Fetal outcomes with and without the use of sugammadex in pregnant patients undergoing non-obstetric surgery: a multicenter retrospective study.

BACKGROUND: The influence of sugammadex exposure during pregnancy on progesterone withdrawal and miscarriage is unknown. We aimed to compare the fetal outcomes in pregnant patients who had undergone non-obstetric surgery with and without sugammadex. METHODS: We retrospectively reviewed the medical charts of pregnant women who underwent non-obstetric surgery at three tertiary perinatal care centers in Japan from January 2013 to December 2020. The women were divided into those who received general anesthesia with sugammadex (GA with SGX) and those who received general anesthesia without sugammadex (GA without SGX). We compared miscarriages and preterm births within four weeks after surgery. RESULTS: Among the 124 women, 73 and 51 were included in the GA with SGX and GA without SGX groups, respectively. The two groups showed no differences in the rate of miscarriages or preterm births (3.0 % vs 4.3 %; odds ratio 1.42, 95 % confidence interval 0.19 to 10.47; P = 1.00). The SGX and no SGX groups were missing outcomes for 8.2 % and 7.8 % of cases, respectively. CONCLUSIONS: Having GA with SGX or GA without SGX did not result in different rates of miscarriage or preterm birth within four weeks after the procedure. These findings do not exclude a potential association between sugammadex exposure during pregnancy and adverse pregnancy outcomes. Missing data may have obscured possible adverse outcomes from sugammadex exposure.

Cigarette smoking, CYP1A1 MspI and GSTM1 genotypes, and colorectal adenomas.

Cigarette smoking has been related to increased risk of colorectal adenomas, but the underlying mechanisms are unknown. Genetic polymorphisms are known for enzymes involved in the activation of polycyclic aromatic hydrocarbons and other tobacco-related carcinogens. Polycyclic aromatic hydrocarbons are activated by cytochrome P4501A1 (CYP1A1) and detoxified by glutathione S-transferases. We investigated the relation of CYP1A1 MspI and GSTM1 genotypes to the risk of colorectal adenomas with special reference to interaction with cigarette smoking among 205 cases of colorectal adenomas and 220 controls with normal total colonoscopy in a male Japanese population. Cigarette smoking was strongly associated with increased risk of colorectal adenomas. Overall, neither the CYP1A1 MspI genotype nor the GSTM1 genotype was related to colorectal adenomas. A significant trend for increased risk of colorectal adenomas associated with smoking was observed for each of the CYP1A1 MspI genotypes, and the increasing trends did not differ by MspI genotype. The positive association between smoking and colorectal adenomas did not vary much with GSTM1 genotypes. Among former and current smokers, adenoma risk did not differ according to the combination of CYP1A1 MspI and GSTM1 genotypes. CYP1A1 MspI and GSTM1 genotypes do not seem to modify the risk of colorectal adenomas associated with cigarette smoking.

Methylenetetrahydrofolate reductase polymorphism and risk of colorectal adenomas.

A homozygous mutation at bp 677 in the gene for the methylenetetrahydrofolate reductase (MTHFR) was previously shown to be associated with a decreased risk of colorectal cancer. We examined the relation between the MTHFR genetic polymorphism and risk of colorectal adenoma in Japanese men using 205 cases of colorectal adenomas and 220 controls of normal total colonoscopy. The homozygous mutation was not measurably associated with colorectal adenomas. The findings corroborate the lack of an association between the MTHFR genotype and colorectal adenomas, but do not deny the possibility that the genotype may be involved in the late stage of colorectal carcinogenesis.

Glutathione S-transferase polymorphisms and risk of colorectal adenomas.

Glutathione S-transferases (GSTs) are a superfamily of detoxification enzymes that may play an important role in human carcinogenesis. While the genetic polymorphisms GSTM1 and GSTT1 have drawn particular interest in relation to cancer susceptibility, previous studies of colorectal cancer are inconsistent regarding their role. We examined the relation between GSTM1 and GSTT1 genotypes combined and colorectal adenomas, and the interaction with cigarette smoking among 205 cases of colorectal adenomas and 220 controls with normal total colonoscopy in Japanese men. Neither GSTM1 nor GSTT1 was related to colorectal adenomas, nor were the null genotypes of GSTM1 and GSTT1 combined. The lack of an association with GSTM1 and GSTT1 genotypes combined persisted even when the analysis was done separately for proximal and distal colorectal adenomas. A three- to fivefold significant increase in the odds of colorectal adenomas was observed among men with a high exposure to cigarette smoking across the genotype groups, and a statistically significant increasing trend was noted within each genotype group. The present findings do not support the role for GSTM1 and GSTT1 genotypes in the development of colorectal adenomas.

