The History of Japanese Anesthesiology.

Anesthesia in Japan has a 200-year history, beginning when Seishu Hanaoka first conducted surgery successfully under general anesthesia in 1804. Despite common belief, Hanaoka was not secretive about his technique using Mafutsusan, and he spawned a generation of Japanese anesthetists, including Gendai Kamada, author of several influential texts. Japanese anesthetists adopted inhalational techniques as they became available. In 1954, the Japanese Society of Anesthesiologists was established; in 1960, "Anesthesiology" was accredited by Japanese government as an officially approved medical specialty; and in 1963, board examinations were established to be an instructor of anesthesia. In 2011, the Japanese Museum of Anesthesiology opened in Kobe, with the mission to collect and preserve literature and equipment related to the history of Japanese anesthesia (Figure 1).

Calcium Phosphate Composition Affects Ureteroscopic Laser Lithotripsy.

The effects of stone composition on transurethral lithotripsy (TUL) have not been sufficiently elucidated. The purpose of this study was to identify how calcium phosphate stone composition impacts TUL. Two hundred eighty-nine cases of semi-rigid and/or flexible TUL for upper urinary tract calculi were reviewed retrospectively. Inclusion criteria were a preoperative assessment by noncontrast computed tomography (NCCT) and a stone composition analysis. Small stones and those without calcium composition were excluded. Stone core radiodensity (SCR) was measured by taking the average of the upper 3 of 5 points in the proximity of the center of the stone on NCCT. Fifty-three patients with calcium phosphate composition (CaP) and 118 patients with calcium oxalate and without phosphate composition were eligible for analysis. SCR was significantly higher in the CaP group (p＜0.01). The CaP patient group needed a significantly longer operation time (p＝0.014) and more laser energy (p＝0.085), and tended to have a lower rate of complete lithotripsy (p＝0.096) and higher incidence of postoperative pyelonephritis (p＝0.181). Stones containing calcium phosphate are harder, demand more laser energy, and require a longer operating time. NCCT evaluation can estimate stone composition preoperatively, and may be a useful tool for predicting operative outcomes.

The Japanese Museum of Anesthesiology in Kobe, Japan.

In 2009, the Japanese Society of Anesthesiologists (JSA) founded the Archives of JSA, which changed into the Japanese Museum of Anesthesiology in 2011. The museum consists of three sections: (1) archives (the collection of historical documents of the JSA), (2) museum (the collection of anesthetic equipment and its related things), and (3) library (the collection of books, journals, leaflets, and related materials). By January 2013, the collections included 2537 Japanese and 1569 foreign language books. JMA collections include 25% of the Japanese anesthesia books published between 1796-2008, making it Japan's largest collection, with the exception of the National Diet Library of Japan. Most of the Japanese books published from 1796 to 2008 are listed and can be searched through the home page.

[Emergency incompatible red cell transfusion to a patient whose blood type was suspended from identification].

We report a case of a 59-year-old woman who presented with hypovolemic shock and compensated acidosis (preoperative arterial blood gases: pH 7.3, P(CO2) 31.9 mmHg, Pa(O2) 112.3 mmHg, base excess -9.8, Hb 6.4 g x dl(-1)) due to perforated descending colon, necessitating emergency surgery. Tracheal intubation had been performed preoperatively. Prior to induction of anesthesia, blood pressure was 106/74 mmHg, heart rate 119 beats x min(-1), and Sp(O2) 100% breathing room air. Anesthesia was induced with remifentanil influsion at a rate of 0.05 mg x kg(-1) x min(-1), sevoflurane 1% and rocuronium bromide 30mg, and was maintained with oxygen, air, remifentanil and sevoflurane. For a critical hypovolemia, in accordance to the guidelines for intraoperative critical hemorrhage and the Japanese practical guidelines for blood components therapy, we started to transfuse incompatible red cell (O+) since the identification of blood typing was suspended. The duration of surgery was 104 min, with an intraoperative total bleeding of 125 ml. Four units of total blood transfusion and 3,050 ml of infusion of Ringer's acetate solution were administered. The patient was transferred to ICU with tracheal intubation. No adverse reactions associated with blood type incompatibility were recognized.

Detection of the full-length transcript variant for neurokinin-1 receptor in human whole blood associated with enhanced reinforcement of clot by substance-P.

