB signaling plays an important role in myocardial remodeling, our results suggest that anesthetics may affect myocardial remodeling through NF‐kB.

Intercostal misplacement of a thoracic epidural catheter discovered during lung cancer surgery: a case report

BACKGROUND

Blind epidural catheter placement can lead to inadvertent misplacement. We present a case of intercostal misplacement of a thoracic epidural catheter.

CASE PRESENTATION

A 67-year-old male underwent left lung cancer surgery via thoracotomy with epidural analgesia via the Th 5-6 intervertebral space, although with some difficulty. We detected dermatomal cold sensory loss around Th five min after initial administration of local anesthetics through the catheter before general anesthesia induction. However, the epidural catheter was intraoperatively found below the fifth rib, running along the course of the intercostal nerve. The catheter was successfully withdrawn via his back, and we postoperatively performed paravertebral block under ultrasound guidance. He did not complain of complications at discharge.

CONCLUSIONS

Detailed bilateral assessment of sensory loss after initial local anesthetic administration might have facilitated preoperative detection of the misplacement. In cases requiring multiple catheter insertion attempts, switching to another analgesic method should be considered.

Shortened cataract surgery by standardisation of the perioperative protocol according to the Joint Commission International accreditation: a retrospective observational study

OBJECTIVES

To investigate the impact of standardisation of the perioperative protocol based on the Joint Commission International (JCI) accreditation guidelines for operating time in cataract surgery.

DESIGN

Retrospective observational study.

SETTING

Single centre in Japan.

PARTICIPANTS

Between March 2014 and June 2016, 3127 patients underwent cataract surgery under topical anaesthesia including 2581 and 546 patients before and after JCI accreditation, respectively.

PRIMARY AND SECONDARY OUTCOMES

We compared three time periods, comprising the preprocedure/surgery time (pre-PT), PT and post-PT, and total PT (TPT) of cataract surgery between patients before and after JCI accreditation, by regression analysis adjusted for age, sex and cataract surgery-associated confounders.

RESULTS

The main outcomes were pre-PT, PT, post-PT and TPT. Pre-PT (19.8±10.5 vs 13.9±8.5 min, p<0.001) and post-PT (3.5±4.6 vs 2.6±2.1 min, p<0.001) significantly decreased after JCI accreditation, while PT did not significantly change (16.8±6.7 vs 16.2±6.3 min, p=0.065). Consequently, TPT decreased on average by 7.3 min per person after JCI accreditation (40.1±13.4 vs 32.8±10.9 min, p<0.001). After adjusting for confounders, pre-PT (β=-5.82 min, 95% CI -6.75 to -4.88), PT (β=-0.76 min, 95% CI -1.34 to -1.71), post-PT (β=-0.85 min, 95% CI -1.24 to -0.45) and TPT (β=-7.43 min, 95% CI -8.61 to -6.24) were significantly shortened after JCI accreditation.

CONCLUSION

Perioperative protocol standardisation, based on JCI accreditation, shortened TPT in cataract surgery under local anaesthesia.

Association between change in self-efficacy and reduction in disability among patients with chronic pain

Purpose

This study aimed to investigate whether changes in psychosocial factors and pain severity were associated with reduction in disability due to pain among patients with chronic pain. We hypothesized that increased self-efficacy would reduce disability.

Patients and methods

This longitudinal observational study included 72 patients. Patients’ psychological and physical variables were assessed before and after 3 months of treatment. Demographic and clinical information were collected, including the Pain Disability Assessment Scale (PDAS), the Pain Self-Efficacy Questionnaire (PSEQ), the Hospital Depression and Anxiety Scale, and the Numeric Rating Scale (NRS) to assess pain intensity. First, univariate regression analyses were conducted to clarify associations between change in PDAS and sex, age, pain duration, changes in psychosocial factors (self-efficacy, anxiety, and depression) and change in pain intensity. Second, multivariate regression was conducted using the variables identified in the univariate analyses (PSEQ and NRS) to detect the most relevant factor for reducing disability.

