Early-life midazolam exposure persistently changes chromatin accessibility to impair adult hippocampal neurogenesis and cognition.

Linkage between early-life exposure to anesthesia and subsequent learning disabilities is of great concern to children and their families. Here we show that early-life exposure to midazolam (MDZ), a widely used drug in pediatric anesthesia, persistently alters chromatin accessibility and the expression of quiescence-associated genes in neural stem cells (NSCs) in the mouse hippocampus. The alterations led to a sustained restriction of NSC proliferation toward adulthood, resulting in a reduction of neurogenesis that was associated with the impairment of hippocampal-dependent memory functions. Moreover, we found that voluntary exercise restored hippocampal neurogenesis, normalized the MDZ-perturbed transcriptome, and ameliorated cognitive ability in MDZ-exposed mice. Our findings thus explain how pediatric anesthesia provokes long-term adverse effects on brain function and provide a possible therapeutic strategy for countering them.

Correction to: What is the predictor of the intraoperative body temperature in abdominal surgery?

In the Original publication of the article, the Table 1 was incorrectly published.

What is the predictor of the intraoperative body temperature in abdominal surgery?

PURPOSE: Inadvertent hypothermia is a relatively common intraoperative complication. Few studies have investigated predictors of body temperature change or the effect of the blanket type used with a forced-air warming device during the intraoperative period. We investigated the predictive factors of intraoperative body temperature change in scheduled abdominal surgery. METHODS: We retrospectively reviewed the data from 2574 consecutive adult patients who underwent scheduled abdominal surgery in the supine position. Temperature data were collected from anesthesia records. Multiple regression analysis was performed at 60, 120, and 180 min after the surgical incision to identify the factors influencing body temperature change. We conducted nonlinear regression analysis using the equation ΔT = α (e-γt-1) + ßt, where ΔT represented the change in intraoperative core temperature (°C), t represented the surgical duration (minutes), and α, ß, and γ were constants. RESULTS: The intraoperative core temperature change was explained by the equation ΔT = 0.59 (e- 0.018t - 1) + 0.0043t. Younger age, higher body mass index (BMI), male sex, laparoscopic surgery, and use of an underbody blanket were associated with increased core temperature at 1 or 2 h after surgical incision. Male sex and an underbody blanket remained strong predictive variables even 3 h after surgical incision, whereas BMI had little explanatory power at this timepoint. The difference in the heating effect of an underbody versus an overbody blanket was 0.0012 °C per minute. CONCLUSIONS: The blanket type of the forced-air warmer, age, sex, laparoscopic surgery, and BMI are predictors of intraoperative core temperature change.

Cardiotonic actions of quercetin and its metabolite tamarixetin through a digitalis-like enhancement of Ca2+ transients.

The plant-derived flavonoid, quercetin (QCT), has many biological actions, including cardioprotective actions, resulting from its antioxidant and anti-inflammatory effects. In this study, effects of QCT and its metabolites on the contraction and Ca2+ transients (CaT) of mouse single cardiomyocytes were simultaneously measured and compared with those of isoproterenol and digoxin. Furthermore, cardiac function and plasma concentrations were analyzed after bolus intravenous administration of QCT in mice. QCT and its metabolite, tamarixetin, as well as isoproterenol and digoxin, enhanced the contraction and CaT of cardiomyocytes. The inotropic action of isoproterenol was accompanied by an increase in the velocities of sarcomere shortening and relengthening and CaT decay through activation of cAMP-dependent protein kinase; however, no such lusitropic effects accompanied the inotropic action of QCT, tamarixetin or digoxin. Intravenous administration of QCT to mice resulted in a sustained increase in cardiac systolic function; QCT was rapidly metabolized to tamarixetin and its plasma concentration was maintained at high levels over a similar time frame as the enhancement of cardiac systolic function. These results suggest that QCT exerts a cardiotonic action in vivo at least, in part, through digitalis-like enhancement of CaT by itself and its metabolite tamarixetin.

Effects of Forced Air Warming on Airflow around the Operating Table.