We have recently reported that a neurotransmitter for pain, substance-P (SP), promotes platelet-dependent clot formation through neurokinin-1 receptors (NK1Rs), in which leukocytes appear to be involved (J Thromb Thrombolysis 2009;27:280-6). Two naturally occurring splice isoforms of NK1R with different signal transduction potency, namely the full-length and the truncated NK1Rs are identified. It is known that human leukocytes express truncated NK1Rs, while in vivo expression of the full-length NK1R has not yet been fully clarified. Modulatory effects of alternative splicing for NK1Rs on clot formation also remain to be evaluated. Expression of the transcript variant mRNA for NK1Rs in human whole blood (n = 20) was evaluated by real-time reverse transcription polymerase chain reaction (RT-PCR). A 15 min time series of the strength of clot, formed after reloading of calcium in citrated whole blood with or without SP (10 nM) and a NK1R antagonist Spantide (1 µM), was measured by using oscillating-probe viscoelastometry. The full-length transcript variant was detected in 5 samples among 20. SP significantly increased the clot strength while Spantide suppressed the SP-derived change. The extent of modulation by SP/NK1R pathway in a subgroup with expression of the full-length transcript variant was three times as potent as those in another subgroup without expression. We conclude that expression of the full-length transcript variant for NK1R can be detected in human whole blood and that such expression is associated with the enhanced reinforcement of clot by SP. Further study is required to nominate this mRNA as a biomarker for prothrombotic risks in painful conditions such as perioperative period.

[Restrict or enforce the preoperative clear liquid intake?: preface and comments].

Restriction of preoperative clear liquid intake causes thirst in many patients but is followed traditionally for many years in the preoperative order by an anesthesiologist in charge. Although many anesthesiologists doubted long the efficacy of this tradition, no one has stopped. In 1999, the ASA guideline on restriction of preoperative clear liquid intake was published. However, this guideline was not yet followed in many institutes and hospitals in Japan. In 2005, the report from north European countries was published and introduced the new idea "Enhanced Recovery after Surgery, ERAS" which consists of many factors. Among these factors, the enforcement of preoperative clear liquid intake was reviewed in this volume.

[Viability period of the rabbit skeletal muscle in the Ca(2+)-induced Ca2+ release (CICR) test].

BACKGROUND: In Japan, malignant hyperthermia susceptibility (MHS) is diagnosed by detecting an enhanced rate of CICR from the sarcoplasmic reticulum in skinned skeletal muscle fibers. We usually consider the CICR test should be completed within 48 hours of muscle excision. We measured the viability period of the CICR test in the following four treatment groups. METHODS: Muscle bundles prepared from a rabbit were dissected and stored in muscle relaxant solution at -30 degrees C, 4 degrees C, 20 degrees C, and 37 degrees C. The CICR rate was measured in a part of the biopsied muscle using chemically skinned fibers that had been prepared according to Endo's method. RESULTS: With muscle bundles stored at -30 degrees C and 37 degrees C, the rate of CICR could not be measured. Function related CICR of the muscle stored at 4 degrees C and 20 degrees C lasted for four days. CONCLUSIONS: This results showed that rate of CICR can be measured for at least 4 days when skeletal muscle bundles of rabbits are stored both at 4 degrees C and at 20 degrees C. Further studies are expected including the optimum conditions on stored temperature and stored days in the human muscle.

[Accidental skin burns by fire of an antiseptic agent ignition by the spark of electric cautery].

Surgical fire is a rare complication during the operative period. But, it is a severe complication when it occurs. There are antiseptic agents with strong inflammability used for skin preparation. We report accidental skin burns caused by the spark of electric cautery. The patient was a 29-year-old (50 kg, 158 cm, physical status ASA1) woman who underwent laparotomy for acute abdomen. Anesthesia was induced and tracheal intubation was performed without trouble. Anesthesia was maintained with oxygen, air, remifentanil and sevoflurane. The skin of the surgical site was sterilized with an alcoholic antiseptic containing chlorhexidine before the operation. Several minutes after the start of operation, a fire occurred on using the electric cautery. Immediately, fire was extinguished by hands. The cover cloth is peeled off and it was confirmed that the burn extended from the right thoracic region to the buttocks. After cooling, it became a burn of II to III degrees. Operation was restarted, and at the end, the patient was allowed to breathe spontaneously for 5 minutes and extubated afterwards. The disinfectant with alcoholic content has a strong inflammability. It is necessary to dry it enough before using cautery.

[Infection control in operation theaters: preface and comments].

