Chronic constriction injury of the sciatic nerve in rats causes different activation modes of microglia between the anterior and posterior horns of the spinal cord

Chronic constriction injury of the sciatic nerve is frequently considered as a cause of chronic neuropathic pain. Marked activation of microglia in the posterior horn (PH) has been well established with regard to this pain. However, microglial activation in the anterior horn (AH) is also strongly induced in this process. Therefore, in this study, we compared the differential activation modes of microglia in the AH and PH of the lumbar cord 7 days after chronic constriction injury of the left sciatic nerve in Wistar rats. Microglia in both the ipsilateral AH and PH demonstrated increased immunoreactivity of the microglial markers Iba1 and CD11b. Moreover, abundant CD68⁺ phagosomes were observed in the cytoplasm. Microglia in the AH displayed elongated somata with tightly surrounding motoneurons, whereas cells in the PH displayed a rather ameboid morphology and were attached to myelin sheaths rather than to neurons. Microglia in the AH strongly expressed NG2 chondroitin sulfate proteoglycan. Despite the tight attachment to neurons in the AH, a reduction in synaptic proteins was not evident, suggesting engagement of the activated microglia in synaptic stripping. Myelin basic protein immunoreactivity was observed in the phagosomes of activated microglia in the PH, suggesting the phagocytic removal of myelin. CCI caused both motor deficit and hyperalgesia that were evaluated by applying BBB locomotor rating scale and von Frey test, respectively. Motor defict was the most evident at postoperative day1, and that became less significant thereafter. By contrast, hyperalgesia was not severe at day 1 but it became worse at least by day 7. Collectively, the activation modes of microglia were different between the AH and PH, which may be associated with the difference in the course of motor and sensory symptoms.

Hemolytic reaction in the washed salvaged blood of a patient with paroxysmal nocturnal hemoglobinuria

Background

In patients with paroxysmal nocturnal hemoglobinuria (PNH), the membrane-attack complex (MAC) formed on red blood cells (RBCs) causes hemolysis due to the patient’s own activated complement system by an infection, inflammation, or surgical stress. The efficacy of transfusion therapy for patients with PNH has been documented, but no studies have focused on the perioperative use of salvaged autologous blood in patients with PNH.

Case presentation

A 71-year-old man underwent total hip replacement surgery. An autologous blood salvage device was put in place due to the large bleeding volume and the existence of an irregular antibody. The potassium concentration in the transfer bag of salvaged RBCs after the wash process was high at 6.2 mmol/L, although the washing generally removes > 90% of the potassium from the blood. This may have been caused by continued hemolysis even after the wash process. Once activated, the complement in patients with PNH forms the MAC on the RBCs, and the hemolytic reaction may not be stopped even with RBC washing.

Conclusions

Packed RBCs, instead of salvaged autologous RBCs, should be used for transfusions in patients with PNH. The use of salvaged autologous RBCs in patients with PNH should be limited to critical situations, such as massive bleeding. Physicians should note that the hemolytic reaction may be present inside the transfer bag even after the wash process.

Carbon monoxide poisoning-induced delayed encephalopathy accompanies decreased microglial cell numbers: Distinctive pathophysiological features from hypoxemia-induced brain damage

Carbon monoxide (CO) causes not only acute fatal poisoning but also may cause a delayed neurologic syndrome called delayed encephalopathy (DE), which occasionally occurs after an interval of several days to several weeks post-exposure. However, the mechanisms of DE have not been fully elucidated. This study aimed to clarify the pathophysiology of CO-induced DE and its distinctive features compared with hypoxemic hypoxia. Rats were randomly assigned to three groups; the air group, the CO group (exposed to CO), and the low O₂ group (exposed to low concentration of O₂). Impairment of memory function was observed only in the CO group. The hippocampus tissues were collected and analyzed for assessment of CO-induced changes and microglial reaction. Demyelination was observed only in the CO group and it was more severe and persisted longer than that observed in the low O₂ group. Moreover, in the CO group, decreased in microglial cell numbers were observed using flow cytometry, and microglia with detached branches were observed were observed using immunohistochemistry. Conversely, microglial cells with shortened branches and enlarged somata were observed in the low O₂ group. Furthermore, mRNAs encoding several neurotrophic factors expressed by microglia were decreased in the CO group but were increased in the low O₂ group. Thus, CO-induced DE displayed distinctive pathological features from those of simple hypoxic insults: prolonged demyelination accompanying a significant decrease in microglial cells. Decreased neurotrophic factor expression by microglial cells may be one of the causes of CO-induced DE.

