Incidence of sodium-glucose cotransporter-2 inhibitor-associated perioperative ketoacidosis in surgical patients: a prospective cohort study.

PURPOSE: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are commonly prescribed anti-diabetic medications with various beneficial effects; however, they have also been associated with ketoacidosis. The aim of this study was to determine the incidence of SGLT2i-associated perioperative ketoacidosis (SAPKA) in surgical patients. METHODS: We conducted a multicenter, prospective cohort study across 16 centers in Japan, enrolling surgical patients with diabetes who were prescribed SGLT2is between January 2021 and August 2022. Patients were monitored until the third postoperative day to screen for SAPKA, defined as urine ketone positivity with a blood pH of < 7.30 and HCO3 level ≤ 18.0 mEq/L, excluding cases of respiratory acidosis. RESULTS: In total, 759 of the 762 evaluated patients were included in the final analysis. Among these, three patients (0.40%) had urine ketones with a blood pH of < 7.30; however, blood gas analysis revealed respiratory acidosis in all three, and none of them was considered to have SAPKA. The estimated incidence of SGLT2i-associated postoperative ketoacidosis was 0% (95% confidence interval, 0%-0.4%). CONCLUSIONS: The observed incidence of SAPKA in our general surgical population was lower than expected. However, given that the study was observational in nature, interpretation of study results warrants careful considerations for biases.

Effects of simulated kyphosis posture on swallowing and respiratory functions.

[Purpose] To evaluate the effects of kyphosis on swallowing and respiratory functions. [Participants and Methods] In 94 healthy adult volunteers, the respiratory (vital capacity, percentage of vital capacity, and cough peak flow and swallowing (hyoid amplitude and tongue pressure) functions, were evaluated under the following conditions: vertical, moderate kyphosis, and severe kyphosis postures defined by the round-back index. [Results] The mean vital capacity and percentage of vital capacity were significantly lower in severe kyphosis than in the vertical posture. The suprahyoid muscle amplitudes, tongue pressure, and cough peak flow was significantly lower in severe kyphosis than in moderate kyphosis or the vertical positions. [Conclusion] The swallowing and breathing functions were significantly lower in volunteers with severe kyphosis than in those with moderate kyphosis or the vertical positions. Although strengthening of the suprahyoid muscles is a typical example of rehabilitation for dysphagia, but it may also be necessary to consider postural adjustment for patients with kyphosis. A comprehensive evaluation of swallowing function that takes both posture and respiratory function into consideration is necessary.

[Danaparoid Sodium Controlled Chronic Disseminated Intravascular Coagulation Associated with Chronic Aortic Dissection and Patent False Lumen for a Long Term:Report of a Case].

The management of chronic disseminated intravascular coagulation( DIC) caused by aortic dissection has not yet been established. We report the successful treatment of a case of aortic dissection with a patent false lumen using danaparoid sodium for acute exacerbation of chronic DIC. 2,000 U danaparoid sodium per day has been stabilizing the coagulative and fibrinolytic parameters and has been relieving bleeding tendencies with no side effects for a long term.

Regional thigh tissue oxygen saturation during cardiopulmonary bypass predicts acute kidney injury after cardiac surgery.

Cardiopulmonary bypass-associated acute kidney injury may appear postoperatively, but predictive factors are unclear. We investigated the potential of regional tissue oxygen saturation as a predictor of cardiopulmonary bypass-associated acute kidney injury. We analyzed the clinical data of 150 adult patients not on dialysis who underwent elective cardiac surgical procedures during January 2015-March 2017. Near-infrared spectroscopy was used to measure regional oxygen saturation. Sensors were placed on the patients' forehead, abdomen, and thigh. The incidence of acute kidney injury was 2% at the end of surgery, 13% at 24 h, and 9% at 48 h, with the highest at 24 h after surgery. The multiple regression analysis revealed that the thigh regional oximetry during cardiopulmonary bypass, oxygen delivery index, and neutrophil count at the end of cardiopulmonary bypass and surgery were independent risk factors for acute kidney injury. The receiver-operating characteristic curve analysis suggested that a cutoff of regional oxygen saturation at the thigh of ≤ 67% was predictive of acute kidney injury within 24 h after surgery. In conclusion, the regional oxygen saturation at the thigh during cardiopulmonary bypass is a crucial marker to predict postoperative acute kidney injury in adults undergoing cardiac surgery.

