Practical guide for safe sedation.

This practical guide has been developed to ensure safe and effective sedation performed in adult patients outside of the operating room, for instance in intensive care units and dental treatment rooms and in the field of palliative care. Sedation levels are classified based on level of consciousness, airway reflex, spontaneous ventilation, and cardiovascular function. Deep sedation induces loss of consciousness and protective reflexes, and can cause respiratory depression and pulmonary aspiration. Invasive medical procedures necessitating deep sedation include cardiac ablation, endoscopic submucosal dissection, and internal radiation therapy. Appropriate analgesia is necessary for procedures that require deep sedation. The sedationist should evaluate the risks of the planned procedure, explain the sedation process to the patient, and obtain the patient's informed consent. Major parameters to be evaluated preoperatively are the patient's airway and general condition. Equipment, instruments, and drugs necessary for emergency situations should be defined and routinely maintained. To prevent aspiration, patients scheduled for moderate or deep sedation should fast preoperatively. In both inpatients and outpatients, biological monitoring should be continued until the discharge criteria are met. Anesthesiologists should be involved in management systems that ensure safe and effective sedation even if they do not personally perform all sedation procedures.

[A Multicenter Questionnaire Survey of Postoperative Delirium -National Hospital Organization, Surgery and Anesthesia Network Group-].

BACKGROUND: Postoperative delirium in the elderly is associated with increased morbidity and risk of injury. However, the opinion of attending surgeons and anes- thesiologists regarding postoperative delirium is uncer- tain, as is the prevention and treatment of the condi- tion, in Japanese hospitals. METHODS: We conducted a multicenter questionnaire survey about postoperative delirium. Survey sheets were sent to 40 hospitals belonging to the National Hospital Organization. RESULTS: Wide variation in the answers from 26 hospitals revealed no common understanding regarding the diagnosis and management of postoperative delir- ium. The incidence of postoperative delirium was reported as 20-30%. It developed on postoperative day 2, with recovery within 1 month. Age, postoperative complications, alcohol abuse, cognitive impairment, sex, and depth of anesthesia were considered to be risk fac- tors. Prevention and treatment strategies included pain control, encouraging normal sleep-wake cycles, and avoiding postoperative complications. Although phar- macologic management with haloperidol or risperidone was also adopted in many facilities, the effect was thought to be uncertain. All respondents agreed that an enormous effort was required in caring for patients with postoperative delirium. CONCLUSIONS: Prospective clinical studies are neces- sary for improving the management of elderly patients with postoperative delirium.

[Conservative treatment improved corrosive esophagitis and pneumomediastinum in a patient who ingested bleaching agent containing sodium hypochlorite and sodium hydroxide].

A 69-year-old man was admitted to the emergency department 3 hours after ingestion of a bleaching agent containing hypochlorous acid and sodium hydroxide in a suicide attempt. Enhanced chest computed tomography scans taken on admission indicated an edematous esophagus and air bubbles in the mediastinum. He underwent endotracheal intubation and mechanical ventilation until day 9 because of laryngeal edema. On day 10, his endoscopy indicated diffuse reddish mucosal hyperemia, erosions, and lacerated mucosal lesions in the esophagus that were indicative of grade 2b corrosive esophagitis. Treatment with a proton pump inhibitor was initiated, with which the condition of the esophagus improved, and on day 44, a slight stricture of the upper part of the esophagus was observed. He was discharged on day 64 without any complaints. The ingestion of sodium hypochlorite induces corrosive esophagitis and acute phase of gastritis. Ingestion of any corrosive agent is known as a risk factor for esophagus cancer in the long-term. In such cases with esophageal stricture, esophagectomy is recommended for preventing esophagus cancer. Considering the age of the patient, however, he did not undergo esophagectomy.

Immunoglobulin G4-related disease diagnosed by prostate biopsy: a case report.