Perioperative management of a patient with Coffin-Lowry syndrome complicated by severe obesity: A case report and literature review

RATIONALE

Coffin-Lowry syndrome (CLS) is a rare inherited disease with specific clinical features, such as mental retardation, facial dysmorphism, and cardiac abnormality. In particular, the characteristic facial features of CLS, including retrognathia and large tongue, are associated with difficult ventilation and/or intubation, which is a serious problem of anesthesia management. However, case reports on anesthesia management of CLS are very limited as there are only two published English reports till date. In this case report, we discuss anesthetic and postoperative considerations in patients with CLS, focusing on difficult airway management, and summarize past reports including some Japanese articles.

PATIENT CONCERNS

A 25-year-old man with CLS was planning to undergo laminectomy because of progressive quadriplegia caused by calcification of the yellow ligament. We suspected difficulty in airway management because of several factors in his facial features, short thyromental and sternomental distances in computed tomography, severe obesity, and sleep apnea syndrome.

DIAGNOSES

Difficult airway was suspected. However, because of mental retardation, awake intubation was considered difficult.

INTERVENTIONS

We selected bronchofiberscope-guided nasotracheal intubation, maintaining spontaneous breathing under moderate sedation with a propofol target-controlled infusion.

OUTCOMES

Airway management was safely performed during anesthesia induction.

LESSONS

In many patients with CLS, difficult intubation was reported, and sedation or slow induction maintaining spontaneous breathing was mainly selected for anesthesia induction. Spontaneous breathing should be maintained during anesthesia induction in case of CLS patients.

Two Japanese Pioneers in Anesthesiology: Seishū Hanaoka and Gendai Kamada

Seishū Hanaoka and Gendai Kamada are two Japanese pioneers in anesthesiology. Seishū Hanaoka was the world's first surgeon on record to successfully perform surgery under general anesthesia in 1804. Seishū discovered that six medicinal herbs containing Datura, stramonium, and Aconitum had anesthetic properties. From these, he developed Mafutsusan. His fame spread across Japan, and he was inundated with requests from patients and prospective students. He founded a private medical school (Shunrinken) and trained more than 1000 students. Gendai Kamada was an outstanding pupil of Seishū Hanaoka. From the perspective of the history of anesthesiology, three of Gendai's achievements had a global impact. (1) In 1839, he wrote the first textbook of clinical anesthesiology, Mafutsuto-ron; (2) in 1840, he authored Gekakihai-zufu, which included some of the oldest illustrations of surgery under general anesthesia; and (3) he trained Gensei Matsuoka, the world's second anesthesiologist.

Mafutsuto-Ron: The First Anesthesia Textbook in the World. Bibliographic Review and English Translation

On October 13, 1804, Seishu Hanaoka performed a mastectomy on Kan Aiya in Hirayama, Kii Province Japan, in what is considered to be the first operation under general anesthesia. She was anesthetized with a mixture of herbs known as Mafutsuto. Although Seishu did not record his anesthetic practices, his student, Gendai Kamada, documented the use of Mafutsuto in Mafutsuto-Ron. Written in 1839, Mafutsuto-Ron is 10 pages and covers six topics, including preoperative management, dosing and administering Mafutsuto, induction of general anesthesia, common errors, and postoperative precautions. Mafutsuto-Ron, therefore, meets the requirements to be considered the first extant anesthesia textbook. We present a complete English translation of Mafutsuto-Ron.

