A rare case report of pseudomyopia after impacted teeth extraction under general anesthesia.

Ophthalmic complications after tooth extraction are rare but discomforting events. This paper reports the rare complications of a 20-year-old male patient who presented with transient blurring of vision after surgical extraction of several teeth under general anesthesia. Additional diagnostic tests were performed to discern the reason for the pseudomyopia. A literature review was carried out by searching for articles published from 1936 to 2019 using the keywords "dental," "ophthalmic," "complication," "blurring of vision," and "accommodation disturbance" in PubMed. Only six patients with detailed ophthalmic symptoms similar to those of our patient have been reported. If blurred vision or a myopic shift in refraction is present, pseudomyopia should be suspected, and cycloplegic refraction is essential for diagnosis. The condition improves spontaneously.

Effects of thermal softening of endotracheal tubes on postoperative sore throat: A randomized double-blinded trial.

BACKGROUND: Postoperative throat complications after intubation are undesirable but frequent outcomes. A randomized, double-blinded study was performed to determine whether thermal softening of endotracheal tubes reduced throat complications after intubation. METHODS: Patients (n = 196) undergoing nasal surgery were randomly allocated into the control group and thermal softening groups. Sore throat and hoarseness were evaluated 1 and 24 hours after extubation. The severity of sore throat was evaluated using the numeric rating scale (NRS). The primary outcome was the incidence of sore throat 1 hour after extubation and sore throat was defined as a painful or scratchy feeling in the throat. The secondary outcomes were the incidence of hoarseness 1 hour after extubation, the incidence of sore throat and hoarseness 24 hours after extubation, severity of sore throat, and vocal cord injuries. RESULTS: The incidence of sore throat 1 hour after extubation was lower in the thermal softening group than in the control group (35.1% vs 52.7%, P = .02). Moreover, thermal softening decreased the mean NRS score for sore throat in the thermal softening group by 10% an hour after extubation (thermal softening group, 1.29 [95% CI, 0.88-1.70] vs control group, 2.33 [95% CI, 1.77-2.89]; P < .01). At 24 hours after extubation, the incidence of sore throat (38.3% vs 40.7%, P = .77) and hoarseness (34.0% vs 35.2%, 0.95 [0.52-1.74], P = .74) were comparable between the two groups. CONCLUSIONS: Intubation using endotracheal tubes with thermal softening significantly decreased the incidence of sore throat 1 hour after extubation when compared with endotracheal tubes without thermal softening.

Randomized crossover trial comparing cervical spine motion during tracheal intubation with a Macintosh laryngoscope versus a C-MAC D-blade videolaryngoscope in a simulated immobilized cervical spine.

BACKGROUND: Maintaining cervical immobilization is essential during tracheal intubation in patients with unstable cervical spines. When using the Macintosh laryngoscope for intubation in patients with cervical immobilization, substantial neck extension is required for visualization of the glottis. However, the C-MAC D-Blade videolaryngoscope may require less neck extension due to its acute angulation. We hypothesized that C-MAC D-Blade videolaryngoscopic intubation would result in less cervical spine movement than Macintosh laryngoscopic intubation. We compared the effects of C-MAC D-Blade videolaryngoscopic intubation and Macintosh laryngoscopic intubation in terms of cervical spine motion during intubation in patients with simulated cervical immobilization. METHODS: In this randomized crossover study, the cervical spine angle was measured at the occiput-C1, C1-C2, and C2-C5 segments before and during tracheal intubation with either a C-MAC D-Blade videolaryngoscope or Macintosh laryngoscope in 20 patients, with application of a neck collar for simulated cervical immobilization. Cervical spine motion was defined as the change in angle measured before and during tracheal intubation. RESULTS: The cervical spine motion at the occiput-C1 segment was measured at 12.1 ± 4.2° and 6.8 ± 5.0° during Macintosh laryngoscopic and C-MAC D-blade videolaryngoscopic intubation, respectively, corresponding to a 44% reduction in cervical spine motion when using the latter device (mean difference, - 5.3; 98.33% CI: - 8.8 to - 1.8; p = 0.001). However, there was no significant difference between the two intubation devices at the C1-C2 segment (- 0.6; 98.33% CI: - 3.4 to 2.2; p = 0.639) or C2-C5 segment (0.2; 98.33% CI: - 6.0 to 6.4; p = 0.929). CONCLUSIONS: The C-MAC D-Blade videolaryngoscope causes less upper cervical spine motion than the Macintosh laryngoscope during tracheal intubation of patients with simulated cervical immobilization. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov on June 26, 2018 ( NCT03567902 ).

Lower intra-abdominal pressure has no cardiopulmonary benefits during laparoscopic colorectal surgery: a double-blind, randomized controlled trial.

