Clinical impact of a combined therapy of peritoneal dialysis and hemodialysis.

AIMS: Although peritoneal dialysis (PD) is recommended as the first-line treatment for end-stage renal disease, limitations exist to achieving good clinical status when the residual renal function (RRF) has declined. Combined therapy with PD and hemodialysis (HD) is the treatment of choice for patients who cannot control body fluid status and/or cannot obtain adequate solute removal by PD alone. The aim of this study was to evaluate the clinical efficacy of this combined therapy. METHODS: In this retrospective study, 53 patients on PD and diagnosed with underdialysis and/or overhydration with declining RRF were recruited. Parameters of volume control, uremic solute removal, anemia, and predictors for encapsulating peritoneal sclerosis (EPS) were compared before and 1 year after combined therapy. RESULTS: The patients' hydration status improved significantly with reductions in atrial natriuretic peptide and blood pressure. Serum creatinine and beta2 microglobulin also decreased significantly. The hemoglobin level increased remarkably from 8.2 ± 1.6 to 10.7 ± 1.2 g/dl (p < 0.01) and the reticulocyte count also increased significantly, even though at the same time the dose of recombinant human erythropoietin decreased significantly. The dialysate to plasma creatinine ratio obtained from the fast peritoneal equilibration test (PET) decreased significantly from 0.65 ± 0.11 to 0.59 ± 0.13, and the level of interleukin 6 in PET drainage also significantly decreased. Furthermore, serum C-reactive protein and fibrinogen decreased significantly. CONCLUSIONS: Combined therapy with PD and HD is an effective way to control fluid status and to correct inadequate solute removal, leading to improvement in inflammation, peritoneal function and anemia.

Transition of mouse de novo methyltransferases expression from Dnmt3b to Dnmt3a during neural progenitor cell development.

Dnmt3a and Dnmt3b, which are known as functional de novo methyltransferases, are responsible for creating genomic methylation patterns during mammalian development. Recently, we have shown that specific expression of Dnmt3b in epiblast, embryonic ectoderm, hematopoietic progenitor cells and spermatogonia cells is followed by Dnmt3a expression (Watanabe D, Suetake I, Tada T, Tajima S (2002) Stage- and cell-specific expression of Dnmt3a and Dnmt3b during embryogenesis. Mech Dev 118:187-190; Watanabe D, Suetake I, Tajima S, Hanaoka K (2004) Expression of Dnmt3b in mouse hematopoietic progenitor cells and spermatogonia at specific stages. Gene Expr Patterns 5:43-49). In this study, we analyzed the expression of mouse de novo methyltransferases during development of the nervous systems. In the embryonic olfactory epithelium (OE), Dnmt3b was specifically expressed in Mash1 positive globose basal cells (i.e. transiently amplifying neural progenitor cells), while Dnmt3a was expressed in immature olfactory receptor neurons. Dnmt3b-positive cells were rarely observed in the adult OE, but were increased in regenerating OE with intranasal ZnSO(4) administration. Dnmt3b was also detected in the E8.5 neural plate, E10.5 spinal cord and retina cells, while Dnmt3a was expressed in postmitotic young neurons. Furthermore, Dnmt3b was specifically expressed in ES cells, while Dnmt3a was transiently expressed during neural cell differentiation of ES cells. Dnmt3b is specifically expressed in progenitor cells during hematopoiesis, spermatogenesis and neurogenesis, suggesting an important role in the initial steps of progenitor cell differentiation. Dnmt3a is expressed in postmitotic young neurons following the Dnmt3b expression. Dnmt3a may be required for the establishment of tissue-specific methylation patterns of the genome. The coordinated expression of de novo methyltransferases from Dnmt3b to Dnmt3a suggests conserved mechanisms of de novo methylation of the genome and different functions for Dnmt3b and Dnmt3a during progenitor cell development.

[Anesthesia for thoracic surgery in elderly patients].

Aging and advances in medical technology have lead to a rise in the number of patients of advanced age undergoing surgery. This is also observed in thoracic surgery. Aging itself is not a disease, but it is one of the risk factors of perioperative complications. Individual assessment of patients is required to ascertain the organ system capacity and functional reserve. The management of anesthesia is based on the characteristic changes in the elderly, related to physiology and pharmacokinetics, taking account of possible perioperative complications.

Is the ARX index a more sensitive indicator of anesthetic depth than the bispectral index during sevoflurane/nitrous oxide anesthesia?