Results

Univariate regression analyses clarified that changes in PSEQ (β = −0.31; 95% CI: −0.54–−0.08, p = 0.008) and NRS (β = 0.24; 95% confidence interval [CI]: 0.01–0.47, p = 0.04) were associated with reduction in PDAS. Multivariate regression analysis demonstrated that change in PSEQ (β = 0.26; 95% CI: −0.50–−0.02; p = 0.01) was associated with a reduction in disability, independent of change in NRS.

Conclusion

These findings suggest improved self-efficacy is associated with reduced disability in patients with chronic pain, independent of reduction in pain intensity. Focusing on improvement in self-efficacy may be an effective strategy in chronic pain treatment in addition to pain relief.

Respiratory failure caused by impending tension pneumothorax after extrapleural pneumonectomy: a case report

Background

Case presentation

Conclusions

High-flow oxygen via tracheostomy facilitates weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction: two case reports

Background

Weaning from prolonged mechanical ventilation is extremely difficult in tracheostomized patients with restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy supplies heated and humidified oxygen gas at > 10 L/minute. However, little has been reported on the use of high-flow oxygen via tracheostomy during weaning from ventilators in patients with restrictive pulmonary dysfunction. We report successful weaning from ventilators in patients with restrictive pulmonary dysfunction using high-flow oxygen via tracheostomy.

Case presentation

The first patient is a 78-year-old Japanese man with severe pneumococcal pneumonia who was mechanically ventilated for more than 1 month after esophagectomy for esophageal cancer. After he underwent tracheostomy because of prolonged mechanical ventilation, restrictive pulmonary dysfunction appeared: tidal volume 230–240 mL and static compliance 14–15 mL/cmH₂O with 10 cmH₂O pressure support ventilation. He was weaned from the ventilator under inspiratory support with high-flow oxygen via tracheostomy over a period of 16 days (flow at 40 L/minute and fraction of inspired oxygen of 0.25). The second patient is a 69-year-old Japanese man who developed aspiration pneumonia after esophagectomy and received prolonged mechanical ventilation via tracheostomy. He developed restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy (flow at 40 L/minute with fraction of inspired oxygen of 0.25) was administered with measurement of the airway pressure and at the entrance of the tracheostomy tube. The measured values were as follows: 0.21–0.3 cmH₂O, 0.21–0.56 cmH₂O, 0.54–0.91 cmH₂O, 0.76–2.01 cmH₂O, 1.17–2.01 cmH₂O, and 1.76–2.01 cmH₂O at 10 L/minute, 20 L/minute, 30 L/minute, 40 L/minute, 50 L/minute, and 60 L/minute, respectively. The airway pressures were continuously positive and did not become negative even during inspiration, suggesting that high-flow oxygen via tracheostomy reduces inspiratory effort. He was weaned from the ventilator under inspiratory support with high-flow oxygen via tracheostomy over a period of 12 days.

Conclusions

High-flow oxygen via tracheostomy may reduce the inspiratory effort and enhance tidal volume by delivering high-flow oxygen and facilitate weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction.

The impact of Joint Commission International accreditation on time periods in the operating room: A retrospective observational study

The Joint Commission International (JCI) is responsible for upholding standards in healthcare and organizations in compliance receive accreditation. JCI requires quality improvement on patient safety goals, but requirements may prolong the total procedure/surgery time and reduce efficiency. Here, we evaluate the impact of JCI requirements on time periods in the operating room. We included patients who received elective and emergency surgeries under general anesthesia at Juntendo University Hospital between December 2014 and June 2016. Patients were classified as before and after JCI accreditation on December 12, 2015. The primary outcome was total procedure/surgery time. Secondary outcomes include five time periods comprising the total procedure/surgery time: pre-anesthesia time, anesthesia induction time, procedure/surgery time, anesthesia awareness time and post-anesthesia time. We compared these time periods between patients before and after JCI accreditation and patients were matched for age, sex and the specific type of surgery. Although total procedure/surgery time did not change significantly, pre-anesthesia time significantly increased (8.2 ± 6.9 minutes vs. 8.5 ± 6.9 minutes, before vs. after JCI, respectively, p = 0.028) and anesthesia induction time significantly decreased (34.4 ± 16.1 minutes vs. 33.6 ± 15.4 minutes, before vs. after JCI, respectively, p = 0.037) after JCI accreditation. Other secondary study outcomes did not change significantly. Quality improvement initiatives associated with time periods in the operating room can be achieved without undermining efficiency.