Use of ambulatory anesthesia with manually assisted ventilation for tympanic membrane regeneration therapy in children

PURPOSE

To present the utility of ambulatory anesthesia using manually assisted ventilation via a facemask for tympanic membrane (TM) regeneration therapy in children.

MATERIAL AND METHODS

The study included 10 children (age 4-11years) in whom the duration of perforation before treatment exceeded 6months and who were followed for at least 1year after treatment between December 2009 and December 2012. Under ambulatory anesthesia using manually assisted ventilation via a facemask, TM regenerative therapy with atelocollagen combined with basic fibroblast growth factor was performed in children who could not tolerate the procedure under local anesthesia alone.

RESULTS

All of the children completed the TM regenerative therapy under ambulatory anesthesia in less than 5min. Complete closure was achieved in nine (81.8%) ears after 1year of postoperative follow-up.

CONCLUSION

TM regenerative therapy can be performed under local anesthesia in less than 5min without a skin incision. However, local anesthesia is often insufficient in small children undergoing this procedure. Therefore, ambulatory anesthesia using manually assisted ventilation via a facemask is appropriate to complete this procedure safely in small children.

Management of patients under general anesthesia with mafutsu-san in Hanaoka-style surgery: comparisons of illustrations from Geka-Kihai-Zufu with descriptions from Mafutsuto-Ron and Yohka-Hiroku

INTRODUCTION

Seishu Hanaoka (1760-1835) left behind no books that he himself had written. This is why many aspects of Hanaoka-style general anesthesia using a mixture of herbal extracts, which he called mafutsu-san, remain unknown. We are able to learn about this technique today because there are several descriptions of it in books written by his students, such as Mafutsuto-Ron ("Treatise on Mafutsuto") by Gendai Kamata (1794-1854) and Yohka-Hiroku ("Secret Records of Surgery") by Gencho Homma (1804-1872). On the other hand, Geka-Kihai-Zufu ("Illustrations of Surgical Cases"), a surgical textbook, by Gendai Kamata, containing one of the oldest illustrations of general anesthesia published in 1840, was recently rediscovered (2011). For the first time, this book revealed, in the form of a picture image, the actual circumstances of Hanaoka-style general anesthesia.

METHODS

We therefore compared the descriptions of general anesthesia featured in these three documents, and thereby investigated the actual anesthetic management and the procedures used.

RESULTS AND CONCLUSIONS

We found that the circumstances under which Hanaoka-style general anesthesia, using fabrics and futon mattresses, as well as blindfolding and constraining the patient's body during surgery, were exactly as described in Mafutsuto-Ron and Yohka-Hiroku. In addition, besides a surgeon conducting an operation, there was a physician who observed the patient's general condition. Gendai Kamata, the author of Geka-Kihai-Zufu, is believed to have recognized the importance of anesthetic care of surgical patients.

[The looks of Gendai Kamada]

We realized the looks of Gendai Kamada. At first, we found in a figure, in "Seishu Hanaoka and His Surgery" by Syuzo Kure, that the portrait described as that of Gendai is his father's. And we discovered the illustrations that illustrate the looks of Gendai in "Gekakihaizufu", which was a textbook of clinical anesthesia and surgery, printed in 1840. Using these illustrations, we realized the looks of Gendai Kamada.

[Incorrect descriptions about Seicho Kamata in "Seishu Hanaoka and his surgery"]

"Seishu Hanaoka and his surgery" by Shuzo Kure is one of the most important books for the study of Seishu Hanaoka. However, several incorrect descriptions have been pointed out in the book. Therefore, we checked the content about Seicho Kamata, a distinguished disciple of Seishu Hanaoka (p.154-163) in the book, and found three incorrect descriptions. The figure being described as that of Seicho Kamata is his father's. His graveyard being described as "Nyohoji" is truly "Daizenji". Seicho Kamata is also described as the second distinguished disciple of Seishu Hanaoka ; however, authors think that he was the first distinguished disciple from his career. Further investigation into the content of the book is necessary.