1.2% Hydrogen gas inhalation protects the endothelial glycocalyx during hemorrhagic shock: a prospective laboratory study in rats.

PURPOSE: Hydrogen gas (H2) inhalation improved the survival rate of hemorrhagic shock. However, its mechanisms are unknown. We hypothesized that H2 protected the endothelial glycocalyx during hemorrhagic shock and prolonged survival time. METHODS: 83 Sprague-Dawley rats were anesthetized with isoflurane. The animals were randomly assigned to 5 groups: room air with no shock, 1.2% H2 with no shock, room air with shock (Control-S), 1.2% H2 with shock (H21.2%-S), and 3.0% H2 with shock (H23.0%-S). Shock groups were bled to a mean arterial pressure of 30-35 mmHg and held for 60 min, then resuscitated with normal saline at fourfold the amount of the shed blood volume. RESULTS: The syndecan-1 level was significantly lower in the H21.2%-S [8.3 ± 6.6 ng/ml; P = 0.01; 95% confidence interval (CI), 3.2-35.8] than in the Control-S (27.9 ± 17.0 ng/ml). The endothelial glycocalyx was significantly thicker in the H21.2%-S (0.15 ± 0.02 µm; P = 0.007; 95% CI, 0.02-0.2) than in the Control-S (0.06 ± 0.02 µm). The survival time was longer in the H21.2%-S (327 ± 67 min, P = 0.0160) than in the Control-S (246 ± 69 min). The hemoglobin level was significantly lower in the H21.2%-S (9.4 ± 0.5 g/dl; P = 0.0034; 95% CI, 0.6-2.9) than in the Control-S (11.1 ± 0.8 g/dl). However, the H23.0%-S was not significant. CONCLUSIONS: Inhalation of 1.2% H2 gas protected the endothelial glycocalyx and prolonged survival time during hemorrhagic shock. Therapeutic efficacy might vary depending on the concentration.

[Thoracic Aortic Rupture of Stanford Type B Acute Aortic Dissection in a Patient with Polycystic Kidney Disease;Report of a Case].

We report a case of a 48-year-old man with polycystic kidney disease (PKD), who was emergently transported to our institution by ambulance because of thoracic aortic rupture of Stanford type B acute aortic dissection. PKD is a congenital disease associated with hypertension( 60%) and cerebrovascular disease (20%). Few reports have described sudden death due to the rupture of an abdominal aortic aneurysm and acute aortic dissection. In this case, emergency hemi-arch replacement was performed successfully. His postoperative course was uneventful, and he was discharged on the 15th postoperative day.

Gene delivery to cone photoreceptors by subretinal injection of rAAV2/6 in the mouse retina.

Adeno-associated virus (AAV) has been studied as a safe delivery tool for gene therapy of retinal blinding diseases such as Leber's congenital amaurosis (LCA). The tropism of recombinant AAV (rAAV) including its specificity and efficiency in targeting retinal cell types has been studied with native or engineered capsids, along with specific promoters. However, one of the rAAV serotypes, rAAV2/6, has not been well-studied based on a report of low infection efficiency in the retina. We investigated the tropism of several rAAVs by subretinal injection in the adult mouse and found that rAAV2/6 predominantly infected cone photoreceptors including the main spectral type. Our data suggest that subretinal injection with rAAV2/6 may provide both an efficacious and specific means of gene delivery to cone photoreceptors in murine retinas.

Field-Induced Antipolar-Polar Structural Transformation and Giant Electrostriction in Organic Crystal.

The field-induced antipolar-polar structural transition in an organic antiferroelectric 2-trifluoromethylnaphthimidazole crystal is investigated by performing synchrotron X-ray diffraction. The polarities of all of the hydrogen-bonded chains become parallel with each other in the presence of an external electric field. The switching is accompanied by a giant electrostriction, which provides 1 order of magnitude larger strain than the piezoelectric strain of the organic ferroelectrics: croconic acid and poly(vinylidene fluoride); however, it is comparable to those of typical commercial piezoelectric ceramics. The crystal structure analysis with electric field shows that the origin of the observed giant electrostriction can be attributed to the shear strain that emerges from the polarity switching of the hydrogen-bonded chains. The antipolar-polar structural transition in antiferroelectrics could be employed for the development of high-performance electrostrictive organic materials.