BACKGROUND: During general anesthesia, hypnotic components have been monitored with electroencephalogram. The bispectral index is derived from a cortical electroencephalogram, but the A-line ARX index is the electroencephalographic response to auditory stimuli. The purpose of this study was to compare the changes of the A-line ARX index and the bispectral index during sevoflurane - nitrous oxide anesthesia. METHODS: One hundred females aged 30-60 years, and scheduled for partial mastectomy, were divided into two groups. Anesthesia was induced with sevoflurane 5% and nitrous oxide in oxygen for 3 min. A laryngeal mask airway was inserted, and anesthesia was maintained with sevoflurane 1-2% and nitrous oxide in oxygen. During surgery, the sevoflurane end-tidal concentration was kept at 0.5%, 1%, or 2% for 5 min before each measurement. Blood pressure, heart rate, and the A-line ARX index (n = 50), and the bispectral index (n = 50) were measured. RESULTS: Blood pressure and heart rate increased following laryngeal mask airway insertion and blood pressure decreased at 2% sevoflurane in both groups similarly. The A-line ARX index, but not the bispectral index, increased significantly by laryngeal mask airway insertion and skin incision. The A-line ARX index decreased at 2% sevoflurane compared with 0.5%, while the bispectral index remained unchanged. CONCLUSION: During sevoflurane-nitrous oxide anesthesia, the A-line ARX index might be a more sensitive indicator of anesthetic depth than the bispectral index.

Usefulness of epidural anesthesia in gynecologic laparoscopic surgery for infertility in comparison to general anesthesia.

BACKGROUND: Although the advantages of epidural anesthesia in open surgery have been established, its usefulness in the setting of laparoscopic surgery remains to be studied. METHODS: Patients undergoing laparoscopic surgery for infertility were randomly administered epidural anesthesia (group A, n = 11) or general anesthesia (group B, n = 9). The operation was performed under 4 mmHg pneumoperitoneum and in the 20 degrees Trendelenburg position. Respiratory function tests using a spirometer and blood gas analysis were performed during the intra- or perioperative period. Pain status was evaluated with visual analog scale scoring. The number of postoperative recovery days needed to resume daily activities was obtained by a questionnaire. RESULTS: Respiratory rate, minute volume, P(a)CO2, % vital capacity (VC), and forced expiratory volume in 1 s (FEV1) % were virtually constant throughout the study period in group A, whereas %VC was decreased immediately after operation in group B (p < 0.05). Minute volume immediately after operation was significantly increased in group B compared with group A (p < 0.01), suggesting shallow respiration in women undergoing general anesthesia. Observed pain scores on abdominal pain, shoulder pain, and dyspnea were very low during operation in group A. Pain scores immediately and 3 h after operation were also minimal in group A, whereas abdominal pain scores at these points were significantly higher in group B than those in group A (both p < 0.01). The number of days required for a half reduction in wound pain, trotting, and full recuperation for group A were less than those for group B (p < 0.05). CONCLUSIONS: Epidural anesthesia, when used in laparoscopic surgery for infertility treatment, has advantages over general anesthesia in terms of analgesic effects, postoperative respiratory function, and a return to preoperative daily activities.

Cerebral ischaemia during cardiac surgery in children detected by combined monitoring of BIS and near-infrared spectroscopy.

BACKGROUND: Children frequently suffer transient cerebral ischaemia during cardiac surgery. We measured cerebral ischaemia in children during cardiac surgery by combining two methods of monitoring. METHODS: We studied 65 children aged between 5 months and 17 yr having surgery to correct non-cyanotic heart disease using hypothermic cardiopulmonary bypass (CPB). During surgery, we measured the Bispectral Index (BIS) and regional cerebral haemoglobin oxygen saturation (SrO2) with near-infrared spectroscopy (NIRS). Cerebral ischaemia was diagnosed if both SrO2 and BIS decreased abruptly when acute hypotension occurred. In each patient, the relationship between SrO2 and arterial blood pressure (AP) was indicated by a plot of mean SrO2 against simultaneous mean AP. RESULTS: We noted 72 episodes of cerebral ischaemia in 38 patients. Sixty-three ischaemic events were during CPB. Cerebral ischaemia was less frequent in older patients. Cerebral ischaemia was more common and more frequent in children under 4 yr old. Haematocrit during CPB was lower and SrO2 was more dependent on AP in children under 4 yr. CONCLUSIONS: Children less than 4 yr of age are more likely to have cerebral ischaemia caused by hypotension during cardiac surgery. Ineffective cerebral autoregulation and haemodilution during CPB may be responsible.

Detection of cerebral hypoperfusion with bispectral index during paediatric cardiac surgery.

