Effects of antipsychotics on intravenous sedation with midazolam and propofol during dental treatment for patients with intellectual disabilities.

BACKGROUND: Some patients with intellectual disabilities (ID) are prescribed antipsychotic drugs for symptomatic treatment of behavioural disorders. Nevertheless, it can still prove difficult to perform dental treatments safely for some patients with ID. In such cases, treatment under intravenous sedation (IVS) is one option. Sedative, hypnotic and α-blocking effects of antipsychotic drugs may cause adverse events, such as severe hypotension, among patients who take antipsychotic drugs regularly. This study aimed to investigate the effects of oral antipsychotic medication on cardiovascular function during IVS. Accordingly, we compared mean blood pressure (MBP) and heart rate (HR) between patients who regularly take antipsychotic drugs and patients who do not. METHODS: Thirty-seven patients with ID were enrolled in this study. All participants were outpatients of Special Care Dentistry of general hospital and received dental treatment under IVS performed with a combination of midazolam and propofol. Eighteen patients regularly took antipsychotics (medication group), and 19 patients were not currently taking antipsychotics (non-medication group). MBP, HR, dose, and effect-site concentration of intravenous sedative medications were measured at three points: 'before IVS', 'at optimal sedation', and 'during dental treatment'. RESULTS: The magnitude of reduction of MBP was significantly smaller in the medication group than in the non-medication group (P < 0.023). However, there were no differences in MBP, HR, dose, and effect-site concentration of midazolam and propofol between groups at any point. CONCLUSION: These results suggest that antipsychotic medication may not have clinically significant adverse effects on cardiovascular fluctuations during dental treatment under IVS for persons with ID.

Pleth variability index can predict spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery.

BACKGROUND: Spinal anaesthesia carries a risk of hypotension. We hypothesized that pleth variability index and perfusion index would assess maternal volume status, and thus, allow identification of patients at higher risk of developing hypotension after spinal anaesthesia for caesarean delivery. METHODS: Fifty patients undergoing elective caesarean delivery were enrolled. All patients received spinal anaesthesia with 0.5% hyperbaric bupivacaine (10 mg) and fentanyl (10 mcg). Blood pressure was measured every minute. Pleth variability index and perfusion index were automatically measured throughout the procedure using pulse oximetry on the index finger. In case of hypotension (systolic blood pressure below 90 mmHg or 80% of the baseline value), ephedrine 5 mg was administered. Receiver-operating characteristic and multivariate logistic regression analyses for spinal anaesthesia-induced hypotension were performed. RESULTS: Hypotension occurred in 32 patients (64%). The areas under the receiver-operating characteristic curve were 0.751 (95% confidence interval: 0.597-0.904) for pleth variability index before anaesthesia, 0.793 (95% confidence interval: 0.655-0.930) for pleth variability index after anaesthesia and 0.731 (95% confidence interval: 0.570-0.892) for perfusion index change (percent change in perfusion index induced by spinal anaesthesia). The optimal threshold value of pleth variability index (after anaesthesia) for predicting hypotension was 18% (sensitivity: 78.1%, specificity: 83.3%). Pleth variability index after spinal anaesthesia was an independent factor for hypotension (odds ratio: 1.21, P = 0.041). CONCLUSIONS: Pleth variability index after spinal anaesthesia was a good predictor of spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery. In addition, perfusion index change after spinal anaesthesia has the potential to predict hypotension.

Role of amyloid type cross beta-structure in the formation of soluble aggregate and gel in heat-induced ovalbumin.

The heat-induced denaturation curve of ovalbumin followed by the ellipticity at 222 nm in circular dichroism spectra was consistent with that monitored by fluorescence with thioflavin T, which is an indication of amyloid fibril formation, while other proteins such as lysozyme and ovotransferrin did not fluoresce with thioflavin T during heat denaturation. The amount of soluble aggregate formed during heat denaturation was proportional to the increase in fluorescence with thioflavin T. The binding of soluble aggregates with thioflavin T was greatly suppressed in heat-denatured ovalbumin in the presence of thioflavin T. The similar inhibition effect of thioflavin T on the gel formation of heat-induced ovalbumin was observed. These results suggest that the amyloidogenic intermolecular beta-structure is involved in the formation of soluble aggregate and gel of heat-induced ovalbumin.