Apolipoprotein E genotype, serum lipids, and colorectal adenomas in Japanese men.

We examined the relation of serum lipids and apolipoprotein E genotype to colorectal adenomas among 205 cases and 220 controls with normal colonoscopy in Japanese men. With adjustment for body mass index, cigarette smoking, alcohol use, and other covaiates, odds ratios of proximal and distal adenomas associated with the presence of an allele varepsilon4 were 0.59 (95% confidence interval 0.23-1.45) and 0.99 (0.50-1.98), respectively. While serum total and LDL cholesterol were unrelated to both proximal and distal adenomas, serum triglycerides were positively related to distal adenomas. The findings suggest that altered lipid metabolism may be differentially associated with tumorigenesis in the proximal and distal colorectum.

Regulation of TNFalpha and interleukin-10 production by prostaglandins I(2) and E(2): studies with prostaglandin receptor-deficient mice and prostaglandin E-receptor subtype-selective synthetic agonists.

To know which receptors of prostaglandins are involved in the regulation of TNFalpha and interleukin 10 (IL-10) production, we examined the production of these cytokines in murine peritoneal macrophages stimulated with zymosan. The presence of PGE(2) or the PGI(2) analog carbacyclin in the medium reduced the TNFalpha production to one-half, whereas IL-10 production increased several fold; and indomethacin caused the reverse effects, suggesting that endogenous prostaglandins may have a regulatory effect on the cytokine production. Among prostaglandin E (EP) receptor-selective synthetic agonists, EP2 and EP4 agonists caused down-regulation of the zymosan-induced TNFalpha production, but up-regulation on the IL-10 production; while EP1 and EP3 agonists showed no effect. Macrophages harvested from prostaglandin I (IP) receptor-deficient mice showed the up- and down-regulatory effects on the cytokine production by the EP2 and EP4 agonists or PGE(2), but no effect was obtained by carbacyclin. On the contrary, macrophages from EP2-deficient mice showed the effect by PGE(2), carbacyclin, and the EP4 agonist, but not by the EP2 agonist; and the cells from EP4-deficient mice showed the effect by PGE(2), carbacyclin, and EP2 agonist, but not by the EP4 agonist. These functional effects of prostaglandins well accorded with the mRNA expression of TNFalpha and IL-10 when such expression was examined by the RT-PCR method. The peritoneal macrophages from normal mice expressed IP, EP2, and EP4 receptors, but not EP1 and EP3, when examined by RT-PCR. Thus the results suggest that PGI(2) and PGE(2) generated simultaneously with cytokines by macrophages treated with zymosan may influence the cytokine production through IP, EP2, and EP4 receptors.

Lichen sclerosus et atrophicus, morphea, and coexistence of both diseases. Histological studies using lectins.

Histological studies using three lectins, lens culinaris agglutinin, soybean agglutinin, and Ulex europaeus agglutinin-I, were carried out in a case of coexistent lichen sclerosus et atrophicus and morphea, five cases of morphea, and two cases of lichen sclerosus et atrophicus. The lectin staining patterns of the formaldehyde-fixed epidermis of patients with morphea were not different from those of normal epidermis, but epidermis of patients with lichen sclerosus et atrophicus showed different staining patterns. Lens culinaris agglutinin stained the basal and the spinous layers of the normal epidermis and that of patients with morphea but stained only the basal cells of the epidermis from patients with lichen sclerosus et atrophicus; epidermal Ulex europaeus agglutinin binding was observed only in the cases of lichen sclerosus et atrophicus. Moreover, in the patient with coexistent diseases, the morphea lesion showed the staining profiles of morphea and the lichen sclerosus et atrophicus lesion showed the staining patterns of lichen sclerosus et atrophicus, respectively.

Clinical features of anterior bradyrhythmia.

The present study examined the clinical significance of anterior bradyrhythmia (AB), which was described by Gibbs and Gibbs in 1964. The significance of AB in this report was indefinite because of unclear criteria and underdeveloped neuroradiology. We proposed a set of criteria of AB and reevaluated the clinical significance of the EEG pattern in correlation with the clinical and the computerized topography (CT) findings of the patients. The study material was 4019 EEGs examined in our laboratory during a 1-year period (1991). AB was recorded in 20 patients (0.5%), whose mean age was 69.8 years. Its incidence tended to increase with age. Sixteen patients [table: see text] (80%) had dementia and were classified into two types according to clinical features, as Binswanger (B)-type and Alzheimer (A)-type. B-type patients had gait disturbance, urinary incontinence, hemiparesis, and ECG abnormalities, and showed leuko-araiosis on CT. A-type patients had only dementia, and showed frontoparietal atrophy on CT. Delirium was found in 7 (35%) out of the 20 patients with AB, which may be an additional factor related to the appearance of the EEG pattern. B-type had lower frequency of AB than A-type. Both types showed slowed background activities; the alpha rhythm of B-type had lower frequency and tended to have higher amplitude than that of A-type. These EEG abnormalities may be indicative of subcortical or cortical dysfunction in the frontal areas.