BACKGROUND: Immunoglobulin G4-related disease is characterized by swelling of various organs throughout the body and nodules/hypertrophic lesions. However, its cause remains unknown. We report a case of immunoglobulin G4-related disease that was diagnosed based on the histopathological findings of prostate biopsy. CASE PRESENTATION: A 72-year-old Japanese man had been treated by a nearby doctor for hypertension, but subsequently developed lower urinary tract symptoms and was prescribed an α1 blocker for 1 year. However, the patient was subsequently referred to our department because his symptoms did not improve. Prostate-specific antigen was 1.258 ng/ml; however, the nodule was palpable in the right lobe on digital rectal examination, and magnetic resonance imaging suggested Prostate Imaging and Reporting and Data System category 3. Therefore, transrectal prostate needle biopsy (12 locations) under ultrasound was performed. Histopathological examination revealed no malignant findings, although infiltration of lymphocytes and plasma cells, and partial fibrosis were observed. No remarkable findings of obstructive phlebitis were observed. Immunoglobulin G4-related disease was suspected, and immunoglobulin and immunoglobulin G4 immunostaining was performed. Immunoglobulin G4 positive plasma cells were observed in a wide range, immunoglobulin G4 positive cells were noted at > 10 per high-power field, and the immunoglobulin G4 positive/immunoglobulin G positive cell ratio was > 40%. Serum immunoglobulin G4 levels were high at 1600 mg/dl. Enhanced abdominal computed tomography findings suggested periaortitis. Additionally, multiple lymphadenopathies were observed around the abdominal aorta. The patient was accordingly diagnosed with immunoglobulin G4-related disease definite, diagnosis group (definite). We proposed steroid treatment for periaortic soft tissue lesions and lower urinary tract symptoms; however, the patient was refused treatment. A computed tomography scan 6 months after diagnosis revealed no changes in the soft tissue lesions around the aorta. Follow-up computed tomography examinations will be performed every 6 months. CONCLUSION: If immunoglobulin G4-related disease is suspected and a highly invasive examination is required for histopathological diagnosis, this can be performed by a relatively minimally invasive prostate biopsy for patients with lower urinary tract symptoms. Further evidence is needed to choose an optimal candidate for prostate biopsy for lower urinary tract symptoms patients with suspicion of immunoglobulin G4-related disease. For patients with lower urinary tract symptoms with immunoglobulin G4-related disease or a history, performing a prostate biopsy may avoid unnecessary treatment. However, if steroid therapy is ineffective, surgical treatment should be considered.

Medicine at mass gatherings: current progress of preparedness of emergency medical services and disaster medical response during 2020 Tokyo Olympic and Paralympic Games from the perspective of the Academic Consortium (AC2020).

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium.

An Oculopharyngeal Subtype of Guillain-Barré Syndrome Sparing the Trochlear and Abducens Nerves.

Guillain-Barré syndrome (GBS) comprises a group of polyneuropathies characterized by rapid progression of limb paralysis. Various subtypes of GBS have been reported. The oculopharyngeal subtype of GBS is currently understood to be primarily a cranial polyneuropathy without limb weakness or cerebellar ataxia. In our case of 62-year-old man, gastrointestinal infection was followed by paranesthesia of the hands. He had bilateral ptosis, pharyngeal disorder, and tongue and bifacial weakness. We diagnosed oculopharyngeal subtype of GBS. It responded to intravenous immunoglobulin. This case highlights the need for further characterization of unusual GBS subtypes.

[Successful palliative surgical treatment for drug-resistant epilepsy after anti-N-methyl-D-aspartate (NMDA) receptor encephalitis: Two case reports].

Epilepsy surgery for patients with drug-resistant epilepsy after anti-N-methyl-D-aspartate (NMDA) receptor encephalitis has been rarely reported. The present study reports two patients with anti-NMDA receptor encephalitis, who later underwent epilepsy surgery due to drug-resistant epilepsy. The patients had refractory status epilepticus in the acute phase. The cerebrospinal fluid was positive for anti-NMDA receptor antibodies. Systemic corticosteroid therapy and plasma exchange were effective. Seizure control, however, worsened over several months after discharge, and was refractory to antiepileptic drugs. They underwent palliative epilepsy surgery, and their seizure control improved. Epilepsy surgery should be considered in patients with drug-resistant epilepsy after anti-NMDA receptor encephalitis.

Cleaved inflammatory lactoferrin peptides in parotid saliva of periodontitis patients.

Lactoferrin (Lf) is a member of the transferrin family of iron-binding anti-bacterial proteins, present in most exocrine secretions, such as saliva, and plays an important role in mucosal defense. In this study, we identified small Lf peptides with Con A low-affinity in the parotid saliva of chronic periodontitis patients by Con A two-dimensional immunoelectrophoresis, Con A affinity chromatography and Western blotting using anti-human Lf polyclonal Ab. N-terminal amino acid sequencing of the four Con A low-affinity Lf peptides confirmed them to be fragments of intact Lf. The detection ratio of the proteinase 3 (PR3)-like activity was elevated in the parotid saliva of periodontitis patients and was associated with the severity of clinical symptoms. PR3 protein was also detected in the parotid saliva of periodontitis patients, and PR3, but not human leukocyte elastase and cathepsin G, degraded intact Lf. Con A low-affinity saliva Lf peptides showed no anti-bacterial activity against Escherichia coli, and had a reduced iron-chelating capacity. Con A low-affinity saliva Lf peptides, PR3-treated Lf preparation and two of four synthetic polypeptides induced the production of interleukin IL-6, monocyte chemoattractant protein-1 and IL-8, and the activation of NF-kappaB in human oral epithelial HSC-2 cells. Furthermore, concentrations of the Lf peptides in the parotid saliva of periodontitis patients were increased with a correlation to the severity of clinical symptoms. These results suggest that Lf in the parotid saliva of periodontitis patients was degraded into small peptides by the PR3-like activity with the capability to induce inflammatory mediators.