BACKGROUND: The bispectral index (BIS) may indicate changes in cerebral activity when the cerebral circulation is affected by acute hypotension. METHODS: We measured BIS and cerebral haemoglobin saturation (Sr(O(2))) by near-infrared spectroscopy in 10 children undergoing cardiac surgery. RESULTS: We noted 14 episodes of simultaneous decreases in Sr(O(2)) and BIS during acute hypotension in five children. An acute decrease in BIS, which coincided with a decrease in Sr(O(2)) suggesting a reduction in cerebral blood flow, was associated with acute slowing of the raw EEG waveforms. CONCLUSIONS: Our findings suggest that an acute decrease in BIS during acute hypotension indicates cerebral hypoperfusion, and that cerebral hypoperfusion caused by hypotension may occur frequently during paediatric cardiac surgery.

Association of HLA-A*3303-B*4403-DRB1*1302 haplotype, but not of TNFA promoter and NKp30 polymorphism, with postherpetic neuralgia (PHN) in the Japanese population.

Herpes zoster is a common disease caused by reactivation of the varicella zoster virus (VZV). In a small number of herpes zoster patients, pain persists beyond 4 weeks or more after healing of vesicular eruptions; this condition is termed postherpetic neuralgia (PHN). Positive associations of human histocompatibility leukocyte antigens (HLA) class I antigens, A33 and B44, with PHN in the Japanese population have been reported. Our hypothesis is that susceptibility genes to PHN might exist in the HLA region and the study objective is to further examine possible associations of genes in HLA class I, II and III regions, HLA-A, -B, -DRB1, tumor necrosis factor alpha (TNFA) promoter, and a natural killer cell activating receptor, NKp30 polymorphisms with PHN. Although TNFA or NKp30 in the class III region had been considered as a candidate locus, we found no associations of TNFA promoter or NKp30 polymorphisms with PHN in this study. We demonstrated that HLA-A*3303, -B*4403 and -DRB1*1302 alleles were significantly associated with PHN (P = 0.0007 for A*3303, P = 0.001 for B*4403 and P = 0.001 for DRB1*1302). The frequency of the HLA-A*3303-B*4403-DRB1*1302 haplotype was also significantly higher in the PHN patients than in the healthy controls (P = 0.0039). Our results suggest that this haplotype might be related to the pathogenesis of PHN.

Do the effects of a protease inhibitor, ulinastatin, on elastase release by blood transfusion depend on interleukin 6?

OBJECTIVE: Blood transfusion induces polymorphonuclear leukocyte elastase (PMNE) and interleukin 6 (IL-6). IL-6 would activate neutrophils to release PMNE. Ulinastatin, a protease inhibitor, inhibits PMNE release by blood transfusion. The purpose of this study was to investigate whether the effects of ulinastatin on PMNE release by blood transfusion come through inhibition of IL-6. DESIGN: Semirandomized, controlled clinical trial. SETTING: Surgical center in a university hospital. PATIENTS: Patients age 35-70 yrs undergoing gastrectomy were enrolled in this study until the four study groups had 12 patients each. INTERVENTIONS: Half of the enrolled patients received ulinastatin at random. After surgery, patients were divided into the following four groups: group A received neither blood transfusion nor ulinastatin, group B received only blood transfusion, group C received only ulinastatin, and group D received both blood transfusion and ulinastatin. The infusion of ulinastatin 300,000 units was started at manipulation of the stomach in the group C and at the start of blood transfusion in the group D. MEASUREMENTS AND MAIN RESULTS: Segmented neutrophil count and plasma concentrations of PMNE and IL-6 were measured. In addition, PMNE and IL-6 concentrations in every unit of concentrated red blood cell transfused and these concentrations in the plasma of the recipient after every unit of transfusion were measured. RESULTS: Blood transfusion increased plasma concentrations of PMNE and IL-6, and the PMNE release from segmented neutrophil. The increase of plasma PMNE but not IL-6 concentration after each unit of blood transfusion was inhibited by ulinastatin. However, ulinastatin did not inhibit the increase of plasma concentrations of PMNE and IL-6 by surgical stimuli of gastrectomy. CONCLUSIONS: Ulinastatin 300,000 units might be useful to inhibit blood transfusion-induced increase of PMNE but not IL-6. The inhibition of PMNE increase by ulinastatin was independent of IL-6.

[The effects of the fat component of propofol solution of ketogenesis during propofol anesthesia].