Clinical aspects of the "third rhythm" of the temporal lobe.

We studied clinical aspects of the "third rhythm," which was first described by Niedermeyer as alpha-like activity of the temporal lobe. By scalp EEG, temporal alpha-like activity was recorded in 15 (0.30%) of 4929 patients over 20 years of age. The temporal alpha-like activity was observed in 5 patients who had clinical and brain imaging findings indicating the presence of a cerebrovascular disorder. The alpha-like rhythm of these patients was left-sided, and wicket spikes appeared in the same region as the alpha-like rhythms in 4 of the 5 patients. In 8 of the 15, the temporal alpha-like rhythm was recorded over the defective bone or replacement bone after intracranial surgery. The alpha-like rhythm of these patients was similar to breach rhythm in the temporal region. The remaining 2 patients had not undergone intracranial surgery nor did they show symptoms of cerebrovascular disorders. The temporal alpha-like rhythms in one of these 2 might be a physiological third rhythm detected by scalp EEG through congenital bone thinning. Our observation supports the existence of intrinsic activity of the temporal lobe (the third rhythm). The third rhythm can be recorded by routine scalp EEG in some clinical conditions, and it is important to recognize this rhythm when one encounters temporal rhythmic activity independent of alpha rhythm of the occipital lobe.

Frontal midline theta rhythm in young healthy adults.

In this study, we examined the relationship between the frontal midline (Fm) theta rhythm that appears when a healthy subject is engaged in mental tasks and the theta rhythm which appears in the frontal region of healthy subjects during light drowsiness. The samples for this study were obtained from 465 EEGs of healthy Japan Air Self Defense Force personnel. The 39 who had frontal theta rhythm during light drowsiness were selected to be included in the theta group. For the control group, 34 subjects were randomly selected from the remaining 426 without frontal theta rhythm. When these subjects were reexamined, the rate of appearance of the frontal midline theta rhythm which appears during light drowsiness was 87.2% in the theta group and 0% in the control group. The rate of appearance of the Fm theta was 94.9% in the theta group and 3.0% in the control group. The two types of frontal theta rhythms closely resembled each other in frequency (94.6%) and distribution (83.8%). Except for the results of the hypomania (Ma) scores, there was no remarkable difference between the two groups when the MMPI was administered. The results of our study suggest that there is a close correlation between the frontal theta rhythm that appears during light drowsiness and the Fm theta.

Development of sleep spindles in young children and adolescents.

The development of sleep spindles was studied quantitatively in 32 healthy subjects between the ages of 4 and 24 years. The peak frequency distribution of the spindles showed a bimodal pattern with 11.0 to 12.75 Hz in the frontal area and 12.5 to 14.5 Hz in the centroparietal area. The two types of spindle activity showed different courses of maturation. The peak frequency of the centroparietal spindles gradually increased linearly with age, whereas the frontal spindles abruptly increased in frequency during early adolescence. Regarding the power spectra, while centroparietal spindles showed little change in power from 4 to 24 years of age, frontal spindles decreased remarkably in power and became stable at about 13 years of age. The two types of spindles and the difference in their development may suggest the existence of different generators or a topographical difference during maturation in the thalamocortical network. The frontal spindle activity could be a good indicator to evaluate CNS maturation in young children and adolescents.

Frontal midline theta rhythm: differentiating the physiological theta rhythm from the abnormal discharge.

The theta rhythm that appears in the frontal midline was studied morphologically and clinically in EEGs performed on 788 patients and 161 normal subjects in their late teens or older. This theta rhythm was classified into 2 types. The Type 1 theta rhythm appeared in short bursts maximally in the Fz lead and spread mainly to the anterior region. It had a high frequency, low voltage and regular waveform. The Type 2 theta rhythm appeared in long runs maximally in the Fz lead and spread mainly to the posterior areas. It had a relatively low frequency, high voltage and irregular waveform. Type 1 was observed in a younger age group (mean age: 20.3 years) that was comprised of healthy subjects and one mentally retarded patient. In no case was the Type 1 theta rhythm accompanied by a paroxysmal EEG abnormality. We therefore believe that Type 1 is a physiological EEG activity (Fm theta). On the other hand, Type 2 was observed in a relatively older age group (mean age: 30.7 years) comprised of patients diagnosed as having epilepsy or intractable headaches. Five of 9 cases showed epileptic EEG abnormalities. We therefore believe that Type 2 might have clinical significance in diagnosis of epilepsy and other cerebral dysfunctions. The EEG pattern that we call the frontal mid-line theta rhythm may be either a physiological theta rhythm or an abnormal discharge. It is possible to determine whether the theta rhythm is the former or the latter, and we believe this differentiation to be clinically important.