In operation theaters, there are many guidelines and precautions for prevention of infection, which we have to practice. Basic idea consists of two parts; one is cross infection among medical staffs, patients and their families, and the other is protection of infection from patients. In this volume, infection control in management of operation theater, anesthesia machines, their related instruments and tools, as well as on central venous catheter insertion and epidural insertion is reviewed in addition to the antibiotic administration in perioperative period.

Bisphenol A in combination with TNF-alpha selectively induces Th2 cell-promoting dendritic cells in vitro with an estrogen-like activity.

Bisphenol A (BPA) is a monomer used in manufacturing a wide range of chemical products, including epoxy resins and polycarbonate. BPA, an important endocrine disrupting chemical that exerts estrogen-like activities, is detectable at nanomolar levels in human serum worldwide. The pregnancy associated doses of 17beta-estradiol (E2) plus tumor-necrosis factor-alpha (TNF-alpha) induce distorted maturation of human dendritic cells (DCs) that result in an increased capacity to induce T helper (Th) 2 responses. The current study demonstrated that the presence of BPA during DC maturation influences the function of human DCs, thereby polarizing the subsequent Th response. In the presence of TNF-alpha, BPA treatment enhanced the expression of CC chemokine ligand 1 (CCL1) in DCs. In addition, DCs exposed to BPA/TNF-alpha produced higher levels of IL-10 relative to those of IL-12p70 on CD40 ligation, and preferentially induced Th2 deviation. BPA exerts the same effect with E2 at the same dose (0.01-0.1 microM) with regard to DC-mediated Th2 polarization. These findings imply that DCs exposed to BPA will provide one of the initial signals driving the development and perpetuation of Th2-dominated immune response in allergic reactions.

[Survey of pediatric sedation in Japan--results of questionnaire to universities of dentistry].

OBJECT: Despite widespread use of sedation for stress management during dental treatment in adults, its prevalence of use for pediatric in patients Japan has not been clarified. We investigated here, the present situation of pediatric sedation by the questionnaire sent to the dental anesthesia departments of university hospitals in Japan. METHODS: Postal survey was conducted of the dental anesthesia departments of university hospitals (29 institutions) throughout the country. Information was requested on hospital policy of indication and technique of pediatric sedation for dental treatment. The causes for avoiding pediatric sedation were also investigated. RESULTS: The response rate was 86.2% (25/29 institutions). Of these respondents, 16 institutions (64%, 16/25 institutions) employ sedation for pediatric dental treatment stress management. The cases performed were around 1-5 cases every month. However, the criteria for employment of pediatric sedation during dental treatment varied among institutes. They preferred to provide general endotracheal anesthesia for pediatric dental procedures, and tended to avoid sedation without airway security for children. CONCLUSIONS: The present survey suggests that pediatric sedation for stress management during dental treatment are employed in more than half of the dental university hospitals. However, there was little consensus regarding pediatric sedation during dental treatment among dental anesthesiologists in Japan.

The role of 20-hydroxyeicosatetraenoic acid in cerebral arteriolar constriction and the inhibitory effect of propofol.

BACKGROUND: We conducted this study to examine, in cerebral parenchymal arterioles, whether 20-hydroxyeicosatetraenoic acid (20-HETE) induces constrictor responses via superoxide and whether propofol reduces this constriction. METHODS: Electrical field stimulation or 20-HETE was applied to rat brain slices monitored by computer-assisted microscopy. In some experiments, a Na(+) channel antagonist tetrodotoxin, a 20-HETE synthesis inhibitor HET0016, a superoxide scavenger, Tiron, nicotinamide adenine dinucleotide phosphate (NADPH) oxidase inhibitors diphenyleneiodonium (DPI) and gp91ds-tat, or propofol was added. The superoxide level in the brain slice and the production rate in the absence of slices were evaluated by dihydroethidium fluorescence or cytochrome c reduction with a superoxide-generating system, respectively. RESULTS: Electrical stimulation induced constriction of the cerebral parenchymal arteriole, whereas this response was abolished by tetrodotoxin, HET0016, Tiron, or DPI. 20-HETE (10(-8)-10(-6) mol/L) produced arteriolar constriction, which was inhibited by Tiron or DPI. Propofol reduced the constriction induced by electrical stimulation or 20-HETE. 20-HETE induced superoxide production in the brain slice, which was reduced by Tiron, gp91ds-tat, or propofol. However, propofol did not alter the superoxide production rate in the absence of brain slices. CONCLUSIONS: Either neuronal transmission-dependent or exogenous 20-HETE seems to induce cerebral parenchymal arteriolar constriction via superoxide production resulting from NADPH oxidase activation. Propofol is likely to prevent this constriction via inhibition of NADPH oxidase, but not by its scavenging effect on superoxide.