A case of herpes zoster ophthalmicus preceded one week by diplopia and ophthalmalgia.

A 66-year-old man presented with headache and ophthalmalgia. Diplopia developed, and he was hospitalized. The left eye had abducent paralysis and proptosis. We diagnosed him with Tolosa-Hunt syndrome and administered methylprednisolone at 1 g/day for 3 days. However, the patient did not respond to treatment. No abnormality was found on his MRI or cerebrospinal fluid examination. Tests showed his serum immunoglobulin G4 and antineutrophil cytoplasmic antibody titers were within normal limits. He also had untreated diabetes mellitus (HbA1c 9.2). One week after first presenting with symptoms, herpes zoster appeared on the patient's dorsum nasi, followed by keratitis and a corneal ulcer. Herpes zoster ophthalmicus with ophthalmoplegia was diagnosed. We began treatment with acyclovir (15 mg/kg) and prednisolone (1 mg/kg, decreased gradually). Ophthalmalgia and the eruption improved immediately. The eye movement disorder improved gradually over several months. It is rare that diplopia appears prior to cingulate eruption of herpes zoster ophthalmicus. We speculated that onset of the eruption was inhibited by strong steroid therapy and untreated diabetes mellitus.

Fiber Optic Sensor for Real-Time Sensing of Silica Scale Formation in Geothermal Water.

We present a novel fiber optic sensor for real-time sensing of silica scale formation in geothermal water. The sensor is fabricated by removing the cladding of a multimode fiber to expose the core to detect the scale-formation-induced refractive index change. A simple experimental setup was constructed to measure the transmittance response using white light as a source and a spectroscopy detector. A field test was performed on geothermal water containing 980 mg/L dissolved silica at 93 °C in Sumikawa Geothermal Power Plant, Japan. The transmittance response of the fiber sensor decreased due to the formation of silica scale on the fiber core from geothermal water. An application of this sensor in the evaluation of scale inhibitors was demonstrated. In geothermal water containing a pH modifier, the change of transmittance response decreased with pH decrease. The effectiveness of a polyelectrolyte inhibitor in prevention of silica scale formation was easily detectable using the fiber sensor in geothermal water.

Expression of IL-2 receptor beta and gamma chains by human gingival fibroblasts and up-regulation of adhesion to neutrophils in response to IL-2.

To investigate the role of human gingival fibroblasts (HGF), the major constituents of gingival tissue in periodontal inflammatory disease, the expression of interleukin-2 receptor (IL-2R) alpha, beta, and gamma chains was examined. Immunohistochemistry showed a pronounced accumulation of CD8(+) T cells in the inflamed lamina propria of gingival tissue from patients with adult periodontitis. HGF express IL-2Rbeta and IL-2Rgamma at mRNA and protein levels, but the expression of IL-2Ralpha could not be detected, as assessed by reverse transcriptase-polymerase chain reaction and flow cytometry. IL-2Rbeta, and -gamma expressed on HGF were functionally active, as addition of neutralizing anti-IL-2Rbeta and -gamma antibodies caused inhibition of the IL-2-induced production of monocyte chemoattractant protein-1 (MCP-1), and addition of IL-2 induced phosphorylation of Janus tyrosine kinase 3, which is critical in signaling through IL-2Rgamma in HGF. The IL-2-induced MCP-1 production was significantly inhibited by pretreatment with neutralizing antibody to IL-15. Addition of IL-2 also induced a marked up-regulation of the expression of intercellular adhesion molecule-1 (ICAM-1) on the surface of HGF, which in turn, significantly augmented the adhesion of human neutrophils, which were inhibited by an anti-ICAM-1 antibody. These results suggest that HGF express functional IL-2Rbetagamma, respond to IL-2 from infiltrated T cells, and actively participate in the inflammatory process in the periodontal region and that IL-15 produced by HGF sustains IL-2-mediated signaling in HGF.

[Effectiveness of ropivacaine and fentanyl for postoperative epidural analgesia following thoracic surgery].