Enhanced Shot Noise of Multiple Andreev Reflections in a Carbon Nanotube Quantum Dot in SU(2) and SU(4) Kondo regimes.

The sensitivity of shot noise to the interplay between Kondo correlations and superconductivity is investigated in a carbon nanotube quantum dot connected to superconducting electrodes. Depending on the gate voltage, the SU(2) and SU(4) Kondo unitary regimes can be clearly identified. We observe enhancement of the shot noise via the Fano factor in the superconducting state. Its divergence at low bias voltage, which is more pronounced in the SU(4) regime than in the SU(2) one, is larger than what is expected from proliferation of multiple Andreev reflections predicted by the existing theories. Our result suggests that the Kondo effect is responsible for this strong enhancement.

Cerebral oximetry for cardiac surgery: a preoperative comparison of device characteristics and pitfalls in interpretation.

Regional cerebral oximetry using near-infrared spectroscopy devices is commonly used for detecting cerebral ischemia during cardiopulmonary bypass, and aim to avoid poor cerebral perfusion which may result in perioperative neurological impairment. Today, several devices that can detect cerebral ischemia are commercially available. Although these devices operate on the same measurement principles, their algorithms for detecting and calculating cerebral ischemia are different and no criteria for directly comparing values measured by such different devices exist. From January 2017 to August 2017, 80 adult cardiovascular surgery patients were enrolled in the prospective study. In each patient, preoperative regional cerebral oxygen saturation values were measured by two different devices and their correlations with various preoperative factors were evaluated. Regional cerebral oxygen saturation levels were significantly higher for values of FORE-SIGHT ELITE (CAS Medical Systems, Branford, CT, USA) (F value) than those of the INVOS 5100C (Medtronic, Minneapolis, MN, USA) (I value). Scalp-cortex distance, hemoglobin concentration, and the presence or absence of hemodialysis showed significant correlations with ratios of measured values specific to each device (F/I). An appropriate device should be selected according to preoperative patient characteristics, and factors influencing regional cerebral oxygen saturation values should be considered to ensure the correct interpretation of measured values. This research was conducted with the approval of the ethics committee of our university (approval number: B16-96).

Correction to: Cerebral oximetry for cardiac surgery: a preoperative comparison of device characteristics and pitfalls in interpretation.

In the original publication, the length unit of the SCD in Table 1 and Fig. 2 has been incorrectly published as cm. The correct length unit is mm.

Early Extubation in the Operating Room after Congenital Open-Heart Surgery.

Early extubation in the operating room after congenital open-heart surgery is feasible, but extubation in the intensive care unit after the operation remains common practice at many institutions. The purpose of this study was to evaluate retrospectively the adequacy of our early-extubation strategy and exclusion criteria through analysis based on the Risk Adjustment in Congenital Heart Surgery method (RACHS-1).This retrospective analysis included 359 cases requiring cardiopulmonary bypass (male, 195; female, 164; weight > 3.0 kg; aged 1 month to 18 years). Neonates and preoperatively intubated patients were excluded. Other exclusion criteria included severe preoperative pulmonary hypertension, high-dose catecholamine requirement after cardiopulmonary bypass, delayed sternal closure, laryngomalacia, serious bleeding, and delayed awakening. The early-extubation rates were compared between age groups and RACHS-1 classes.Overall, 83% of cases (298/359) were extubated in the operating room, classified by RACHS-1 categories as follows: 1, 59/59 (100%); 2, 164/200 (84%); 3, 61/78 (78%); and 4-6, 10/22 (45%). The early extubation rate in categories 1-3 (86%, 288/337) was significantly higher than for categories 4-6 (45.5%, 10/22) (P < 0.001). Because they met one of the exclusion criteria, 61 patients (17%) were not extubated in the operating room. Eight patients (2.7%) required re-intubation after early extubation in the operating room, and longer operation time was significantly associated with re-intubation (P < 0.001).Extubation in the operating room after congenital open-heart surgery was feasible based on our criteria, especially for patients in the low RACHS-1 categories, and involves a very low rate of re-intubation.