Ventilation failure after lateral jackknife positioning for robot-assisted lung cancer surgery in a patient after lingula-sparing left upper lobectomy

BACKGROUND

Ventilation failure commonly occurs when a standard left-sided double-lumen tube is used in patients after left upper lobectomy having remarkable angulation of the left main bronchus. We present a female without remarkable angulation, in whom ventilation failure occurred after lateral jackknife positioning.

CASE PRESENTATION

A 73-year-old female after lingula-sparing left upper lobectomy without remarkable angulation was scheduled for robot-assisted right upper lobectomy. Ventilation failure with a standard left-sided double-lumen tube occurred when she was placed not in the lateral position but in the lateral jackknife position required for robotic surgery. After replacement by the Silbroncho® left-sided double-lumen tube, adequate one-lung ventilation became possible.

CONCLUSIONS

Ventilation failure with a standard tube may occur more easily when patients with bronchial angulation are placed in the lateral jackknife than lateral position due to posture-induced exacerbations of bronchial angulation. The Silbroncho® tube seems useful in such situations.

Influence of pharyngeal airway respiration pressure on Class II mandibular retrusion in children: A computational fluid dynamics study of inspiration and expiration

OBJECTIVES

To examine the influence of negative pressure of the pharyngeal airway on mandibular retraction during inspiration in children with nasal obstruction using the computational fluid dynamics (CFD) method.

SETTING AND SAMPLE POPULATION

Sixty-two children were divided into Classes I, II (mandibular retrusion) and III (mandibular protrusion) malocclusion groups.

MATERIAL AND METHODS

Cone-beam computed tomography data were used to reconstruct three-dimensional shapes of the nasal and pharyngeal airways. Airflow pressure was simulated using CFD to calculate nasal resistance and pharyngeal airway pressure during inspiration and expiration.

RESULTS

Nasal resistance of the Class II group was significantly higher than that of the other two groups, and oropharyngeal airway inspiration pressure in the Class II (-247.64 Pa) group was larger than that in the Class I (-43.51 Pa) and Class III (-31.81 Pa) groups (P<.001). The oropharyngeal airway inspiration-expiration pressure difference in the Class II (-27.38 Pa) group was larger than that in the Class I (-5.17 Pa) and Class III (0.68 Pa) groups (P=.006).

CONCLUSION

Large negative inspiratory pharyngeal airway pressure due to nasal obstruction in children with Class II malocclusion may be related to their retrognathia.

New-onset atrial fibrillation: an update

New-onset atrial fibrillation (NOAF) is the most common perioperative complication of heart surgery, typically occurring in the perioperative period. NOAF commonly occurs in patients who are elderly, or have left atrial enlargement, or left ventricular hypertrophy. Various factors have been identified as being involved in the development of NOAF, and numerous approaches have been proposed for its prevention and treatment. Risk factors include diabetes, obesity, and metabolic syndrome. For prevention of NOAF, β-blockers and amiodarone are particularly effective and are recommended by guidelines. NOAF can be treated by rhythm/rate control, and antithrombotic therapy. Treatment is required in patients with decreased cardiac function, a heart rate exceeding 130 beats/min, or persistent NOAF lasting for ≥ 48 h. It is anticipated that anticoagulant therapies, as well as hemodynamic management, will also play a major role in the management of NOAF. When using warfarin as an anticoagulant, its dose should be adjusted based on PT-INR. PT-INR should be controlled between 2.0 and 3.0 in patients aged < 70 years and between 1.6 and 2.6 in those aged ≥ 70 years. Rate control combined with antithrombotic therapies for NOAF is expected to contribute to further advances in treatment and improvement of survival.