To examine the effects of the fat component in propofol solution on the fat metabolism during propofol anesthesia, we measured the urine ketone body (UKB) and blood concentrations of 3-hydroxybutyrate (3-OHBA) and glucose. The anesthesia was maintained with propofol, fentanyl, and vecuronium. Infusion fluid without glucose was used while we measured the concentration of 3-OHBA. UKB was detected only when the concentration of 3-OHBA was more than 400 mumol.ml-1. The blood concentration of 3-OHBA increased in proportion to the total amount of propofol solution, while UKB did not show any such relationship. Furthermore, the rate of increase of 3-OHBA was larger in the group whose concentration of 3-OHBA was higher than the normal range. The blood concentration of glucose ranged within the normal fasting level. There were no cases who needed special treatment for hyperketonemia in this study. We concluded that 3-OHBA was a more sensitive indicator of ketogenesis than UKB, and that ketogenesis was accelerated both by propofol anesthesia with the lipidemic solution of propofol and by fasting before surgery. The acceleration of ketogenesis was especially marked in the patients with hyperketonemia.

Attenuation of haemodynamic responses to tracheal intubation by the styletscope.

Tracheal intubation often causes a haemodynamic response probably generated by direct laryngoscopy. The StyletScope is a new intubation device that does not require direct laryngoscopy. We prospectively measured haemodynamic changes after tracheal intubation using the StyletScope. The increase of heart rate was less during tracheal intubation with the StyletScope when compared with the Macintosh laryngoscope.

Lactate levels in cirrhotic patients undergoing liver resection.

BACKGROUND/AIMS: The role of lactate in liver ischemia-reperfusion injury in cirrhosis has not been clarified. METHODOLOGY: One hundred patients with hepatocellular carcinoma who underwent partial liver resection under Pringle's maneuver were included in this study. Blood lactate was measured before the operation, three times during the surgery and on the first postoperative day to calculate its rate of accumulation or elimination. Aminotransferase levels were also recorded perioperatively. We calculated the rate of lactate accumulation during the pre-ischemic and ischemic phases and the elimination rate during the post-ischemic phase, and examined the correlation between these results and the clinical findings. RESULTS: The rate of lactate accumulation during the pre-ischemic and ischemic phases was correlated with the preoperative indocyanine green retention rate (P = 0.04 and P = 0.004, respectively). The indocyanine green retention rate tended to be correlated with the rate of lactate elimination during the post-ischemic phase (P = 0.06). CONCLUSIONS: The blood lactate profile might be a reliable indicator of liver function during the perioperative period in cirrhotic patients who undergo liver resection with Pringle's maneuver.

Propofol-induced bronchoconstriction: two case reports.

IMPLICATIONS: Bronchoconstriction was induced by anesthetic induction with propofol in two patients with allergic diseases. One had severe bronchospasm improved by epinephrine. Propofol should be used with caution in patients with allergic disease.

[Anesthetic management for gastrojejunostomy in a patient with hemiplegia and recurrent laryngeal nerve palsy].

A 70-year-old man who had undergone a low anterior resection for primary rectal cancer 9 years before complained of anorexia, hemiplegia, and recurrent laryngeal nerve palsy. The anorexia was caused by duodenal stenosis due to swollen lymph nodes, the hemiplegia was caused by a metastatic brain tumor, and the recurrent laryngeal nerve palsy was caused by metastases of the cancer to the mediastinal space. Metastases were also found in the bilateral lungs, liver, ureter, and cervical vertebra. In choosing the anesthesia for the gastrojejunostomy to improve the malnutrition of this patient, we decided, on the basis of the patient's full stomach, malnutrition, hypovolemia, hemiplegia, cerebral compression, recurrent laryngeal nerve palsy, renal dysfunction, and respiratory dysfunction, to use thoracic epidural anesthesia rather than spinal anesthesia or general anesthesia. Thoracic epidural anesthesia could provide sufficient analgesia, and the operation was uneventful. In anesthetic management of an end-stage patient undergoing a palliative operation like this, we should consider the purpose of the operation, its complications, and further complications which may be induced by anesthesia in order to plan out an anesthetic regimen unlikely to lead to harmful events in perioperative period.

[Anesthetic management of a hyper-obese patient by target-controlled infusion (TCI) of propofol and fentanyl].

We gave total intravenous anesthesia to an over-100% hyper-obese patient using target-controlled infusion (TCI) of propofol and fentanyl. To keep him asleep, we maintained his BIS in a range of 40 to 60 by adjusting the target concentration of propofol. For the target concentration of fentanyl, we chose 2 ng.ml-1 at incision and 1.6 ng.ml-1 during the operation. At the patient's emergence from anesthesia, his estimated blood concentration of propofol was 1.51 micrograms.ml-1 and his BIS was 80. The relationship between BIS value and effect-site concentration of propofol was almost the same as that assessed in ordinary adults of a normal weight. We conclude that the estimated concentration of propofol is a good indicator of the effect of propofol and that TCI is a useful technique in obese patients as well as in ordinary adults.