Dexmedetomidine preserves the endothelial glycocalyx and improves survival in a rat heatstroke model.

PURPOSE: Heatstroke causes systemic inflammation, followed by vascular endothelial damage. The normal vascular endothelium is coated by endothelial glycocalyx (EGCX). Dexmedetomidine (DEX) has an anti-inflammatory effect, but there has been little investigation on the influence of heatstroke on EGCX and the effect of DEX on this condition. Therefore, we examined whether EGCX was disrupted in heatstroke and if DEX improved survival and preserves EGCX. METHODS: Anesthetized Wistar rats were randomly assigned to three groups: a DEX group treated with DEX (5 µg/kg/h) and 0.9% saline infused continuously at 10 ml/kg/h during heat exposure; a NSS group given 0.9% saline during heat exposure; and a SHAM group given 0.9% saline alone without heat exposure. Heatstroke was induced by exposure to an ambient temperature of 40 °C with relative humidity of 60%. The survival rate was assessed up to 2 h after the start of heat exposure. Plasma levels of syndecan-1 and the thickness of EGCX using electron microscopy were measured when the systolic blood pressure fell to less than 80 mmHg. RESULTS: The survival rate after 2 h of heat exposure was significantly higher in the DEX group compared to the NSS group (89% vs. 22%, P = 0.004). Plasma levels of syndecan-1 were 0.6 ± 1.3, 9.7 ± 5.9, and 2.1 ± 3.4 ng/ml in the SHAM, NSS and DEX groups, respectively (P = 0.013). The thickness of EGCX was significantly higher in the DEX group compared with the NSS group (P = 0.001). CONCLUSIONS: EGCX was disrupted in heatstroke, and DEX improved survival and preserved EGCX.

[Omental Flap for the Device Infection of the HeartMate II].

Case 1:An 18-year-old male underwent emergent left extracorporeal ventricular assist device(eVAD) implantation for a cardiogenic shock because of dilated cardiomyopathy (DCM). After listing for heart transplant, he underwent a HeartMate II implantation as bridge-to-bridge(BTB) therapy. The omental flap was simultaneously used to prevent device infection that could have been induced by the infected malgranulation around the cannulas of the eVAD. Eventually, he was discharged and waiting for transplantation. Case 2:A 30-year-old male with DCM underwent emergent eVAD implantation for left ventricular support, centrifugal veno-pulmonary artery extracorporeal membrane oxygenation (ECMO) for right ventricular and respiratory support, and mitral valve replacement. After weaning of ECMO, he was listed for a heart transplant and underwent a HeartMate II implantation as BTB therapy. However, liver dysfunction and malnutrition prolonged wound healing. Despite applying vacuum assist closure device to promote wound healing, part of the driveline and pump housing were exposed. Therefore, radical debridement and omentopexy were performed for infection control. He was discharged after complete wound healing.

Quantum Fluctuations along Symmetry Crossover in a Kondo-Correlated Quantum Dot.

Universal properties of entangled many-body states are controlled by their symmetry and quantum fluctuations. By the magnetic-field tuning of the spin-orbital degeneracy in a Kondo-correlated quantum dot, we have modified quantum fluctuations to directly measure their influence on the many-body properties along the crossover from SU(4) to SU(2) symmetry of the ground state. High-sensitive current noise measurements combined with the nonequilibrium Fermi liquid theory clarify that the Kondo resonance and electron correlations are enhanced as the fluctuations, measured by the Wilson ratio, increase along the symmetry crossover. Our achievement demonstrates that nonlinear noise constitutes a measure of quantum fluctuations that can be used to tackle quantum phase transitions.

Daily transient discontinuation of extracorporeal LVAD to prevent thromboembolism of mechanical aortic valve prosthesis.

