Pilot Study of Changes in Presepsin Concentrations Compared With Changes in Procalcitonin and C-Reactive Protein Concentrations After Cardiovascular Surgery.

OBJECTIVE: The authors investigated the presepsin-concentration profile after cardiac surgery compared with those of procalcitonin (PCT) and C-reactive protein (CRP). DESIGN: A single-center, prospective, observational clinical study. SETTING: Hirosaki University Hospital. PARTICIPANTS: Patients who underwent cardiovascular surgery without preoperative infection and end-stage kidney disease requiring dialysis. The patients also were subdivided into 2 groups with respect to the use of cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS: Presepsin, PCT, and CRP were measured 4 times: before the induction of anesthesia (baseline), postoperative day (POD) 0, POD 1, and POD 2. Data are expressed as median (25th, 75th interquartiles). A total of 33 patients were examined: 22 patients with CPB and 11 without CPB. For the entire patient series, the presepsin concentrations on POD 0 (220 [166-445] pg/mL), POD 1 (328 [210-581] pg/mL), and POD 2 (310 [202-368] pg/mL) were increased significantly (p < 0.05) compared with baseline (176 [123-275] pg/mL). The PCT and CRP concentrations on POD 1 (0.57 [0.27-1.29] ng/mL and 5.4 [3.1-8.8] mg/dL) and POD 2 (0.64 [0.33-1.43] ng/mL and 11.8 [4.4-17.0] mg/dL) also were increased significantly (p < 0.05) compared with baseline (0.04 [0.03-0.06] ng/mL and 0.07 [0.03-0.22] mg/dL). However, the median concentrations of presepsin up to POD 2 were less than the reported cut-off value (600 pg/mL) to detect infections, whereas those of PCT were above the reported cut-off value (0.5 ng/mL). The increases in presepsin and PCT concentrations were independent of the use of CPB. CONCLUSIONS: Cardiovascular surgery significantly increased presepsin concentrations, earlier than PCT and CRP.

Near-infrared imaging polarimetry of LkCa 15: A possible warped inner disk.

We present high-contrast H-band polarized intensity images of the transitional disk around the young solar-like star LkCa 15. By utilizing Subaru/HiCIAO for polarimetric differential imaging, the angular resolution and the inner working angle reach 0.07 and r = 0″.1, respectively. We obtained a clearly resolved gap (width ≲ 27 au) at ~48 au from the central star. This gap is consistent with images reported in previous studies. We also confirmed the existence of a bright inner disk with a misaligned position angle of 13° ±4° with respect to that of the outer disk, i.e., the inner disk is possibly warped. The large gap and the warped inner disk both point to the existence of a multiple planetary system with a mass of ≲ 1 M Jup.

The accuracy of non-invasively continuous total hemoglobin measurement by pulse CO-Oximetry undergoing acute normovolemic hemodilution and reinfusion of autologous blood.

BACKGROUND: Non-invasively continuous total hemoglobin (SpHb) measurement has not been assessed adequately in acute bleeding and rapid blood transfusion during surgery. Thus, we have assessed the efficacy of SpHb during both acute normovolemic hemodilution (ANH) and autologous blood transfusion (ABT). METHODS: Twenty-four patients undergoing urological and gynecological surgery were enrolled. ANH was induced by withdrawing blood of 800 g with simultaneous fluid administration. When surgical hemostasis was completed, collected blood was reinfused. Measurement of SpHb, perfusion index (PI) and real total Hb (tHb) were done before and after each 400 ml blood removal (-0, -400, -800 ml) and reinfusion (+0, +400, +800 ml). RESULTS: A Bland-Altman analysis for repeated measurements showed a bias (precision) g/dl of 1.12 (1.25), 1.43 (1.24) and 1.10 (1.23) for all data, during ANH and during ABT, respectively. Additionally, a bias (precision) increased with a reduction in tHb (g/dl): ≥10.0; 0.74 (1.30), 8.0-10.0; 1.15 (1.12) and <8.0; 1.60 (1.28). Although the difference between SpHb and tHb was almost zero before anesthesia induction, it became significant just before ANH and did not change further by ANH and ABT. Significant correlations between SpHb and tHb for all data (r = 0.75, n = 228, p < 0.001) were observed. PI slightly correlated with the difference between SpHb and tHb (r = 0.38, n = 216, p < 0.001). Furthermore, before and after induction of anesthesia, PI also correlated with the difference between SpHb and tHb (r = 0.42, n = 23, p = 0.048 and r = 0.51, n = 22, p = 0.016, respectively). CONCLUSIONS: The present data suggest that SpHb may overestimate tHb during ANH and ABT. In addition, PI and tHb levels had an impact on the accuracy of SpHb measurements.