Measurement properties of comorbidity indices in maternal health research: a systematic review

Background

Maternal critical illness occurs in 1.2 to 4.7 of every 1000 live births in the United States and approximately 1 in 100 women who become critically ill will die. Patient characteristics and comorbid conditions are commonly summarized as an index or score for the purpose of predicting the likelihood of dying; however, most such indices have arisen from non-pregnant patient populations. We sought to systematically review comorbidity indices used in health administrative datasets of pregnant women, in order to critically appraise their measurement properties and recommend optimal tools for clinicians and maternal health researchers.

Methods

We conducted a systematic search of MEDLINE and EMBASE to identify studies published from 1946 and 1947, respectively, to May 2017 that describe predictive validity of comorbidity indices using health administrative datasets in the field of maternal health research. We applied a methodological PubMed search filter to identify all studies of measurement properties for each index.

Results

Our initial search retrieved 8944 citations. The full text of 61 articles were identified and assessed for final eligibility. Finally, two eligible articles, describing three comorbidity indices appropriate for health administrative data remained: The Maternal comorbidity index, the Charlson comorbidity index and the Elixhauser Comorbidity Index. These studies of identified indices had a low risk of bias. The lack of an established consensus-building methodology in generating each index resulted in marginal sensibility for all indices. Only the Maternal Comorbidity Index was derived and validated specifically from a cohort of pregnant and postpartum women, using an administrative dataset, and had an associated c-statistic of 0.675 (95% Confidence Interval 0.647–0.666) in predicting mortality.

Conclusions

Only the Maternal Comorbidity Index directly evaluated measurement properties relevant to pregnant women in health administrative datasets; however, it has only modest predictive ability for mortality among development and validation studies. Further research to investigate the feasibility of applying this index in clinical research, and its reliability across a variety of health administrative datasets would be incrementally helpful. Evolution of this and other tools for risk prediction and risk adjustment in pregnant and post-partum patients is an important area for ongoing study.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1558-3) contains supplementary material, which is available to authorized users.

[Perioperative Management of Medications Used for Comorbidities: Preface and Comments]

Surgical patients often take medications for preex- isting diseases. It is recommended to continue antihy- pertensive agents on the day of surgery in hyperten- sive patients. Two exceptions are angiotensin II recep- tor antagonist (ARB) and angiotensin converting enzyme inhibitors (ACEi) because of increased risk of hypotension during anesthesia. It is important to re- sume antihypertensive agents within a day or a few days postoperatively. Antipsychotic agents and antiepi- leptic drugs often cause arrhythmias and hypotension. The risk of neuroleptic malignant syndrome and sero- tonin syndrome should be noted. The patients on chronic opioids should require meticulous perioperative pain manageient Decisions about continuing or with- holding medications should be made on a case-by-case basis.

[With the Characteristics of Chronic Pain Patients, Can the Therapeutic Effect of Antidepressant Duloxetine be Predicted?]

BACKGROUND

Duloxetine, an antidepressant, is used for treatment of pain, but the factors related to its effectiveness are not well known, and therefore we have performed a retrospective study.

METHODS

Over a 22-month period from June 2012 patients with pain lasting for 3 months or more, with an NRS of 4 or higher, and given duloxetine within 3 months from their first diagnosis, were extracted from the medical records. These patients were compared and studied regarding their scores of the HADS (hos- pital anxiety and depression scale) at the time of first visit, duration of the disease, type of patient, and treat- ment effect after 1 month.

RESULTS

The subjects were 61 patients, and they were categorized based on the presence of anxiety, the presence of dysphoria whether from organic or inor- ganic condition, and the duration of the disease, and no significant difference in the effectiveness of duloxetine was found.

CONCLUSIONS

Duloxetine had an overall effectiveness of 50.8%, regardless of the presence of anxiety or depression, the duration of the disease and the type of diseases.