BACKGROUND: Forced air warming systems are used to maintain body temperature during surgery. Benefits of forced air warming have been established, but the possibility that it may disturb the operating room environment and contribute to surgical site contamination is debated. The direction and speed of forced air warming airflow and the influence of laminar airflow in the operating room have not been reported. METHODS: In one institutional operating room, we examined changes in airflow speed and direction from a lower-body forced air warming device with sterile drapes mimicking abdominal surgery or total knee arthroplasty, and effects of laminar airflow, using a three-dimensional ultrasonic anemometer. Airflow from forced air warming and effects of laminar airflow were visualized using special smoke and laser light. RESULTS: Forced air warming caused upward airflow (39 cm/s) in the patient head area and a unidirectional convection flow (9 to 14 cm/s) along the ceiling from head to foot. No convection flows were observed around the sides of the operating table. Downward laminar airflow of approximately 40 cm/s counteracted the upward airflow caused by forced air warming and formed downward airflow at 36 to 45 cm/s. Downward airflows (34 to 56 cm/s) flowing diagonally away from the operating table were detected at operating table height in both sides. CONCLUSIONS: Airflow caused by forced air warming is well counteracted by downward laminar airflow from the ceiling. Thus it would be less likely to cause surgical field contamination in the presence of sufficient laminar airflow.

Prediction of hemodynamic fluctuations after induction of general anesthesia using propofol in non-cardiac surgery: a retrospective cohort study.

BACKGROUND: Although propofol is a common anesthetic agent for the induction of general anesthesia, hemodynamic fluctuations are occasionally prominent during induction/intubation. The aims of this study were to determine the influential factors on enhanced hemodynamic fluctuation and to establish a prediction formula to quickly determine the dose of propofol to protect against hemodynamic fluctuations. METHODS: This retrospective cohort study patients (n = 2097) were 18 years or older. They underwent general anesthesia induction using propofol and orotracheal intubation for non-cardiac surgery at Kyushu University Hospital during April 2015 to March 2016. Preoperative patient clinical information was collected from anesthesia preoperative evaluation records. Intraoperative data were obtained from computerized anesthesia records. If patients' post-induction mean arterial blood pressure (MAP) decreased or increased 30% or more from their pre-induction MAP, they were determined to have enhanced hemodynamic fluctuations. Unconditional logistic regression was used to assess the adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Structural equation modeling (SEM) was conducted to simultaneously examine the direct and indirect effect (path coefficient = r) of potential variables. RESULTS: In the SEM analysis, age was significantly associated with enhanced hemodynamic fluctuations (adjusted odds ratio = 1.008, 95% CI = 1.001-1.015, P = 0.03). Age (path coefficient (r) = - 0.0113, 95% CI = - 0.0126-0.010, P < 0.001), American Society of Anesthesiologists physical status (ASA-PS) (r = - 0.0788, 95% CI = - 0.1431-0.0145, P = 0.02), sex (r = 0.057, 95% CI = 0.0149-0.9906, P = 0.01), and fentanyl dose (r = 0.1087, 95% CI = 0.0707-0.1467, P < 0.001) influenced the dose of propofol in induction. The prediction formula of "Propofol dose (mg) = [2.374 - 0.0113 × age (year) - 0.0788 (if ASA-PS 3 or 4) + 0.057 (if female) + 0.1087 × fentanyl dose (µg/kg)] × body weight (kg)" was derived. CONCLUSIONS: Age was associated with hemodynamic fluctuations in induction. Although the prediction formula is considered to be acceptable, future studies validating whether it can decrease patients' risk of enhanced hemodynamic fluctuations in clinical situations are necessary.

Effects of preoperative plasma exchange therapy with albumin replacement fluid on blood coagulation in patients undergoing ABO-incompatible living-donor kidney transplantation using rotational thromboelastometry.