Impact of robot-assisted laparoscopic prostatectomy on the management of general anesthesia: efficacy of blood withdrawal during a steep Trendelenburg position.

INTRODUCTION: Robot-assisted laparoscopic prostatectomy (RALP) is being increasingly used. However, a steep Trendelenburg position and pneumoperitoneum during RALP has an impact on the respiratory, cardiovascular and cerebrovascular systems. To prevent complications, restrictive fluid management and blood withdrawal have been utilized in our hospital. We examined differences in the anesthetic management between RALP and radical retropubic prostatectomy (RRP), and the efficacy of blood withdrawal. METHODS: Medical records of patients who underwent radical prostatectomy in our hospital between January 2012 and October 2013 were retrospectively reviewed. Demographic data, intraoperative blood and fluid administration, perioperative complications and the length of hospital stay were compared among patients receiving RRP, and those receiving RALP with and without blood withdrawal (n = 78, 46 and 68, respectively). RESULTS: Patients receiving RALP with and without blood withdrawal received a smaller volume of crystalloid during surgery than those receiving RRP (mean ± SD, 5.8 ± 2.3 and 4.2 ± 1.6 vs 14.3 ± 4.1 ml/kg/h, p < 0.001). Median estimated blood loss was 885 g (80-2,800 g) for RRP and 50 g for RALP (3-950 g and 3-550 g, respectively), p < 0.001. None of the patients undergoing RALP received red blood cells, but three patients undergoing RRP did so. RALP with blood withdrawal reduced postoperative hospital stay by 45 % (6 vs 11 days). Four patients receiving RALP without blood withdrawal had delayed extubation due to severe laryngeal edema, which did not occur in any of the patients receiving RALP who had blood withdrawal. Renal function did not differ among the groups. CONCLUSIONS: RALP was associated with less blood loss, no allogeneic transfusion and shorter postoperative hospital stay. This study indicated that blood withdrawal could prevent severe laryngeal edema.

Quantitative measurement of blood remifentanil concentration: development of a new method and clinical application.

We have developed a new detection method of blood remifentanil concentration using a gas chromatography-mass spectrometry(GC-MS) with fentanyl as the internal standard(IS). The detection was performed at m/z 168 and 245 for remifentanil and fentanyl, respectively. In addition, the retention times of remifentanil and fentanyl were 5 min 45 s and 6 min 51 s, respectively. The standard curve of relationship between remifentanil concentration and the ratio of the peak area of remifentanil to fentanyl was satisfactorily fitted as linear regression (R(2) = 0.998, p < 0.01). Intra- and inter-assay CV was 10.5 and 11.5 %, respectively. In the clinical setting, 21 adult patients undergoing elective surgery under propofol-remifentanil TIVA were enrolled. To determine blood remifentanil concentrations, arterial blood was obtained at 0-30 min after cessation of remifentanil infusion at 0.2 µg/kg/min. Blood samples were given into sample tubes(chilled on ice) containing citric acid 50 % 60 µl which inactivates all esterase, and then stored at -20 °C until assay. Measured blood remifentanil concentration was 3.59 ± 0.74 ng/ml at the end of remifentanil infusion, and the ime for a decrease in blood remifentanil concentration by half was ~2 min. Remifentanil concentration was below the detection limit 30 min after the cessation. Thus, we have confirmed that this new method is clinically applicable.

Corrected right ventricular end-diastolic volume and initial distribution volume of glucose correlate with cardiac output after cardiac surgery.