[Anesthetic Management of Gynecological Laparoscopic Surgery]

Indications for laparoscopic gynecologic surgery have been broadened. Although it is a rather noninvasive surgical procedure, it requires meticulous anesthetic management. Intraoperatively, hemodynamic and respiratory changes occur due to carbon dioxide insuf- flation, increased intraperitoneal pressure, and head- down position. Ventilator setting should be changed to cope with decreased chest-lung compliance and increased load of carbon dioxide during pneumoperitoneum in the head-down position. Mild hypercarbia may be per- mitted during this period to avoid ventilator-induced lung injury. Because the incidence of postoperative nausea and vomiting is high, it is recommended to use total intravenous anesthesia and prophylactic use of multiple antiemetics such as droperidol and dexameth- asone.

[Successful One-lung Ventilation with a Right-sided Double-lumen Tube in a Patient with a Right Upper Tracheal Bronchus, who Underwent Left Pneumonectomy for Left Hilar Lung Cancer]

A 60-year-old male patient with left hilar lung cancer was scheduled to undergo left pneumonectomy or left sleeve lower lobectomy. Preoperative computer tomographic and bronchoscopic examinations revealed that the bronchus (B1) to the right apical segment (S1) was a tracheal bronchus (TB) originating from the trachea approximately 10 mm above the carina. Because the left main bronchus was to be dissected, a right-sided double-lumen tube (DLT) was selected to completely protect the right lung from spillage of secretions or cancer cells from the left lung. The right-sided DLT was placed so as to fit its lateral opening of the bronchial lumen to normal upper branches (B2, B3), while sacrificing ventilation of S1 with an abnormal branch (B1). However, one-lung ventilation (OLV) of the right lung could not be achieved, since a gas leakage from the opened tracheal lumen occurred, most probably due to intra-lobar micro-airway communications between S1 and S2/S3. The DLT was withdrawn until the blue bronchial cuff occluded the orifice of the TB (B1). Although the upper half of the blue bronchial cuff appeared above the tracheal carina, OLV through the two bronchial lumen openings could be achieved due to a specific, slanted doughnut shape of the blue bronchial cuff and the location of the abnormal branch (B1) approximate to the carina. Left pneumonectomy using successful OLV was completed safely without hypoxemia or hypercapnea. Our experience indicates that management of OLV for patients with a thoracheal bronchus needs special considerations of the exact location of the TB and intra-lobar micro-airway communications, in addition to types of scheduled surgical procedures.

Polymyxin B hemoperfusion prevents acute kidney injury in sepsis model

BACKGROUND

Direct hemoperfusion with a polymyxin B-immobilized column (PMX-DHP) adsorbs endotoxin and has been used for the treatment of septic shock. Yet, the mechanisms by which PMX-DHP acts on acute kidney injury are only partially understood.

MATERIALS AND METHODS

Rats were anesthetized, tracheostomized, and placed on mechanical ventilation. The animals were randomized to three groups: a cecal ligation and puncture (CLP) + dummy-DHP group (n = 10), a CLP + PMX-DHP group (n = 10), and a sham group (n = 4). Four hours after CLP, a dummy-DHP or PMX-DHP was performed for 1 h. The heart rate, mean arterial pressure, arterial blood gases, and plasma concentrations of creatinine, lactate, potassium, interleukin (IL)-6, and IL-10 were measured at 0 h and 8 h. Eight hours after CLP, the kidney was harvested, and histopathologic examination was performed. The expressions of cleaved poly (ADP-ribose) polymerase (PARP) and nuclear factor (NF)-κB p65 were examined by immunohistochemistry. A terminal deoxynucleotide transferase dUTP nick-end labeling assay was performed to detect apoptotic nuclei in kidney sections.

RESULTS

PMX-DHP maintained hemodynamics and the acid-base balance and significantly (P < 0.05) decreased the plasma concentrations of lactate, creatinine, potassium, IL-6, and IL-10 compared with dummy-DHP. PMX-DHP significantly (P < 0.001) attenuated the expressions of cleaved PARP and NF-κB p65 in renal tubular cells and renal tubular cell apoptosis compared with dummy-DHP.

CONCLUSIONS

These findings suggest that PMX-DHP may protect against acute kidney injury not only by inhibiting the NF-κB signaling pathway but also by preventing renal tubular cell apoptosis.