BACKGROUND: Epidural ropivacaine is now a common drug used for postoperative analgesia. However, little information is available concerning regression of sensory blockade and analgesia following prolonged epidural infusion of ropivacaine. We investigated the efficacy of ropivacaine and fentanyl for postoperative analgesia after thoracic surgery. METHODS: Thirty patients undergoing thoracic surgery were enrolled. After surgery with general and thoracic epidural anesthesia, continuous epidural infusion of 0.2% ropivacaine+fentanyl (1.67 microg x ml(-1)) was started at a rate of 6 ml x h(-1) for patients whose height was more than 155 cm and 4 ml x h(-1) for those below 155 cm with possibility of an additional bolus injection of 3 ml at least every 60 min. RESULTS: An additional epidural injection of 3 ml produced a decrease in VAS without significant changes of vital signs. The greatest VAS was 10+/-25 mm in the incision site and 36+/-38 mm in the ipsilateral shoulder. Sensory blockade was sustained until the morning after the day of surgery. Also blood pressure and heart rate were stable throughout the observation period. There were no adverse effects except for slight nausea in three patients. CONCLUSIONS: A bolus of 3 ml with continuous 4-6 ml x h(-1) epidural injection of ropivacaine plus a small dose of fentanyl would decrease postoperative pain with stable vital signs in patients after thoracic surgery.

[Comparison of propofol LCT and propofol MCT/LCT regarding the injection pain at different sites and the memory].

BACKGROUND: Incidence and intensity of pain on intravenous injection of propofol LCT were compared with those of propofol MCT/LCT. METHODS: Eighty adult patients scheduled to receive general anesthesia were divided into two groups, propofol LCT (Group L, AstraZeneca) and propofol MCT/LCT (Group M, Maruishi Pharmaceutical). The peripheral vein was inserted with an 18 gauge intravenous catheter at the dorsal hand, the wrist, or the anterior brachial region. Propofol 2.0 mg x kg(-1) was injected at the speed of 5 mg x sec(-1). Noninvasive arterial blood pressure, heart rate, a BIS value and a degree of pain were measured. We used chi2 analysis and Wilcoxon t-test for statistical evaluation. RESULTS: There was a significantly larger incidence of injection pain in the Group L than the Group M (70% vs. 30%). The pain at the brachial region was significantly less as compared with the wrist or the dorsal hand in both groups. The ratio of patients having the memory of pain on the next day to those complaing the injection pain was 50% in the Group L and 36% in the Group M. There were no significant differences between the two groups in changes in BIS values and doses of propofol necessary for the loss of consciousness. CONCLUSIONS: The results suggest that propofol MCT/LCT elicits less pain on injection than propofol LCT. The injection pain is less at the brachial region than the wrist or the hand. Amnesia of pain may be obtained both with propofol MCT/ LCT and propofol LCT.

Regression of sensory and motor blockade, and analgesia during continuous epidural infusion of ropivacaine and fentanyl in comparison with other local anesthetics.

OBJECTIVE: To compare the regression of sensory and motor blockade, and the analgesia during continuous epidural infusion between ropivacaine and other local anesthetics. DESIGN: Two studies were conducted. Study 1: Eighty patients were scheduled for orthopedic procedures of the lower extremity under lumbar epidural anesthesia. Following the operation, continuous infusion of a randomized solution (0.2% ropivacaine, 0.125% bupivacaine, 0.5% lidocaine, or 0.2% ropivacaine with 2.5 microg/mL fentanyl) was commenced at a rate of 6 mL/h. The regression of sensory and motor blockade were compared among the groups. Study 2: After gynecologic abdominal surgery, 39 patients were randomized to one of the three epidural infusion groups: 0.2% ropivacaine, 0.125% bupivacaine, or 0.2% ropivacaine with 2.5 microg/mL fentanyl at a rate of 6 mL/h with an additional bolus injection of 3 mL, which can be used when patients have pain. Visual analog scale (VAS) was compared among the groups. RESULTS: Study 1: The level of sensory blockade in all the groups appeared to decrease progressively. However, the regression of sensory blockade was significantly prolonged in patients treated with ropivacaine. The addition of fentanyl to ropivacaine augmented this prolonged analgesic effect. Study 2: VAS after the bolus in the ropivacaine and the ropivacaine + fentanyl groups were significantly lower than that in the bupivacaine group. Patients in the ropivacaine + fentanyl group required significantly fewer supplemental bolus injections. CONCLUSIONS: Continuous epidural infusion of ropivacaine may induce a slower regression of sensory blockade compared with bupivacaine and lidocaine. The addition of fentanyl to ropivacaine can enhance this prolonged analgesic effect with little effect on motor blockade. Epidural infusion of ropivacaine with fentanyl provides effective pain relief, possibly because of the maintenance of sensory blockade by ropivacaine and fentanyl.