[Pharmacodynamics of pain perception and polymorphism].

The regulation of biotransformation started with the mechanism of mass action between the concentrations of the substrates (product) and enzyme. Thereafter by understanding the protein tertiary structure, allosteric control mechanism appeared. The enzyme induction was brought into a new aspect by the development of genetic analysis. As a cellular economy, energy charge was found to be a new regulatory mechanism for glycolytic pathway. These regulatory systems showed a single concentration-effect curve of pharmacodynamics. By introduction of silent or non sense gene as in atypical cholinesterase, a given function was not operated. As most doctors are aware of the diverse sensitivity to opioids among patients, numbers and species of opioid receptors might be the cause. By extensive gene analysis, polymorphism may explain this phenotype. The polymorphism may also play an important role in the pain mechanism such as incidence of neuropathic pain and in the modulation of pain. You will find several curves of pharmocodynamics.

Cytokine-dependent modification of IL-12p70 and IL-23 balance in dendritic cells by ligand activation of Valpha24 invariant NKT cells.

CD1d-restricted invariant NKT (iNKT) cells play crucial roles in various types of immune responses, including autoimmune diseases, infectious diseases and tumor surveillance. The mechanisms underlying their adjuvant functions are well understood. Nevertheless, although IL-4 and IL-10 production characterize iNKT cells able to prevent or ameliorate some autoimmune diseases and inflammatory conditions, the precise mechanisms by which iNKT cells exert immune regulatory function remain elusive. This study demonstrates that the activation of human iNKT cells by their specific ligand alpha-galactosylceramide enhances IL-12p70 while inhibiting the IL-23 production by monocyte-derived dendritic cells, and in turn down-regulating the IL-17 production by memory CD4(+) Th cells. The ability of the iNKT cells to regulate the differential production of IL-12p70/IL-23 is mainly mediated by a remarkable hallmark of their function to produce both Th1 and Th2 cytokines. In particular, the down-regulation of IL-23 is markedly associated with a production of IL-4 and IL-10 from iNKT cells. Moreover, Th2 cytokines, such as IL-4 and IL-13 play a crucial role in defining the biased production of IL-12p70/IL-23 by enhancement of IL-12p70 in synergy with IFN-gamma, whereas inhibition of the IFN-gamma-promoted IL-23 production. Collectively, the results suggest that iNKT cells modify the IL-12p70/IL-23 balance to enhance the IL-12p70-induced cell-mediated immunity and suppress the IL-23-dependent inflammatory pathologies. These results may account for the long-appreciated contrasting beneficial and adverse consequence of ligand activation of iNKT cells.

[New frontier in perioperative blood component therapy--preface and comments].

The latest revision of Japanese practical guidelines for the blood component therapy, edited by the Ministry of Health, Labour and Welfare of Japan in 2005, consisted of several crucial points including: emergency red cell transfusion for critically ill patients; the computer crossmatch; and non-erythrocyte blood component therapy based on diagnosis for coagulopathy. The guidelines issued by the Japanese Society of Anesthesiologists as well as the Japan Society of Transfusion Medicine and Cell Therapy (2008) further focused on the strategy for perioperative massive blood loss. Seven feature articles following this opening article summarizes the topics for the new frontier in perioperative blood component therapy in Japan.

[Diagnosis and transfusion algorithm for the management of perioperative coagulopathy].

The present article reviewed the management of coagulopathy in the perioperative setting, following the Japanese practical guidelines for the blood component therapy, edited by the Ministry of Health, Labour and Welfare of Japan in 2005. The threshold concentrations of platelets, prothrombin time international normalized ratio (PT-INR) and activated partial thromboplastin time (APTT) were optimized for the perioperative critical care under active and/or microvascular bleeding, based on currently available randomized controlled trials. Discontinuation or modification of anticoagulants as well as antiplatelets is essential for the safe perioperative care. Several factors, including normothermia, normovolemia, as well as the maintenance of plasma calcium levels within normal range, are important for the management of coagulopathy. Platelet counts, PT, APTT, and if possible, other point-of-care testing including thromboelastography and its modified techniques should be performed following visual inspection of abnormal bleeding. The transfusion algorithms based on causal diagnosis of coagulopathy optimize the risk/ benefit ratio of perioperative transfusion therapy.