[Drug Delivery System in Pain Treatment--Preface and Comments: Understanding the Concept of Drug Delivery System is Important for Anesthesiologists]

Drug delivery system (DDS) is a pharmaceutical technique to enhance effective drug delivery, to reduce adverse effects and to determine time-course of drug delivery. DDS facilitates the maintenance of the drug levels at the target. The delivery of drugs via the mucous membranes in the oral cavity and the rectum is often used to achieve the systemic effects. Sublingual delivery assures rapid absorption and bioavailability. Opioids are often given by either sublingual or buccal route to treat cancer breakthrough pain. Controlled-release tablets and transdermal patches of opioids are often used to treat cancer and severe intractable pain. Understanding of the concept of DDS is important not only to use various drugs rationally but to develop new drugs.

[Satisfaction with delivery and maternal identity with epidural labor analgesia among Japanese women with children younger than 3 years of age: a web-based survey]

BACKGROUND

In Japan, it has been thought that pain during labor develops maternal identity and there are cultural and psychological barriers to the use of epidural labor analgesia. The objective of this study was to examine epidemiologic data and psychological data about satisfaction with delivery and maternal identity with epidural labor analgesia.

METHODS

A web-based survey was randomly conducted in 1,000 women (ages, 20-40 years) with children under the age of 3 years. The questionnaire included the basic characteristics of the participants and children, their experiences with delivery and two scales to evaluate satisfaction of delivery and maternal identity.

RESULTS

There were a total of 1,030 respondents and 50 (5.0%) respondents reported having epidural labor analgesia. Scores about self-evaluation scales for satisfaction of delivery and maternal identity among women of epidural labor analgesia were not significantly different with those among women of spontaneous delivery.

CONCLUSIONS

Satisfaction with delivery and maternal identity are not influenced by chosing epidural labor analgesia.

[Postoperative cognitive dysfunction: Preface and Comments]

Postoperative cognitive dysfunction (POCD) has been highlighted over a decade. Although perioperative stroke is obvious central nervous system pathology, POCD is often subtle and unrecognized. No consensus on the definition for POCD has been reached. POCD may be attributed to preoperative, surgical, anesthetic, or adverse perioperative events. POCD often occurs frequently in elderly patients even after minor surgical procedures. POCD may last years after surgery and may impair the patient's social activity including premature departure from the workforce. Although neuroinflammation is suggested as an important predisposing factor, our knowledge on other predisposing factors is limited and effective preventive measure is unknown.

Perioperative management of carinal pneumonectomy: a retrospective review of 13 patients

Carinal pneumonectomy is a challenging procedure because of the difficulties in surgical technique, intraoperative airway management, and postoperative respiratory and anastomotic complications. However, information regarding the anesthetic and intraoperative respiratory management of this procedure is scarce. This report describes our routine anesthetic and respiratory management strategy in patients undergoing carinal pneumonectomy. Medical records of 13 patients who underwent carinal pneumonectomy under combined general and epidural anesthesia between 2008 and 2012 were analyzed retrospectively. Eleven patients underwent right carinal pneumonectomy and two underwent left carinal pneumonectomy. A left double-lumen tube was used in all but one case, in which endobronchial intubation was difficult because of intrabronchial invasion of the tumor. A 6.0-mm-long reinforced endobronchial tube was intubated into the main bronchus of the non-operative side from the surgical field during carinal resection. There were no episodes of severe hypoxemia or hypercapnia during surgery. Twelve patients were extubated immediately after surgery. No patient developed post-thoracotomy acute lung injury or required postoperative reintubation despite poor preoperative respiratory function. The 30-day mortality rate was 0%. Our airway management protocol for carinal pneumonectomy enables positive surgical outcomes.