[A case of lumbosacral lipoma and its interesting histological findings].

A case of 3-month-old girl with lumbosacral lipoma is reported. She had a large soft tissue mass (4 X 5 cm) in the lumbosacral region initially noted at birth. Interpendicular distances below L2 were dilated on X-P. CT image demonstrated a sharply outlined low density area (approximately -80 H. U.) which occupied the latter half of the spinal canal in the level of L2 to S1 level. Defect of vertebral arch was also seen. Lipoma was removed subtotally with laminectomy. CT image demonstrated clear sharp margin of the tumor, neural tissue free zone were not found intraoperatively. Post-operative course was uneventful. Specimen showed the mature adipose tissue which contained rich blood vessels and connective tissue. Connective tissue was composed of collagen fibers and elastic fibers. Small aberrant nerve fibers and smooth muscle fibers were sporadically noted in specimens obtained from nearby transitional area of its lipoma and spinal cord. Although there were a few reports about the morphology of lipoma, the existence of nerve cell, neuroglia, embryonic bone, cartilage, smooth muscle fiber, striated muscle fiber, respiratory-like cell and others were reported in the previous reports. Our histological findings also suggest that the lipoma possibly arise from pluripotential caudal cell mass which survived by disturbance of the 3rd stage of neural tube formation (retrogressive differentiation).

[Developmental characteristics of frontal spindle and centro-parietal spindle].

The frequency and power of EEG sleep spindles during sleep stage 2 were analysed in 56 subjects between the age of 3 to 25 years in order to define the maturational pattern of two types of spindles. Although 24 of the 56 subjects were medicated with a single anticonvulsant, there was no remarkable difference in spindle maturation patterns between the subjects who received monotherapy and unmedicated subjects. The frontal spindles matured differently than centro-parietal spindles. The frequency of centro-parietal spindles developed gradually with age, whereas frontal spindles matured with a rather sudden increase of frequency during puberty. Although the power of centro-parietal spindles showed little changes with age, the power of frontal spindles declined remarkably during the first decade and settled down to a constant level after puberty. The developmental characteristics of these two kinds of spindles may reflect a difference in synchronicity of the thalamo-cortical pathway maturation including the inhibitory system. Both centro-parietal spindles and frontal spindles tended to develop slightly earlier in females than in males. The lag of spindle maturation in males might implicate developmental procedures in females. Separate observation of these two types of spindles is necessary for better understanding of sleep spindles as an indicator of central nervous system development.

[Problems regarding palliative home care for end-stage cancer patients after the enforcement of the care insurance system].

Since in a home care nurse station the arrangement of personnel is planned to carry out patient's home care in accordance with the individual patient's Care Plan, to provide palliative home care to end-stage cancer patients who frequently require extraordinary visits, it is necessary to employ full-time nurses. On the other hand, to make ends meet there must be at least two full-time nurses for every seven end-stage cancer patients in a home care nurse station monthly. However, a home care nurse station taking care of seven end-stage cancer home patients monthly is very rare. According to these circumstances only several special home care nurse stations are able to provide palliative home care to end-stage cancer patient; thus, palliative home care for such patients is generally provided by hospital or doctor's office staff members. Therefore, if the authorities concerned intend to accelerate to care the end-stage cancer patient at home, several additional charges which are able to be claimed in ordinary home care nurse station must be able to be claimed in hospital or doctor's office in the same way.

[Indication and effectiveness of endoscopic percutaneous gastrostomy as a route of parenteral alimentation for the home care patient].

We are managing 8 home care patients who have a gastrostomy made using an endoscopic percutaneous technique as a route of parenteral alimentation. Based on our experience, the preconditions for an endoscopic percutaneous gastrostomy as a route of parenteral alimentation are 1. normal gastrointestinal function, 2. difficulty in swallowing, 3. possibility that the caregiver can manage the gastrostomy. When we performed an endoscopic percutaneous gastrostomy as a route of parenteral alimentation for 8 home care patients, we obtained the several advantages mentioned below. 1. Swallowing pneumonia was prevented. 2. Adequate amount of alimental liquid could be infused. 3. Patient could take a bath or shower with the gastrostomy, and good QOL was realized. 4. The home care patient with the gastrostomy could have a satisfactorily long life.