BACKGROUND: Higher intra-abdominal pressure may impair cardiopulmonary functions during laparoscopic surgery. While 12-15 mmHg is generally recommended as a standard pressure, the benefits of lower intra-abdominal pressure are unclear. We thus studied whether the low intra-abdominal pressure compared with the standard pressure improves cardiopulmonary dynamics during laparoscopic surgery. METHODS: Patients were randomized according to the intra-abdominal pressure and neuromuscular blocking levels during laparoscopic colorectal surgery: low pressure (8 mmHg) with deep-block (post-tetanic count 1-2), standard pressure (12 mmHg) with deep-block, and standard pressure with moderate-block (train-of-four count 1-2) groups. During the laparoscopic procedure, we recorded cardiopulmonary variables including cardiac index, pulmonary compliance, and surgical conditions. We also assessed postoperative pain intensity and recovery time of bowel movement. The primary outcome was the cardiac index 30 min after onset of laparoscopy. RESULTS: Patients were included in the low pressure with deep-block (n = 44), standard pressure with deep-block (n = 44), and standard pressure with moderate-block (n = 43) groups. The mean (SD) of cardiac index 30 min after laparoscopy was 2.7 (0.7), 2.7 (0.9), and 2.6 (1.0) L min-1 m-2 in each group (P = 0.715). The pulmonary compliance was higher but the surgical condition was poorer in the low intra-abdominal pressure than the standard pressure (both P < 0.001). Other variables were comparable between groups. CONCLUSION: We observed few cardiopulmonary benefits but poor surgical conditions in the low intra-abdominal pressure during laparoscopy. Considering cardiopulmonary dynamics and surgical conditions, the standard intra-abdominal pressure may be preferable to the low pressure for laparoscopic surgery.

Computed Tomographic Window Setting for Bronchial Measurement to Guide Double-Lumen Tube Size.

OBJECTIVES: The bronchial diameter measured on computed tomography (CT) can be used to guide double-lumen tube (DLT) sizes objectively. The bronchus is known to be measured most accurately in the so-called bronchial CT window. The authors investigated whether using the bronchial window results in the selection of more appropriately sized DLTs than using the other windows. DESIGN: CT image analysis and prospective randomized study. SETTING: Tertiary hospital. PARTICIPANTS: Adults receiving left-sided DLTs. INTERVENTIONS: The authors simulated selection of DLT sizes based on the left bronchial diameters measured in the lung (width 1,500 Hounsfield unit [HU] and level -700 HU), bronchial (1,000 HU and -450 HU), and mediastinal (400 HU and 25 HU) CT windows. Furthermore, patients were randomly assigned to undergo imaging with either the bronchial or mediastinal window to guide DLT sizes. Using the underwater seal technique, the authors assessed whether the DLT was appropriately sized, undersized, or oversized for the patient. MAIN MEASUREMENTS AND RESULTS: On 130 CT images, the bronchial diameter (9.9 ± 1.2 mm v 10.5 ± 1.3 mm v 11.7 ± 1.3 mm) and the selected DLT size were different in the lung, bronchial, and mediastinal windows, respectively (p < 0.001). In 13 patients (17%), the bronchial diameter measured in the lung window suggested too small DLTs (28 Fr) for adults. In the prospective study, oversized tubes were chosen less frequently in the bronchial window than in the mediastinal window (6/110 v 23/111; risk ratio 0.38; 95% CI 0.19-0.79; p = 0.003). No tubes were undersized after measurements in these two windows. CONCLUSIONS: The bronchial measurement in the bronchial window guided more appropriately sized DLTs compared with the lung or mediastinal windows.

Effect-site concentration of remifentanil required to blunt haemodynamic responses during tracheal intubation: A randomized comparison between single- and double-lumen tubes.

Objective To investigate the effect-site concentration of remifentanil required to blunt haemodynamic responses during tracheal intubation with a single-lumen tube (SLT) or a double-lumen tube (DLT). Methods Patients scheduled for thoracic surgery requiring one-lung ventilation were randomly allocated to either the SLT or DLT group. All patients received a target-controlled infusion of propofol and a predetermined concentration of remifentanil. Haemodynamic parameters during intubation were recorded. The effect-site concentration of remifentanil was determined using a delayed up-and-down sequential allocation method. Results A total of 92 patients were enrolled in the study. The effective effect-site concentrations of remifentanil required to blunt haemodynamic responses in 50% of patients (EC50) estimated by isotonic regression with bootstrapping was higher in the DLT than the SLT group (8.5 ng/ml [95% confidence interval (CI) 8.0-9.5 ng/ml] versus 6.5 ng/ml [95% CI 5.6-6.7 ng/ml], respectively). Similarly, the effective effect-site concentrations of remifentanil in 95% of patients in the DLT group was higher than the SLT group (9.9 ng/ml [95% CI 9.8-10.0 ng/ml] versus 7.0 ng/ml [95% CI 6.9-7.0 ng/ml], respectively). Conclusions This study demonstrated that a DLT requires a 30% higher EC50 of remifentanil than does an SLT to blunt haemodynamic responses during tracheal intubation when combined with a target-controlled infusion of propofol. Trial registration Clinicaltrials.gov identifier: NCT01542099.