Comparison of the value of tissue-sealing devices for thoracoscopic pulmonary lobectomy in small children: a first report

Accurate division and sealing of lung parenchyma particularly in cases of total or near total incomplete fissure are crucial for preventing air leakage following thoracoscopic pulmonary lobectomy (TPL). However, conventional endoscopic stapling devices cannot be used during TPL in small children because of limited space. Consequently, Ligasure (LS) and Enseal (ES) devices are being used instead. We are the first to compare LS and ES for efficacy and efficiency during TPL. Of 26 TPL (6 upper, 3 middle, and 17 lower) performed for congenital adenomatoid malformation (n = 16) and sequestration (n = 10), incomplete fissure was found in 14. TPL (LS = 11; ES = 15) was performed conventionally in the lateral decubitus position with single lung ventilation using four 5 mm trocars. All cases had a chest tube inserted intraoperatively that was left in situ. Patient demographics, location of pathology, incidence of incomplete fissure, mean age/weight at TPL, mean blood loss, and mean operative time were all similar. However, duration of chest tube insertion was significantly shorter in ES because there was less postoperative air leakage (1.3 vs. 3.9 days; p < 0.05). ES would appear to seal lung parenchyma more effectively during TPL based on the shorter duration of chest tube insertion.

Usefulness of stroke volume index obtained with the FloTrac/ Vigileo system for the prediction of acute kidney injury after radical esophagectomy

PURPOSE

To assess the impact of stroke volume index (SVI) at the end of esophagectomy upon postoperative renal function.

METHODS

We reviewed medical records of 128 patients undergoing esophagectomy. Intraoperative hemodynamics were monitored with the FloTrac sensor/Vigileo monitor system in addition to standard monitors. Patients were divided into two groups according to SVI at the end of surgery: the normal SVI group (n = 76), with SVI ≥ 35 ml/m2, and the low SVI group (n = 52), with SVI<35 ml/m2. We compared postoperative renal function, indicated by serum creatinine and estimated glomerular filtration rate, on post-operative days 0 through 3. We also compared numbers of patients who developed postoperative acute kidney injury (AKI).

RESULTS

Although there were no intergroup differences in preoperative renal function or other intraoperative hemodynamic variables, including arterial pressure, central venous pressure, stroke volume variation, a volume of infusion, urine output, and the total intraoperative in-out balance, estimated glomerular filtration rate was significantly lower and serum creatinine was significantly higher in the low SVI group than in the normal SVI group on postoperative days 1 and 2 (P<0.05). In addition, more patients developed postoperative AKI in the low SVI group than in the normal SVI group (12 of 52 vs. 5 of 76, P = 0.015).

CONCLUSIONS

Low SVI at the end of esophagectomy may represent a risk factor for AKI in the early postoperative period. Further studies are required to examine whether maintaining SVI above 35 ml/m2 reduces the incidence of AKI after esophagectomy.

Effects of anesthesia with sevoflurane and propofol on the cytokine/chemokine production at the airway epithelium during esophagectomy

Post-operative pulmonary complications such as pneumonia, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are closely associated with morbidity and mortality after esophagectomy. One lung ventilation (OLV) is commonly used during esophagectomy. However, the effect of the anesthetic agents on the inflammatory response induced by OLV has yet to be evaluated, particularly during esophagectomy, which causes several complications in the lung. The aim of the present study was to determine the effects of anesthetic agents, such as sevoflurane or propofol, on the inflammatory reactions at the airway. Twenty patients undergoing esophagectomy were randomized to receive either sevoflurane (n=10) or propofol (n=10) as a main anesthetic agent. Epithelial lining fluid (ELF) was obtained from ventilated‑dependent lung (DL) and collapsed non-dependent lung (NDL) by a bronchoscopic microsampling method. The levels of inflammatory cytokines and chemokine [tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, IL-10 and IL-12p70] in the ELF were measured using multiplexed bead-based immunoassays before and after OLV. The results indicated that the levels of IL-6 in ELF were significantly increased in both the ventilated DL and collapsed NDL after OLV compared with the levels prior to OLV in the sevoflurane group. By contrast, there was no significant change in the IL-6 levels in the propofol group in the ventilated DL and collapsed NDL before and after OLV. Similarly, IL-8 levels were markedly increased in the ventilated DL and collapsed NDL after OLV compared with those before OLV in the sevoflurane group, whereas there was no significant change in IL-8 levels in the propofol group in the ventilated DL and collapsed NDL before and after OLV. In contrast to the changes in IL-6 and IL-8 levels, levels of IL-10, an anti-inflammatory cytokine, were not obviously changed in both the ventilated DL and collapsed NDL before and after OLV in the sevoflurane group. However, IL-10 levels in the propofol group were increased in the ventilated DL and collapsed NDL after OLV compared with those before OLV. Of note, the levels of TNF-α, IL-1β and IL-12p70 in ELF were below the detection limits. These observations suggested that propofol anesthesia more potently suppresses the surgical stress-induced inflammatory perturbation at the local milieu of the airway during esophagectomy compared with sevoflurane anesthesia.