BACKGROUND: ABO-incompatible living-donor kidney transplantation (LDKT) requires immunotherapy and plasma exchange therapy (PEX). PEX with albumin replacement fluid reportedly decreases fibrinogen levels. However, no reports have described the effects of PEX with albumin replacement fluid on blood coagulation parameters and blood loss during the perioperative period. Therefore, we investigated the effects of preoperative PEX on blood coagulation parameters and blood loss during the perioperative period in patients undergoing ABO-incompatible LDKT as measured by rotational thromboelastometry (ROTEM®). METHODS: Twenty-eight patients undergoing LDKT were divided into the PEX group (ABO incompatible with PEX, n = 13) and non-PEX group (ABO compatible without PEX, n = 15). ROTEM® parameters, standard laboratory test parameters, bleeding volume, and transfusion volume were compared between PEX and non-PEX group. MCEplatelet, which represents platelet contribution to clot strength and where "MCE" stands for maximum clot elasticity, was calculated from the difference in MCE between EXTEM and FIBTEM. RESULTS: The bleeding volume during surgery and the intensive care unit (ICU) stay was significantly higher in the PEX than non-PEX group (p < 0.01). Maximum clot firmness (MCF) of EXTEM (MCFEXTEM), MCFFIBTEM, and MCEplatelet was significantly lower in the PEX than non-PEX group (p < 0.01). In the PEX group, the bleeding volume during surgery was very strongly correlated with the baseline MCFEXTEM and MCEplatelet, and the bleeding volume during the ICU stay was strongly correlated with the postoperative MCFEXTEM and MCEplatelet. CONCLUSIONS: These results suggest that the increased blood loss in the PEX group during surgery and the ICU stay was associated with decreased platelet contribution to clot strength as measured by ROTEM®. TRIAL REGISTRATION: UMIN-Clinical Trial Registry UMIN000018355 . Registered 21 July 2015.

The relationship between seizure in electroconvulsive therapy and pupillary response using an automated pupilometer.

OBJECTIVES: Seizure duration and morphology, postictal suppression, and sympathetic nervous system activation are all recommended as assessments of adequate seizure in electroconvulsive therapy (ECT). However, blood pressure and heart rate are not typically assessed as part of sympathetic nervous system activation because of the administration of anesthetic or cardiovascular agents during ECT. Although the pupils are known to reflect to the activity of autonomic nervous system and the degree of brain damage, previous studies have not examined the relationship between seizure of electroconvulsive therapy and pupillary response. METHODS: We conducted 98 sessions of ECT with 13 patients, divided into two groups according to seizure quality: (1) adequate or (2) inadequate. Pupillary light reflex [% constriction = (maximum resting pupil size {MAX} - minimum pupil size after light stimulation)/MAX × 100] was measured using a portable infrared quantitative pupilometer before anesthesia induction and immediately after electrical stimulation. RESULTS: The number regarded as adequate was 67 times and as inadequate was 31 times. Maximum pupil size at the control and immediately after electrical stimulation was similar between the adequate and inadequate groups. Pupillary light reflex was similar at the control between both groups, but significantly smaller immediately after stimulation in the adequate group (2.5 ± 3.6%) compared with the inadequate group (10.6 ± 11.5%). Receiver operating characteristic curve analysis revealed that pupillary light reflex (> 5.5%) predicted adequate seizure. CONCLUSIONS: The current findings suggest that pupillary constriction immediately after ECT could provide a helpful method for assessing the efficacy of ECT.

Association Between Serum Vitamin D and All-Cause and Cause-Specific Death in a General Japanese Population　- The Hisayama Study.

BACKGROUND: Few studies have investigated the association between serum vitamin D levels and mortality in general Asian populations.Methods and Results:We examined the association of serum 1,25-dihydroxyvitamin D (1,25(OH)2D) levels with the risk of all-cause and cause-specific death in an average 9.5-year follow-up study of 3,292 community-dwelling Japanese subjects aged ≥40 years (2002-2012). The multivariable-adjusted hazard ratio (HR) for all-cause death increased significantly with lower serum 1,25(OH)2D levels (HR 1.54 [95% confidence interval, 1.18-2.01] for the lowest quartile, 1.31 [0.99-1.73] for the 2nd quartile, 0.94 [0.70-1.25] for the 3rd quartile, 1.00 [Ref.] for highest quartile; P for trend <0.001). A similar association was observed for cardiovascular and respiratory infection death (both P for trend <0.01), but not for cancer death or death from other causes. In the stratified analysis, the association between lower serum 1,25(OH)2D levels and the risk of respiratory infection death was stronger in subjects with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2than in those with eGFR ≥60 mL/min/1.73 m2; there was a significant heterogeneity in the association between eGFR levels (P for heterogeneity=0.04). CONCLUSIONS: The findings suggested that a lower serum 1,25(OH)2D level is a potential risk factor for all-cause death, especially cardiovascular and respiratory infection death, in the general Japanese population, and that lower serum 1,25(OH)2D levels greatly increase the risk of respiratory infection death in subjects with kidney dysfunction.