Patients with mechanical aortic valves are generally contraindicated for left ventricular assist device (LVAD) insertion because the prosthetic valve often becomes fixed in closed position. A 41-year-old woman with mechanical aortic valve prosthesis experienced sudden chest pain and developed cardiogenic shock. A paracorporeal pulsatile LVAD and a monopivot centrifugal pump as a right VAD (RVAD) were implanted. The mechanical aortic valve was intentionally left in place. Soon after the operation, LVAD support was discontinued daily for few seconds to allow the mechanical aortic valve to open and to avoid thrombus formation. The patient was successfully weaned off RVAD and received anticoagulation therapy with warfarin. On postoperative day 141, she was transferred to a university hospital where a HeartMate II LVAD was implanted, and the aortic valve was successfully replaced with a bioprosthetic valve. The patient is currently awaiting heart transplantation.

Factors associated with a low initial cerebral oxygen saturation value in patients undergoing cardiac surgery.

Regional cerebral oximetry using near-infrared spectroscopy device, an INVOS 5100 C (Medtronic, Minneapolis, MN, USA), during cardiac surgery aims to avoid perioperative neurological impairment, especially during cardiopulmonary bypass. However, it is not uncommon to encounter critically low initial cerebral regional oxygen saturation or a low value unresponsive to intervention. Therefore, it is important to identify factors associated with low saturation value other than true cerebral hypoxia. We investigated the relationship between preoperative regional cerebral oxygen saturation and clinical variables during cardiac surgery. From January 2013 to May 2016, 462 patients underwent elective cardiac surgery. Patient's ≤12 years of age, with acute cerebral infarction, with previous intracranial hemorrhage or neurosurgery, with concomitant aortic surgery, and having off-pump coronary artery bypass surgery were excluded. The remaining 223 patients were monitored by intraoperative regional cerebral oximetry. Univariate analysis found that scalp-cortex distance, cerebrospinal fluid thickness, left ventricular ejection fraction, hemoglobin concentration, estimated glomerular filtration rate, and hemodialysis were significantly correlated with the initial regional oxygen saturation value. Multiple regression analysis revealed that scalp-cortex distance, left ventricular ejection fraction, hemoglobin, and hemodialysis remained as significant variables. A receiver operating characteristic analysis found that for a low initial regional oxygen saturation value of 40%, the thresholds of scalp-cortex distance, left ventricular ejection fraction, and hemoglobin concentration were 17.6 mm, 45.2%, and 7.5 g/dl, respectively. In conclusion, brain atrophy, poor left ventricular function, anemia, and hemodialysis were associated with low initial cerebral regional oxygen saturation values in adult cardiac surgery patients.

[Replacement of a Tracheal Tube by Concomitant Use of an Aintree Intubation Catheter? and a Tube Exchanger].

A tracheal tube can be safely replaced by using a tube exchanger (TE). However, only a thin TE can be used to replace a double-lumen tracheal tube (DLT) with a standard single-lumen tracheal tube (SLT). We successfully replaced a DLT to a SLT by inserting an Aintree Intubation Catheter® (AIC) over a TE in two cases. The AIC (diameter : 19 Fr, overall length : 56 cm) is mainly used for the replacement of various supra- glottic apparatuses using a SLT. In our cases, an AIC with an internal diameter of 4.7 mm was placed over a thin TE with an external diameter of 3.7 mm (11 Fr) to increase the support, and the difference between the SLT with an internal diameter of 7.5 mm and an AIC with an external diameter of 6.3 mm (19 Fr) was decreased, resulting in smooth replacement of the tubes. Even for those cases in which tube replacement might be difficult, acute administration of oxygen could be provided using an AIC with a larger internal lumenthan TE. In conclusion, replacement of a DLT with a SLT i safe and useful through the concomitant use of an AI( and a TE.

What can we learn from noise? - Mesoscopic nonequilibrium statistical physics.

Mesoscopic systems - small electric circuits working in quantum regime - offer us a unique experimental stage to explorer quantum transport in a tunable and precise way. The purpose of this Review is to show how they can contribute to statistical physics. We introduce the significance of fluctuation, or equivalently noise, as noise measurement enables us to address the fundamental aspects of a physical system. The significance of the fluctuation theorem (FT) in statistical physics is noted. We explain what information can be deduced from the current noise measurement in mesoscopic systems. As an important application of the noise measurement to statistical physics, we describe our experimental work on the current and current noise in an electron interferometer, which is the first experimental test of FT in quantum regime. Our attempt will shed new light in the research field of mesoscopic quantum statistical physics.