Stenosis of the trachea caused by retrosternal ossification

An abnormal anatomic structure of the thoracic inlet causing stenosis of the trachea is rare. This case report illustrates a man presenting tracheal stenosis caused by retrosternal ossification, and discusses its clinical significance and possible pathogenesis.

Functional changes of N-methyl-D-aspartic acid and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate channels in gerbil hippocampal CA1, in relation to postischemic enhancement of glutamate receptor-mediated responses

Glutamate receptor-mediated responses have been reported to be enhanced in the postischemic CA1 pyramidal neurons before the appearance of delayed neuronal death, and the enhancement has been thought to be one of crucial factors leading postischemic CA1 pyramidal neurons to irreversible neuronal injury. In the present study, we examined what changes in functional properties of N-methyl-D-aspartic acid (NMDA) and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) channels are responsible for the enhanced postischemic glutamate receptor-mediated responses. Gerbils were subjected to 5-min ischemia to induce the enhancement of glutamate receptor-mediated responses and the hippocampal slices were prepared 3 h after ischemia. Single channel activities evoked by NMDA and AMPA were recorded from outside-out patches excised from the postischemic CA1 pyramidal neurons. The main conductance levels of NMDA and AMPA channels in the postischemic CA1 pyramidal neurons were not significantly different from those in control CA1 pyramidal neurons. The mean open time and the open-state probability of NMDA and AMPA channels significantly increased in the postischemic CA1 pyramidal neurons (NMDA channels: mean open time, 1.4-fold increase; open-state probability, 1.5-fold increase) (AMPA channels: mean open time, 1.3-fold increase; open-state probability, 1.8-fold increase). These findings indicate that the increases in the mean open time and the open-state probability of NMDA and AMPA channels are responsible for the enhancement of postischemic NMDA and non-NMDA receptor-mediated responses.

Postischemic enhancements of N-methyl-D-aspartic acid (NMDA) and non-NMDA receptor-mediated responses in hippocampal CA1 pyramidal neurons

Glutamate receptor-mediated responses were investigated by using a whole-cell recording and an intracellular calcium ion ([Ca2+]i) imaging in gerbil postischemic hippocampal slices prepared at 1, 3, 6, 9, 12, and 24 hours after 5-minute ischemia. Bath application of N-methyl-D-aspartic acid (NMDA), alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA), and kainate showed that NMDA-, AMPA- and kainate-induced currents were enhanced in postischemic CA1 pyramidal neurons at 1 to 12 hours after 5-minute ischemia. NMDA and non-NMDA receptor-mediated excitatory postsynaptic currents (EPSC) were examined in postischemic CA1 pyramidal neurons at 3 hours after 5-minute ischemia to confirm whether synaptic responses are enhanced in the postischemic CA1 pyramidal neurons. The amplitudes of NMDA- and non-NMDA-receptor-mediated EPSC were enhanced in the postischemic CA1 pyramidal neurons. NMDA-, AMPA-, and kainate-induced [Ca2+]i elevations were also examined to determine whether the enhancement of currents is accompanied by the enhancement of [Ca2+]i elevation. The enhancements of NMDA-, AMPA-, and kainate-induced [Ca2+]i elevations were shown in the postischemic CA1. These results indicate that NMDA and non-NMDA receptor-mediated responses are persistently enhanced in the CA1 pyramidal neurons 1 to 12 hours after transient ischemia, and suggest that the enhancement of glutamate receptor-mediated responses may act as one of crucial factors in the pathologic mechanism responsible for leading postischemic CA1 pyramidal neurons to irreversible neuronal injury.

Effects of pre- and postischemic administration of thiopental on transmitter amino acid release and histologic outcome in gerbils

BACKGROUND

The mechanism by which barbiturates protect neurons against ischemia is unclear, particularly when they are given after ischemia or reperfusion begins. Because an excess release of excitatory neurotransmitters causes postsynaptic membrane depolarization, which triggers neuronal damage in ischemia, the effects of thiopental on histologic outcome, ischemia-induced amino acid release, and anoxic depolarization in gerbils were studied.