The effects of tramadol on postoperative shivering after sevoflurane and remifentanil anesthesia.

BACKGROUNDS: Remifentanil has been reported to cause post-anesthetic shivering (PAS). Higher doses of remifentanil reportedly induce more intense PAS. Tramadol, a synthetic opioid that acts at multiple sites, is considered to be an effective treatment for PAS, but the evidence for its therapeutic benefit after remifentanil anesthesia is limited. We investigated the effect of tramadol on the incidence of PAS after remifentanil anesthesia. METHODS: Sixty-three patients who had undergone upper abdominal surgery under general anesthesia were studied retrospectively. Tramadol was administered at induction of anesthesia. The patients were divided into four groups: HT(+), high dose remifentanil (1-1.5 µg/kg/min) with tramadol; HT(-), high dose remifentanil without tramadol; LT(+), low dose remifentanil (0.15-0.25 µg/kg/min) with tramadol; and LT(-), low dose remifentanil without tramadol. We recorded perioperative changes in nasopharyngeal temperature and episodes of PAS on emergence from anesthesia. RESULTS: The incidences of PAS in both tramadol treatment groups were significantly lower than the groups that did not receive tramadol. Nasopharyngeal temperature after surgery fell significantly more from baseline in the tramadol treatment groups compared with the non-treatment groups. CONCLUSION: Tramadol administered at induction of anesthesia appears to suppress PAS following remifentanil anesthesia.

The effects of anesthetic agents on pupillary function during general anesthesia using the automated infrared quantitative pupillometer.

Pupil reactivity can be used to evaluate central nervous system function and can be measured using a quantitative pupillometer. However, whether anesthetic agents affect the accuracy of the technique remains unclear. We examined the effects of anesthetic agents on pupillary reactivity. Thirty-five patients scheduled for breast or thyroid surgery were enrolled in the study. Patients were divided into four groups based on the technique used to maintain anesthesia: a sevoflurane-remifentanil (SEV/REM) group, a sevoflurane (SEV) group, a desflurane-remifentanil (DES/REM) group, and a propofol-remifentanil (PRO/REM) group. We measured maximum resting pupil size (MAX), reduction pupil size ratio (%CH), latency duration (LAT) and neurological pupil index (NPi). A marked reduction in MAX and %CH compared with baseline was observed in all groups, but LAT was unchanged during surgery. NPi reduced within the first hour of surgery in the SEV/REM, SEV, and DES/REM groups, but was not significantly different in the PRO/REM group. Compared with the PRO/REM group, mean %CH and NPi in patients anesthetized with SEV/REM, SEV or DES/REM were markedly lower at 1 h after surgery had commenced. There was no correlation between NPi and bispectral index. Fentanyl given alone decreased pupil size and %CH in light reflex, but did not change the NPi. NPi was decreased by inhalational anesthesia not but intravenous anesthesia. The difference in pupil reactivity between inhalational anesthetic and propofol may indicate differences in the alteration of midbrain reflexs in patients under inhalational or intravenous anesthesia.

[Retrospective Evaluation of Hypoxia and Silent Regurgitation during Laparoscopic Sleeve Gastrectomy].