PURPOSE: Appropriate adjustment of cardiac preload is essential to maintain cardiac output (CO), especially in patients after cardiac surgery. This study was intended to determine whether index of right ventricular end-diastolic volume (RVEDVI), corrected RVEDVI using ejection fraction (cRVEDVI), index of initial distribution volume of glucose (IDVGI), or cardiac filling pressures are correlated with cardiac index (CI) following cardiac surgery in the presence or absence of arrhythmias. METHODS: Eighty-six consecutive cardiac surgical patients were studied. Patients were divided into two groups: the non-arrhythmia (NA) group (n = 72) and the arrhythmia (A) group (n = 14). Three sets of measurements were performed: on admission to the ICU and daily on the first 2 postoperative days. The relationship between each cardiac preload variable and cardiac index (CI) was evaluated. A p value less than 0.05 indicated statistically significant differences. RESULTS: Each studied variable was not different between the two groups immediately after admission to the ICU. cRVEDVI had a linear correlation with CI in both group (NA group: r = 0.67, n = 216, p < 0.001; A group: r = 0.77, n = 42, p < 0.001), but RVEDVI had a poor correlation with CI (NA group: r = 0.27, n = 216, p < 0.001; A group: r = 0.19, n = 42, p = 0.036). IDVGI had a linear correlation with CI (NA group: r = 0.49, n = 216, p < 0.001; A group: r = 0.61, n = 42, p < 0.001), Cardiac filling pressures had no correlation with CI. CONCLUSION: Our results demonstrated that cRVEDVI and IDVGI were correlated with CI in the presence or absence of arrhythmias. cRVEDVI and IDVGI have potential as indirect cardiac preload markers following cardiac surgery.

Direct imaging and astrometric detection of a gas giant planet orbiting an accelerating star.

Direct imaging of gas giant exoplanets provides information on their atmospheres and the architectures of planetary systems. However, few planets have been detected in blind surveys with direct imaging. Using astrometry from the Gaia and Hipparcos spacecraft, we identified dynamical evidence for a gas giant planet around the nearby star HIP 99770. We confirmed the detection of this planet with direct imaging using the Subaru Coronagraphic Extreme Adaptive Optics instrument. The planet, HIP 99770 b, orbits 17 astronomical units from its host star, receiving an amount of light similar to that reaching Jupiter. Its dynamical mass is 13.9 to 16.1 Jupiter masses. The planet-to-star mass ratio [(7 to 8) × 10-3] is similar to that of other directly imaged planets. The planet's atmospheric spectrum indicates an older, less cloudy analog of the previously imaged exoplanets around HR 8799.

[Case of fluminant myocarditis with fatal pulmonary edema even after introduction of bi-ventricular assist devices].

A 15-year-old man developed cardiopulmonary dysfunction 4 days after flu-like symptom, and was transfered to our hospital and diagnosed as a fulminant myocarditis (FM). Intraaortic ballon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were immediately initiated. However, cardiac function did not recover until 7 days after admission to the ICU, and bilateral ventricular assist devices (BiVAD) were introduced with extracorporeal membrane oxygenation (ECMO). Right ventricular assist device (RVAD) with ECMO was established by right atrial blood withdrawal and pulmonary arterial blood supply using centrifugal pump. After operation of BiVAD, to main LVAD flow, frequent blood-and-fluids volume loading and increase in RVAD flow were necessary due to postoperative bleeding and massive foamy sputum. However, even after hemostasis had been established, the pulmonary edema continued and it was difficult to maintain LVAD flow because of endless transudation from the lungs. Eventually, he developed MOF and passed away 9 days after the admission to ICU. As in cases of end-stage dilated cardiomyopathy, outflow of RVAD into the left atrium instead of the pulmonary artery was demonstrated effective in avoiding trans-pulmonary leakage, and outflow of RVAD into the left atrium may be beneficial to patients with FM who need BiVAD but suffered severe pulmonary edema.

[Effects of propofol and ketamine on postoperative hepatic and renal function: comparison between fentanyl and remifentanil as an adjuvant].