Mortality in psychiatric patients, with a specific focus on cancer mortality associated with schizophrenia.

BACKGROUND: Higher mortality rates among psychiatric patients compared with the general population have been widely reported. On the other hand, lower cancer mortality for schizophrenics has been occasionally pointed out. Few studies from Japan have investigated mortality among psychiatric patients, and this study is the first large-scale follow-up in this country. METHODS: A total of 4980 patients admitted to a national mental hospital from 1948 through 1982 were followed up until 31 August 1985. The standardized mortality ratios (SMR) were calculated in comparison to the general population, using the person-years method. RESULTS: The SMR for total deaths and those for malignancy were as follows for males/females respectively: 2.55/3.02 and 0.84/1.37 for schizophrenia, 1.76/2.37 and 1.44/2.10 for depression, 2.45/3.04 and 1.18/1.82 for mania, 1.81/1.90 and 0.27/1.07 for neurosis, 5.55/4.33 and 1.85/3.34 for alcohol/drug abuse, and 3.65/3.57 and 1.01/0.72 for organic brain syndrome. CONCLUSIONS: The SMR for total deaths were significantly elevated in schizophrenia, depression, mania, neurosis, alcohol/drug abuse, and organic brain syndrome, respectively. The SMR for malignancy were not elevated nor lowered significantly in any of these disease categories. The SMR for stomach cancer in male schizophrenics was significantly lower (0.27; P < 0.05).

Dopamine, serotonin and alpha-adrenergic receptor blocking activities in serum and their relationships to prolactin level in schizophrenic patients receiving long-term chlorpromazine treatment.

The clinical application of a dopamine radioreceptor assay for neuroleptics has been proposed. Simultaneous monitoring of serum antidopaminergic (anti-DA), antiserotonergic (anti-5HT) antiadrenergic (anti-NA) activities may provide a better understanding of clinical effects of neuroleptics. Serum anti-DA and anti-5HT activities were estimated by competition for 3H-spiperone binding to dopamine and serotonin receptors in rat brain, respectively, and anti-NA activity by competition for 3H-WB-4101 binding to alpha-receptors. Thirty-one patients receiving maintenance doses of chlorpromazine (CPZ) chronically were studied. Serum activities varied among patients receiving the same dose, but correlated significantly with dose. Anti-DA activity also correlated with both anti-5HT anti-NA activities, and the average ratio of anti-5HT or anti-NA to anti-DA activity was slightly reduced by metabolism of CPZ. However, some patients had a different spectrum of serum activities from that of in vitro activities. Serum prolactin (PRL) correlated weakly with all the serum activities. The serum PRL anti-DA activity ratio appeared to be independent of anti-5HT or anti-NA activity, suggesting the predominant involvement of anti-DA activity in the stimulation of PRL release.

Novel aberrant nuclear behavior in abortive conjugation of Tetrahymena thermophila: joint selection of a meiotic product and macronucleus during nuclear selection.

In conjugation of Tetrahymena thermophila, the paroral zone, cortical cytoplasm in the vicinity of the cytostome, is the site where nuclear selection occurs; one of the four meiotic products is selected in this site prior to the production of gametic pronuclei. During inbreeding cross experiments, several sterile strains were obtained which showed aberrant nuclear behavior. Conjugants of these strains normally underwent meiosis, resulting in the generation of four meiotic products. They, however, failed to complete the process of nuclear selection and aborted the subsequent conjugation sequences. During nuclear selection, macronucleus was frequently selected instead of a meiotic product. A novel aberrant nuclear behavior was observed: Macronucleus and a meiotic product were jointly selected and the both nuclei simultaneously attached to the same paroral zone. When this simultaneous attachment occurred in one partner cell of a pair, nuclear selection was never observed in the other partner cell. This result suggests that a conjugating pair has only two attachment sites on the paroral zone during nuclear selection, and that the distribution of the sites is occasionally distorted in abortive conjugation.