BACKGROUND: The proportion of obese people is gradually increasing. In recent years, laparoscopic sleeve gastrectomy has been performed as a weight loss surgery. We reported the extent of respiratory complications and the keys of anesthetic management in this procedure. METHODS: Forty consecutive morbidly obese patients received laparoscopic sleeve gastrectomy. A sample for arterial blood gas analysis was taken after intubation and at the end of the operation. Moreover, to examine the risk of silent aspiration, 16 patients were subjected to measuring the gastric juice volume and pH of the pharynx. RESULTS: Oxygenation index (P/F ratio) after intuba- tion was markedly reduced, but there was no correla- tion with the BMI On the other hand, P/F ratio at the end of surgery improved in patients with low BMI Hypercapnia was rare after extubation, but respiratory rate was increased in the patients with high BMI Gas- tric secretion after induction was increased, but there was no overt sign of silent regurgitation of gastric juice. CONCLUSIONS: Oxygenation was extremely deterio- rated immediately after intubation in the morbidly obese patients. There is a need for aggressive respira- tory management because intraoperative oxygenation was not improved in the patients with high BMI.

A spatiotemporal signature of cortical pain relief by tactile stimulation: An MEG study.

Recently, the cortical mechanisms of tactile-induced analgesia have been investigated; however, spatiotemporal characteristics have not been fully elucidated. The insular-opercular region integrates multiple sensory inputs, and nociceptive modulation by other sensory inputs occurs in this area. In this study, we focused on the insular-opercular region to characterize the spatiotemporal signature of tactile-induced analgesia using magnetoencephalography in 11 healthy subjects. Aδ (intra-epidermal electrical stimulation) inputs were modified by Aß (mechanical tactile stimulation) selective stimulation, either independently or concurrently, to the right forearm. The optimal inter-stimulus interval (ISI) for cortical level modulation was determined after comparing the 40-, 60-, and 80-ms ISI conditions, and the calculated cortical arrival time difference between Aδ and Aß inputs. Subsequently, we adopted a 60-ms ISI for cortical modulation and a 0-ms ISI for spinal level modulation. Source localization using minimum norm estimates demonstrated that pain-related activity was located in the posterior insula, whereas tactile-related activity was estimated in the parietal operculum. We also found significant inhibition of pain-related activity in the posterior insula due to cortical modulation. In contrast, spinal modulation was observed both in the posterior insula and parietal operculum. Subjective pain, as evaluated by the visual analog scale, also showed significant reduction in both conditions. Therefore, our results demonstrated that the multisensory integration within the posterior insula plays a key role in tactile-induced analgesia.

Differences in anatomical relationship between vertebral artery and internal jugular vein in children and adults measured by ultrasonography.

Cannulation of the internal jugular vein (IJV) under ultrasound guidance can reduce complications, such as common carotid artery (CCA) puncture, accidental vertebral artery (VA) puncture. However, these complications still occur, especially in pediatric patients probably due to anatomical predisposition of VA. This study compared differences in anatomical location of VA and IJV between pediatric and adult patients. Children with body weight <20 kg (n = 16) and adults who required central venous or pulmonary arterial pressure monitoring (n = 21) were enrolled. After induction of general anesthesia and tracheal intubation, patients were positioned for IJV cannulation. Images of the right CCA, IJV and VA were recorded by ultrasonography. The size of each vessel, anatomical relationship of other vessels, distance between vessels and between each vessel and skin were measured. The size of VA relative to IJV was significantly larger in children than in adults (14 vs 7 %, P < 0.001). The absolute and relative distance between IJV and VA were significantly shorter in children than those in adults (P < 0.01). The anatomical relationships between IJV and CCA and that between IJV and VA were not different between children and adults. In children, VA was relatively larger and located closer to IJV than adults. The results call for careful attention to the position of VA during ultrasound-guided IJV cannulation especially in children.

The miR-506-Induced Epithelial-Mesenchymal Transition is Involved in Poor Prognosis for Patients with Gastric Cancer.