BACKGROUND: The aim of this study was to assess the effects of two different opioids, fentanyl and remifentanil, as an adjuvant in propofol-ketamine based total intravenous anesthesia (PFK and PRK) on post-anesthetic hepatic and renal function. METHODS: We conducted a review of patients undergoing total or subtotal esophagectomy over a 2-year period, in which pre- and post-anesthesia values of seven hepatic function tests, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, alkaline phosphatase, gamma glutamyl-transpeptidase, total bilirubin, prothrombin time-international normalized ratio, and two renal function tests, blood urea nitrogen, as well as serum creatinine, were evaluated. RESULTS: Total numbers of patients in PFK or PRK were 51 and 18, respectively. In PRK group, duration of surgery was longer than that in PFK group, 537 +/- 155 and 453 +/- 67 (min, mean +/- SD), respectively. More patients in PRK group required blood transfusion compared with PFK group. There was no significant interaction between any hepatic or renal function test and anesthesia. In addition, there was no significant difference of increasing rates in hepatic and renal function tests between PFK and PRK. CONCLUSIONS: The hepatic and renal function after esophagectomy was comparable between PFK and PRK.

Safety and efficacy of plasma exchange therapy for Kawasaki disease in children in intensive care unit: case series.

BACKGROUND: We have reviewed four cases of Kawasaki disease treated with plasma exchange with 5% albumin in electrolyte-balanced solution, according to the recommended guidelines for Kawasaki disease in the intensive care unit, as their responses to intravenous immunoglobulin therapy were poor. CASE PRESENTATION: The four cases were aged between 5 months and 3 years and weighted between 6.4 and 15.6 kg. The plasma levels of C-reactive protein were significantly decreased after plasma exchange (p < 0.05). The dilatations of the coronary artery were found in two cases, but both of them were ameliorated until 1 month after the onset and the other cases recovered without any complications. However, we recognized that one case showed marked decreases in coagulation factors, especially in fibrinogen after each plasma exchange even with a transfusion of fresh frozen plasma. CONCLUSIONS: Plasma exchange with 5% albumin was effective for refractory Kawasaki disease. However, as there was a possibility of coagulation disorder, attention should be given to changes in coagulation factors like fibrinogen, especially in small patients who need frequent plasma exchange.

Circumstellar disks of the most vigorously accreting young stars.

Stars may not accumulate their mass steadily, as was previously thought, but in a series of violent events manifesting themselves as sharp stellar brightening. These events can be caused by fragmentation due to gravitational instabilities in massive gaseous disks surrounding young stars, followed by migration of dense gaseous clumps onto the star. Our high-resolution near-infrared imaging has verified the presence of the key associated features, large-scale arms and arcs surrounding four young stellar objects undergoing luminous outbursts. Our hydrodynamics simulations and radiative transfer models show that these observed structures can indeed be explained by strong gravitational instabilities occurring at the beginning of the disk formation phase. The effect of those tempestuous episodes of disk evolution on star and planet formation remains to be understood.

High-Contrast Imaging of Intermediate-Mass Giants with Long-Term Radial Velocity Trends.

A radial velocity (RV) survey for intermediate-mass giants has been operated for over a decade at Okayama Astrophysical Observatory (OAO). The OAO survey has revealed that some giants show long-term linear RV accelerations (RV trends), indicating the presence of outer companions. Direct imaging observations can help clarify what objects generate these RV trends. We present the results of high-contrast imaging observations of six intermediate-mass giants with long-term RV trends using the Subaru Telescope and HiCIAO camera. We detected co-moving companions to γ Hya B ( 0.61 - 0.14 + 0.12 M ⊙ ) , HD 5608 B (0.10 ± 0.01M ⊙), and HD 109272 B (0.28 ± 0.06M ⊙). For the remaining targets(ι Dra, 18 Del, and HD 14067) we exclude companions more massive than 30-60 M Jup at projected separations of 1''-7''. We examine whether these directly imaged companions or unidentified long-period companions can account for the RV trends observed around the six giants. We find that the Kozai mechanism can explain the high eccentricity of the inner planets ι Dra b, HD 5608 b, and HD 14067 b.

Direct imaging of bridged twin protoplanetary disks in a young multiple star.

Studies of the structure and evolution of protoplanetary disks are important for understanding star and planet formation. Here we present the direct image of an interacting binary protoplanetary system. Both circumprimary and circumsecondary disks are resolved in the near-infrared. There is a bridge of infrared emission connecting the two disks and a long spiral arm extending from the circumprimary disk. Numerical simulations show that the bridge corresponds to gas flow and a shock wave caused by the collision of gas rotating around the primary and secondary stars. Fresh material streams along the spiral arm, consistent with the theoretical scenarios in which gas is replenished from a circummultiple reservoir.