Comparative laboratory toxicity of neem pesticides to honey bees (Hymenoptera: Apidae), their mite parasites Varroa jacobsoni (Acari: Varroidae) and Acarapis woodi (Acari: Tarsonemidae), and brood pathogens Paenibacillus larvae and Ascophaera apis.

Laboratory bioassays were conducted to evaluate neem oil and neem extract for the management of key honey bee (Apis mellifera L.) pests. Neem pesticides inhibited the growth of Paenibacillus larvae (Ash, Priest & Collins) in vitro but had no effect on the growth of Ascophaera apis (Olive & Spiltoir). Azadirachtin-rich extract (neem-aza) was 10 times more potent than crude neem oil (neem oil) against P. larvae suggesting that azadirachtin is a main antibiotic component in neem. Neem-aza, however, was ineffective at controlling the honey bee mite parasites Varroa jacobsoni (Ouduemans) and Acarapis woodi (Rennie). Honey bees also were deterred from feeding on sucrose syrup containing > 0.01 mg/ml of neem-aza. However, neem oil applied topically to infested bees in the laboratory proved highly effective against both mite species. Approximately 50-90% V. jacobsoni mortality was observed 48 h after treatment with associated bee mortality lower than 10%. Although topically applied neem oil did not result in direct A. woodi mortality, it offered significant protection of bees from infestation by A. woodi. Other vegetable and petroleum-based oils also offered selective control of honey bee mites, suggesting neem oil has both a physical and a toxicological mode of action. Although oils are not as selective as the V. jacobsoni acaricide tau-fluvalinate, they nonetheless hold promise for the simultaneous management of several honey bee pests.

[Studies on the constituents of trichosanthes root. III. Constituents of roots of Trichosanthes bracteata Voigt].

From the fresh roots of Trichosanthes bracteata Voigt., the following substances were identified: methyl palmitate, palmitic acid, suberic acid, alpha-spinasterol, stigmast-7-en-3 beta-ol, alpha-spinasterol 3-O-beta-D-glucopyranoside, stigmast-7-en-3 beta-ol 3-O-beta-D-glucopyranoside, glyceryl 1-palmitate, glyceryl 1-stearate, bryonolic acid, cucurbitacin B, isocucurbitacin B, 3-epi-isocucurbitacin B, 23,24-dihydrocucurbitacin B, 23,24-dihydroisocucurbitacin B, 23,24-dihydro-3-epi-isocucurbitacin B, cucurbitacin D, isocucurbitacin D and D-glucose. This root contains more than 6 times cucurbitacin of the root of T. kirilowii Maxim. var. japonicum Kitam.

[A successful surgical treatment of WPW syndrome associated with tricuspid atresia].

The occurrence of both tricuspid atresia and WPW syndrome is quite rare. To our knowledge, only two operated cases have been reported. In this report, a 8-year-old boy with this combination was reported. Tachycardia via the right side accessory pathway was for the first time pointed out after Kreutzer's operation. Epicardial mapping showed the earliest excitation at the right free wall. When fatty tissue around this area was removed by CUSA, a large cardiac vein appeared. By holding this vein with a forceps, the delta wave disappeared temporarily. ACP seemed to be present near this vein. Permanent disappearance of the delta wave was obtained after ligation and division. Four months after surgery, he is free from tachycardia attacks.

[A familial case of ADPKD with intracranial aneurysms detected by MR angiography].