METHODS

The effects of different doses of thiopental administered before or after ischemia were examined morphologically by assessing delayed neuronal death in hippocampal CA1 pyramidal cells produced by forebrain ischemia for 3 min in gerbils. The ischemia-induced changes in output of aspartate, glutamate, glycine, taurine, and gamma-aminobutyric acid were measured using a microdialysis-high-performance liquid chromatography procedure, and the differences among a halothane-anesthetized group, a thiopental-administered group, and a group given thiopental after a period of ischemia were evaluated. The changes induced in the direct-current potential in the hippocampal CA1 area by forebrain ischemia were compared in animals anesthetized with halothane and those given thiopental.

RESULTS

Preischemic administration of thiopental at all doses decreased the risks for delayed neuronal death (P < 0.01). Post-ischemic administration at a dosage of 2 mg.kg-1.min-1 for 60 min protected neurons, but the same dose for 10 min did not ameliorate the cell injury. Forebrain ischemia produced marked increases in all amino acids 3 to 6 min after the start of recirculation in the halothane-anesthetized gerbils, whereas thiopental anesthesia (2 mg.kg-1.min-1) reduced these increases throughout the experimental period, except for glycine (P < 0.01). The initiation of thiopental after reflow did not markedly diminish these increases. Thiopental anesthesia prolonged the onset of anoxic depolarization and reduced its maximal amplitude.

CONCLUSIONS

Thiopental helps protect the brain from ischemia, although treatment with this agent after ischemia requires a larger dose than that before ischemia. The effect of preischemic treatment may be related to the suppression of the excitatory amino acid release and the direct-current potential shift.

[Cardiovascular instability in schizophrenic patients may be caused by alpha 1-blocking activity of major tranquilizer--measurement by isometric handgrip test]

In order to prove the hypothesis that cardiovascular instability of schizophrenic patients is caused by alpha 1-blocking effect of major tranquilizer, we measured the blood pressure (BP), the heart rate (HR), and serum epinephrine and norepinephrine levels before and after isometric handgrip (IHG) test in schizophrenic patients and normal adults (control). The results were as follow: (1) In schizophrenic patients systolic BP rose significantly less than in controls after IHG test. (2) HR in patient group was constantly higher than in control group. (3) Though HR after IGH test decreased in normal group, there was no significant difference in HR before and after IHG test in patient group. (4) In patient group, norepinephrine level was higher than in control group before IHG test but it did not increase after IHG test, while it did increase in normal group. It is concluded that alpha 1-receptors are selectively blocked and the reactivity to norepinephrine is reduced in schizophrenic patients who has been taking a major tranquilizer. This results in the impairment of the ability to control immediately BP corresponding to postural change and to exercise, which probably causes instability in circulatory state in schizophrenic patients under general anesthesia.

[A case of suspected liver dysfunction induced by sevoflurane anesthesia]

We report a case of suspected liver dysfunction after general anesthesia with sevoflurane. A 30 day old male infant underwent inguinal herniorrhaphy under sevoflurane anesthesia (sevoflurane concentration: 1.3-1.5% with 50% oxygen and nitrous oxide). Two days after the operation, he developed frequent vomiting, anorexia and fever. GOT, GPT and LDH values were 242 Ku, 326 Ku and 901 Wu, respectively and peaked at 520 Ku, 709 Ku and 1000 Wu 12-16 days after the operation. Clinical symptoms and the laboratory data became normal within 2 months. The antibody titers of EB-virus, cytomegalo-virus and HA-virus were all within normal ranges and HBs antigen was negative. There were no blood transfusion or antibiotics administration before the onset, and no epidemic of hepatitis around him. His mother had no history of hepatitis during her pregnancy. Lymphocyte stimulation test for indication of sevoflurane allergy was also negative. From these evidences, toxic (not allergic) liver dysfunction due to exposure to sevoflurane was considered to be the most probable diagnosis.