BACKGROUND: MicroRNAs have roles in the regulation of the epithelial-mesenchymal transition (EMT). Findings have shown that miR-506 inhibits the expression of SNAI2 and that low expression of miR-506 is associated with poor prognoses in ovarian and breast cancers. This study investigated the role of miR-506 in survival and the EMT in patients with gastric cancer. METHODS: In this study, miR-506 and SNAI2 mRNA levels were measured in 141 cases of gastric cancer by quantitative reverse transcription polymerase chain reaction, and the protein expressions of SNAI2 and E-cadherin in 39 cases were validated by immunohistochemical analysis. Next, the associations between their expression levels and clinicopathologic factors were evaluated. In addition, cell proliferation, migration, and luciferase activity of the 3' untranslated region (UTR) of SNAI2 were analyzed using pre-miR-506 precursor in two human gastric cancer cell lines. RESULTS: Low expression of miR-506 was significantly correlated with poor overall survival in both the univariate analysis (P = 0.016) and the multivariate analysis (P < 0.05). Low miR-506 expression was significantly correlated with high SNAI2 expression (P = 0.009) and poorly differentiated type (P = 0.015). In vitro, miR-506 suppressed SNAI2 expression by binding to its 3'UTR, resulting in increased expression of E-cadherin (P < 0.05), verified by immunohistochemical analysis. Pre-miR-506 transfected cells showed significantly suppressed cell proliferation and migration (P < 0.05) compared with the control cells. CONCLUSIONS: The EMT was directly suppressed by miR-506, and its low expression was an independent prognostic factor in gastric cancer patients. The data indicated that miR-506 may act as a tumor suppressor and could be a novel therapeutic agent.

In-line pressure within a HOTLINE® Fluid Warmer, under various flow conditions.

Roller pump infusion devices are widely used for rapid infusion, and may be combined with separate warming devices. There may be instances however, where the pressures generated by the roller pump may not be compatible with the warming device. We assessed a commonly used roller pump in combination with a HOTLINE® Fluid Warmer, and found that it could generate pressures exceeding the HOTLINE® manufacturers specifications. This was of concern because the HOTLINE® manufacturer guideline states that not for use with pressure devices generating over 300 mmHg. Pressure greater than 300 mmHg may compromise the integrity of the HOTLINE® Fluid Warming Set. The aim of this study was to compare in-line pressure within a HOTLINE® Fluid Warmer at different infusion rates of a roller pump using various sizes of intravenous cannulae. The rapid infusion system comprised a 500 mL-normal saline bag, roller pump type infusion device, HOTLINE® Fluid Warmer (blood and fluid warmer system), and six different sizes of intravenous cannulae. In-line pressure was measured proximal to the HOTLINE® (pre-warmer) and proximal to the cannula (post-warmer), at flow rate of 50-160 mL/min. The in-line pressures increased significantly with increasing flow rate. The pre-warmer pressures exceeded 300 mmHg when the flow rate was ≥120 mL/min with 20-gauge, 48 mm length cannula, 130 with 20-gauge, 25 mm cannula, and 160 mL/min with 18-gauge, 48 mm cannula. However, they were <300 mmHg at any flow rates with 18-gauge, 30 mm cannula and 16-gauge cannulae. The post-warmer pressures exceeded 300 mmHg at the flow rate of 140 mL/min with 20-gauge, 48 mm cannula, and 160 mL/min with 20-gauge, 25 mm cannula, while they were <300 mmHg at any flow rates with 18 and 16-gauge cannulae. The in-line pressure within a HOTLINE® could exceed 300 mmHg, depending on the flow rate and size and length of cannula. It is important to pay attention to the size and length of cannulae and flow rate to keep the maximum in-line pressure<300 mmHg when a roller pump type infusion device is used.

[Why should clinicians be engaged in research and publication?].

Why should clinicians be engaged in research and publication? The reason is that they have to deliver comprehensive medical care for patients. Clinicians endeavor to improve their clinical skills by learning updated medical knowledge and new techniques in order to save lives. By taking part in research and publications, clinicians are able to contribute actively to the progress in medicine contrary to passive involvement in it without research and publications. Mission of Japanese Society of Anesthesiologists (JSA), clearly mention that JSA aims to advance high quality research and developing new methods in medicine. JSA also necessitates, as a minimum requirement for Board Certified Anesthesiologists, presentations in annual meeting of JSA or related society meetings and also publications in Journal of Anesthesia, an official journal of JSA, or other related anesthesia journals. By experiencing research and publications, clinicians can obtain knowledge, skills as well as attitudes, which are also useful in everyday clinical work, such as logical way of thinking, how to write papers to be understood, tolerance to peer review and objective evaluation, and maintaining spirit of enterprise in their career.