The management and screening of unruptured asymptomatic intracranial aneurysm (ICA) in patients with ADPKD and those with a family history of ICA remains a subject of considerable controversy. In recent years, it has been revealed that MRA (magnetic resonance angiography) can define the circle of Willis to allow detection of ICA as small as 3-4 mm. We report a case of a 63-year-old man with ADPKD and his family. No definite aneurysm was observed by angiography screening at 46 years of age, when he was referred for hemodialysis. For the past three years, his family history revealed that three relatives were suffering from subarachnoid hemorrhage at the ages of 32, 36 and 39 years, respectively, two of whom had ICA and one had arterio-venous malformation detected by angiography. Whether they had ADPKD was unknown, but two were suggestive of ADPKD. Therefore, our case underwent MRA as screening for ICA, which showed an ICA with a diameter of 5mm in the anterior communicating artery. The ICA was confirmed as being 6 mm in diameter by conventional angiography. His niece and her son, who had ADPKD, also underwent MRA, which showed a suspicious image of a 2 mm ICA in the latter case. These results suggest that prophylactic screening for ICA is important in an ICA clustering family. MRA is useful in screening for ICA and in the follow-up study on the natural course of ICA.

[Skeletal muscle ventricle used for right ventricle assistance].

There are a number of advantages in using an electrically stimulated autogenous skeletal muscle to construct an auxiliary ventricle to assist a heart. The purpose of this study was to determine the feasibility of biological right ventricular assistance using long-term electrically stimulated skeletal muscle grafts. In fourteen dogs, the latissimus dorsi muscles and the right thoracodorsal nerves were exposed and unipolar pulse generator was implanted. The initial rate of 70 cycle/min. was increased to a rate of 100 cycle/min. Six or 12 months later, the latissimus dorsi was wrapped around a latex pouch equipped with inflow and outflow valved conduit (skeletal muscle ventricles; SMVs). The SMVs were connected to main pulmonary artery and right atrium. These SMVs were stimulated 20 Hz for 200 msec at a fixed rate of 90 cycle/min, the hemodynamic changes with or without skeletal muscle ventricular assistance (SMVA) were measured. In as animals the circulation failed after total right ventricular bypass without SMVA. But the SMVA increased aortic blood pressure, aortic blood flow, left atrial pressure and peak pulmonary pressure significantly. There was a linear correlation between central venous pressure and skeletal muscle ventricular assist flow. Histologic studies showed the conditioned muscles had a greater percentage of slow-twitch, fatigue resistant fibers on ATPase stain. These results suggested the long-term electrical conditioning skeletal muscle could be possible to use SMVs in humans to provide support in children with some types of congenital heart disease.

[Surgical management of infective endocarditis].

We reviewed fourty-six patients who had undergone surgery for infective endocarditis in the past fifteen years and identified risk factors affecting the outcome. Twenty-nine patients had infection of the native valve only, 11 had infective endocarditis associated with congenital heart disease, and 6 had prosthetic valve endocarditis. Overall hospital mortality was 6.5%. Prosthetic valve endocarditis carried a higher mortality (33%) than native valve endocarditis (3.4% or congenital heart disease with infective endocarditis (0%). For the patients with active endocarditis, the early mortality rate was higher (13%) than with inactive endocarditis (3.2%). Staphylococcal infections were more likely to cause severe valve destruction and residual infection than streptococcal infection. Our results indicated that surgical management of infective endocarditis should be done after the completion of adequate antibiotic therapy. Early diagnosis should reduce the mortality, prevent fatal complications, and lead to qualitative improvement of infective endocarditis.

[Treatment of Wolff-Parkinson-White syndrome associated with asthma].

We performed division of accessory pathways in five asthma patients associated with Wolff-Parkinson-White (WPW) syndrome, for whom the administration of a beta-blocker for the tachycardia is contraindicated, and the administration of bronchodilators for the asthma attack may cause premature ventricular contractions. As a result, the tachycardic attacks disappeared postoperatively, both at rest and following administration of bronchodilators. Radical treatment of WPW syndrome by division the accessory pathway is considered to be necessary for the safe treatment of asthma.