[Perioperative management of patients with cardiomyopathies: preface and comments]

Cardiomyopathies are a heterogeneous group of diseases of the myocardium. Cardiomyopathies are characterized by myocardial dysfunction resulting in heart failure due to systolic dysfunction and/or diastolic dysfunction. Prognosis of the patients with cardiomyopathies is usually poor due to progressive heart failure. Sudden death due to serious arrhythmia is not uncommon. Because of the heterogeneity of cardiomyopathies, the perioperative management of the patients with cardiomyopathies varies according to the pathological physiology. Management of low cardiac output is important as well as arrhythmias. Because of arrhythmias such as atrial fibrillation and poor ventricular function, anticoagulation is also important. Through evaluation and management of implantable pacemakers and implantable cardioverter defibrillator are essential.

[A case of malignant psoas syndrome diagnosed while treating sciatica]

While attempting to treat a 71-year-old male patient who had been diagnosed with sciatica from spinal canal stenosis, we discovered his prior cancer metastasizing to the psoas. We initially administered epidural block to him after confirming his prior rectal cancer had not metastasized to lumbar vertebral bones, but the block did not satisfactorily alleviate his pain, and he had difficulty stretching his lower limbs. CT scan to re-examine the cause revealed a metastasized cancer in the psoas. From this experience, we believe malignant psoas syndrome should be considered in addition to metastasis to lumbar vertebral bones, when evaluating lower back to lower limb pain in patients with previous cancer history.

[Case of two-stage carotid artery stenting managed with ultrasound-guided carotid sinus nerve block]

We report the use of ultrasound-guided carotid sinus nerve block for circulatory management during two-stage carotid artery stenting (CAS) in a patient with symptomatic carotid stenosis complicated with decreased cerebral perfusion reserve. The patient was a 70-year-old man with symptoms of ocular ischemia and markedly decreased perfusion of the left cerebral hemisphere observed in single photon emission computed tomography. Ultrasound-guided carotid sinus nerve block was conducted to prevent CAS perioperative circulatory fluctuations caused by carotid sinus reaction (CSR). We did not observe any hemodynamic instability during CAS. There were no complications associated with the nerve block. Although further research is required, the present findings suggest that ultrasoundguided carotid sinus nerve block may safely and effectively prevent CSR in CAS.

[A case of intraoperative cardiac arrest in a patient with mitochondrial encephalomyopathy undergoing lung resection]

We report a case of intraoperative cardiac arrest in a patient with mitochodorial encephalomyopathy undergoing pulmonary wedge resection. The patient is a 50-year-old female who had been diagnosed as progressive external ophthalmoplegia at the age of 44 and underwent resection of mediastinal tumor 11 months before without major events. The patient was found to have lung cancer in the left lung and scheduled for wedge resection. Induction and maintenance of anesthesia using remifentanil and propofol infusion with rocuronium were uneventful until traction and resection of the left bronci when profound hypotension with systolic arterial pressure of 20 mmHg and sinus bradycardia occurred. The rhythm deteriorated to ventricular fibrillation which was refractory to pharmacological therapy including adrenaline (a total dose of 5 mg), lidocaine and nifekalant, and DC shock. The patient was finally stabilized after intraaortic balloon pumping and percutaneous cardiopulmonary support. Although the diagnosis of Takotsubo myopathy was made by echocardiography after surgery, the cause of cardiac arrest was not known.