[Two Cases of Fetuses with Difficult Airway that Survived by the EXIT (Ex Utero Intrapartum Treatment) Procedure].

We successfully managed two fetuses complicated with suspected airway obstruction after birth by the EXIT (ex utero intrapartum treatment) procedure, whose placental circulation was maintained till their airway was secured during the cesarean section. The first fetus was suspected to have airway obstruction due to a large neck mass. At 36 weeks of gestation, the EXIT procedure was undertaken performing the tracheal intubation successfully by laryngoscope. The second fetus with micrognathia was expected to have airway obstruction after birth. The EXIT procedure was undertaken at 35 weeks of gestation. The tracheal intubation by laryngoscope or by stylet scope was impossible, and the airway was secured by tracheostomy. The direct roles of anesthesiologists in the EXIT procedure are to let the uterus relax enough, deal with bleeding, and manage the fetal airway. The EXIT procedure is a specialized operation in which various specialists are involved, and a variety of judgments are necessary within a short time. Therefore, all concerned personnel should discuss previously to make a concensus on the processes during the procedure. The organization may be also an important role of the anesthesiologists in the EXIT procedure.

Chemokine (C-C motif) receptor 5 is an important pathological regulator in the development and maintenance of neuropathic pain.

BACKGROUND: The chemokine family has been revealed to be involved in the pathogenesis of neuropathic pain. In this study, the authors investigated the role of chemokine (C-C motif) ligand 3 and its receptors chemokine (C-C motif) receptor 1 and chemokine (C-C motif) receptor (CCR) 5 in neuropathic pain. METHODS: A spinal nerve injury model was established in adult male Wistar rats. The von Frey test and hot plate test were performed to evaluate neuropathic pain behavior, and real-time quantitative reverse transcription polymerase chain reaction, in situ hybridization, and immunohistochemistry were performed to understand the molecular mechanisms. RESULTS: The expression levels of chemokine (C-C motif) ligand 3 and CCR5 messenger RNA in the spinal cord were up-regulated after nerve injury, which was possibly due to CD11b-positive microglia. Single intrathecal administration of recombinant chemokine (C-C motif) ligand 3 produced biphasic tactile allodynia; each phase of pain behavior was induced by different receptors. Intrathecal injection of CCR5 antagonist suppressed the development of tactile allodynia (12.81 ± 1.33 g vs. 3.52 ± 0.41 g [mean ± SEM, drug vs. control in paw-withdrawal threshold]; P < 0.05, n = 6 each) and could reverse established tactile allodynia (10.87 ± 0.91 g vs. 3.43 ± 0.28 g; P < 0.05, n = 8 and 7). Furthermore, Oral administration of CCR5 antagonist could reverse established tactile allodynia (8.20 ± 1.27 g vs. 3.18 ± 0.46 g; P < 0.05, n = 4 each). CONCLUSIONS: Pharmacological blockade of CCR5 was effective in the treatment of the development and maintenance phases of neuropathic pain. Thus, CCR5 antagonists may be potential new drugs for the treatment of neuropathic pain.

Anesthetic Management of an Adult Patient Post a Fontan Procedure in Laparoscopic Surgery: A Case Report.

We report the successful anesthetic management of laparoscopic surgery in a 21-year-old female patient with Fontan circulation. A preoperative careful review of cardiac catheterization results helped assess the risk of the surgery and implement anesthetic management. Intraoperative management focused on minimizing the impact on pulmonary vascular resistance and venous return by optimizing ventilation and applying lower pneumoperitoneum pressure without tilting the position. Milrinone was administered to reduce pulmonary vascular resistance and provide inotropic support with minimally invasive monitoring. The patient remained stable throughout the procedure without complications. This case highlights the importance of thorough preoperative assessment, individualized intraoperative management, and collaboration with the surgical team when caring for adult Fontan patients undergoing laparoscopic surgery.