Validation of the APACHE IV model and its comparison with the APACHE II, SAPS 3, and Korean SAPS 3 models for the prediction of hospital mortality in a Korean surgical intensive care unit.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) IV model has not yet been validated in Korea. The aim of this study was to compare the ability of the APACHE IV with those of APACHE II, Simplified Acute Physiology Score (SAPS) 3, and Korean SAPS 3 in predicting hospital mortality in a surgical intensive care unit (SICU) population. METHODS: We retrospectively reviewed electronic medical records for patients admitted to the SICU from March 2011 to February 2012 in a university hospital. Measurements of discrimination and calibration were performed using the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test, respectively. We calculated the standardized mortality ratio (SMR, actual mortality predicted mortality) for the four models. RESULTS: The study included 1,314 patients. The hospital mortality rate was 3.3%. The discriminative powers of all models were similar and very reliable. The AUCs were 0.80 for APACHE IV, 0.85 for APACHE II, 0.86 for SAPS 3, and 0.86 for Korean SAPS 3. Hosmer and Lemeshow C and H statistics showed poor calibration for all of the models (P < 0.05). The SMRs of APACHE IV, APACHE II, SAPS 3, and Korean SAPS 3 were 0.21, 0.11 0.23, 0.34, and 0.25, respectively. CONCLUSIONS: The APACHE IV revealed good discrimination but poor calibration. The overall discrimination and calibration of APACHE IV were similar to those of APACHE II, SAPS 3, and Korean SAPS 3 in this study. A high level of customization is required to improve calibration in this study setting.

Dexmedetomidine increases the activity of excitatory amino acid transporter type 3 expressed in Xenopus oocytes: the involvement of protein kinase C and phosphatidylinositol 3-kinase.

Dexmedetomidine, an α2 adrenergic agonist, has neuroprotective and anticonvulsant properties in addition to its sedative and anxiolytic effects. We hypothesized that dexmedetomidine would increase the activity of excitatory amino acid transporter type 3 (EAAT3) and that this effect would involve protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K), two protein kinases known to regulate EAAT3 activity. EAAT3 was expressed in Xenopus oocytes by injecting its mRNA. Two-electrode voltage clamping was used to record membrane currents before, during, and after application of 30 µM l-glutamate in the presence of 0.1-30 nM dexmedetomidine. Dexmedetomidine-treated oocytes were also exposed to a PKC activator (phorbol-12-myristate-13-acetate [PMA]), PKC inhibitors (chelerythrine, staurosporine, and calphostin C), and PI3K inhibitors (wortmannin and LY294002) before current measurement. Dexmedetomidine application resulted in a concentration-dependent increase in the EAAT3 activity in response to l-glutamate. The kinetic study showed that dexmedetomidine significantly increased the Vmax without changing Km. Treatment of oocytes with PMA significantly increased transporter currents compared with controls, but treatment with dexmedetomidine plus PMA did not further increase the response compared with PMA or dexmedetomidine alone. In addition, pre-treatment of oocytes with PKC inhibitors and PI3K inhibitors significantly abolished the dexmedetomidine-enhanced EAAT3 activity. These results suggest that dexmedetomidine increases the activity of EAAT3 expressed in Xenopus oocytes. PKC and PI3K seem to mediate this effect. These findings may explain the neuroprotective and anticonvulsant effects of dexmedetomidine.

Effective artificial proteases synthesized by covering silica gel with aldehyde and various other organic groups.

Organic artificial proteases with broad substrate specificity were synthesized by covering the surface of silica gel with aldehyde and the functional groups present in amino acids. The artificial proteases hydrolyzed ovalbumin, albumin, hemoglobin, gamma-globulin with half-lives as short as 50 min at 25 degrees C or 7 min at 50 degrees C.

Analogues of aspartic proteases synthesized by densely covering silica gel with carboxyl groups.

Aspartic protease analogues synthesized by covering the surface of silica gel with carboxyl groups effectively hydrolyzed hemoglobin and gamma-globulin. It is proposed that the carboxyl group is involved in both complexation of the protein substrate and the catalytic cleavage of the peptide bonds of the complexed proteins.

Silica-based artificial protease exploiting aldehyde groups as catalytic elements.

An artificial protease synthesized by covering the surface of silica gel with aldehyde and indole groups effectively hydrolyzed albumin and gamma-globulin. It is proposed that the aldehyde group is involved in both complexation of the protein substrate and the catalytic cleavage of the peptide bonds of the complexed proteins.