[Anesthetic management of a patient with gunshot injury in the neck and the chest].

We present a case of a 27-year-old man with gunshot injury in the neck and the chest. On admission, he had an entry wound in the neck and his chest radiograph showed left hemopneumothorax. Nasal endotracheal intubation and chest drainage were immediately performed. Angiography revealed pseudoaneurysm of the left carotid artery and fistula between the artery and the innominate vein. The patient showed progressive severe facial edema due to the fistula. Anesthesia was induced and maintained with fentanyl and sevoflurane. The carotid artery was repaired with an autologous saphenous vein graft. Although one lung ventilation (OLV) was requested for partial resection of the left lung, replacing the endotracheal tube was impossible due to severe facial edema. OLV was successfully performed by blocking the left main trunchus with a 7 Fr Fogarty catheter placed under fiberscopic monitoring. The patient recovered without any serious complications. Prompt and proper airway management is required in gun shot injury of the neck and chest.

[Preliminary report: the efficacy of clonidine hydrochloride ointment for postherpetic neuralgia].

The combination of clonidine hydrochloride, alpha 2-agonist, and opioid is useful for relieving the pain due to surgical procedures or cancer. The routes of administrations used are intravenous, intramuscular as well as intrathecal, epidural and transmucosal. However, transdermal clonidine has not been reported. We, therefore, investigated the analgesic effect of local administration of clonidine ointment. Ten patients with postherpetic neuralgia (PHN) were selected randomly. They were requested to fill out a questionnaire after applying clonidine ointment (150 micrograms/ointment 1 g) to the painful area. Items included in the questionnaire were: effectiveness, visual analog scale (VAS) before and after the administration of clonidine ointment, onset time, with or without allodynia and effectiveness to allodynia in the former case, side effects, and patients' background. Analysis of the answers indicates that clonidine ointment produced a satisfactory effect in nine patients. Onset time was within a few minutes in most patients. No patients suffered any side effects. Specific mechanism of effectiveness or the site affected has not been confirmed in this study, but considering the quick onset, it is presumed that the site where the ointment was applied was the very site that was affected. Clonidine hydrochloride ointment was effective in relieving the symptoms of PHN.

Lactate is correlated with the indocyanine green elimination rate in liver resection for cirrhotic patients.

UNLABELLED: The role of lactate in liver ischemia-reperfusion injury in cirrhosis has not been clarified. Fifty patients with hepatocellular carcinoma who underwent partial liver resection under Pringle's maneuver were included in this study. We performed the indocyanine green clearance test before the operation and three times during the surgery to calculate its elimination rate. Blood lactate and base excess were measured at the corresponding times. Systolic and diastolic systemic arterial pressure, heart rate, cardiac index, and esophageal temperature were monitored. Aminotransferase levels were recorded the day before the operation, 1 h after the operation, and on the first and third postoperative days. We calculated the increase or decrease in lactate levels during the preischemic, ischemic, and postischemic phases, and examined the correlation between these results and the changes in indocyanine green elimination rate and some clinical factors. The lactate levels increased before reperfusion and began to decrease after reperfusion. The lactate increase and decrease during the ischemic and postischemic phases correlated with the change in indocyanine green elimination rate (P < 0.0001 and P = 0.02 for the respective phases). The lactate increase during the preischemic phase correlated with the duration of the preischemic phase (P < 0.0001). In cirrhotic patients who undergo liver resection with Pringle's maneuver and who do not show postoperative liver failure, the blood lactate profile might be a reliable indicator of liver metabolic capacity during surgery. IMPLICATIONS: In cirrhotic patients who underwent liver resection with Pringle's maneuver, the lactate increase and decrease during the ischemic and postischemic phases correlated with the change in the indocyanine green elimination rate. The blood lactate profile might be a reliable indicator of liver metabolic capacity during surgery.

[Anesthesia for emergency surgery in a patient with Shy-Drager syndrome].

A 53-year-old man with Shy-Drager syndrome underwent emergency surgery for the resection of the larynx under general anesthesia. Anesthesia was induced with fentanyl 0.1 mg and thiopental 100 mg, and endotracheal intubation was facilitated with vecuronium 8 mg. The onset of action of vecuronium was very slow. Anesthesia was maintained with about 1% of sevoflurane, with nitrous oxide 3 l.min-1 in oxygen 3 l.min-1. Norepinephrine was effective for hypotension while dopamine was not. He was extubated on the first postoperative day without any complications. The effects of vecuronium, norepinephrine, and dopamine might be changed in the patient with Shy-Drager syndrome.