Successful intraoperative management of laparoscopic hysterectomy in a patient with Eisenmenger syndrome: a case report.

BACKGROUND: Patients with Eisenmenger syndrome (ES) requiring noncardiac surgery are at a significantly high risk of perioperative morbidity and mortality. However, perioperative management of patients with ES requiring laparoscopic surgery remains unclear. CASE PRESENTATION: We describe the case of a patient with ES who underwent laparoscopic hysterectomy under general anesthesia with a peripheral nerve block. The objectives of the perioperative management included the following: (1) maintaining systemic vascular resistance and cardiac output through euvolemia, facilitated by the infusion of noradrenaline, and (2) preventing a reduction in oxygen-carrying capacity and factors that elevate pulmonary vascular resistance, such as pain, hypoxia, and decreased body temperature. Although laparoscopic procedures involved an increased risk in patients with ES, they are less invasive than open surgeries. CONCLUSION: This report describes the successful anesthetic management of a patient with ES, ensuring a balance between systemic and pulmonary vascular resistance.

Reply to Su et al. Comment on "Matsumoto et al. Remimazolam's Effects on Postoperative Nausea and Vomiting Are Similar to Those of Propofol after Laparoscopic Gynecological Surgery: A Randomized Controlled Trial. J. Clin. Med. 2023, 12, 5402".

We thank the authors for their insightful and thoughtful commentary on our recent publication [...].

Two-Color Spatially Resolved Tuning of Polymer-Coated Metasurfaces.

For the realization of truly reconfigurable metasurface technologies, dynamic spatial tuning of the metasurface resonance is required. Here we report the use of organic photoswitches as a means for the light-induced spatial tuning of metasurface resonances. Coating of a dielectric metasurface, hosting high-quality-factor resonances, with a spiropyran (SPA)-containing polymer enabled dynamic resonance tuning up to 4 times the resonance full-width at half-maximum with arbitrary spatial precision. A major benefit of employing photoswitches is the broad toolbox of chromophores available and the unique optical properties of each. In particular, SPA and azobenzene (AZO) photoswitches can both be switched with UV light but exhibit opposite refractive index changes. When applied to the metasurface, SPA induced a red shift in the metasurface resonance with a figure of merit of 97 RIU-1, while AZO caused a blue shift in the resonance with an even greater sensitivity of 100 RIU-1. Critically, SPA and AZO can be individually recovered with red and blue light, respectively. To exploit this advantage, we coated a dielectric metasurface with spatially offset SPA- and AZO-containing polymers to demonstrate wavelength-dependent, spatially resolved control over the metasurface resonance tuning.

Climate Change Policies and Older Adults: An Analysis of States' Climate Adaptation Plans.

BACKGROUND AND OBJECTIVES: As climate change drives more frequent and intense weather events, older adults face disproportionate impacts, including having the highest mortality rates from storms, wildfires, flooding, and heat waves. State governments are critical in deploying local resources to help address climate change impacts. This policy study analyzes states' climate adaptation plans to assess the methods through which they address the impact of climate change on older adults. RESEARCH DESIGN AND METHODS: This study uses content analysis to analyze available climate change adaptation plans for all U.S. states for strategies designed to increase the resilience of older adults to the impacts of climate change. RESULTS: A total of 19 states have climate adaptation plans, of which 18 describe older adults as a population group with specific health impacts and risk factors. There are 4 categories of adaptation strategies for older adults that includes communications, transportation, housing, and emergency services. State plans vary in terms of the risk factors and adaptation strategies included. DISCUSSION AND IMPLICATIONS: To varying degrees, states' climate change adaptation planning addresses health, social, and economic risks specific to older adults, as well as strategies for mitigating those risks. As global warming continues, collaborations between public and private sectors and across regions will be needed to prevent negative outcomes such as forced relocation and other social and economic disruptions as well as disparate morbidity and mortality.

Extreme Heat Vulnerability Among Older Adults: A Multilevel Risk Index for Portland, Oregon.

BACKGROUND AND OBJECTIVES: Extreme heat is an environmental health equity concern disproportionately affecting low-income older adults and people of color. Exposure factors, such as living in rental housing and lack of air conditioning, and sensitivity factors, such as chronic disease and social isolation, increase mortality risk among older adults. Older persons face multiple barriers to adaptive heat mitigation, particularly those living in historically temperate climates. This study measures two heat vulnerability indices to identify areas and individuals most vulnerable to extreme heat and discusses opportunities to mitigate vulnerability among older adults. RESEARCH DESIGN AND METHODS: We constructed two heat vulnerability indices for the Portland, OR, metropolitan area: one using area scale proxy measures extracted from existing regional data and another at the individual scale using survey data collected following the 2021 Pacific Northwest Heat Dome event. These indices were analyzed using principal component analysis and Geographic Information Systems. RESULTS: Results indicate that the spatial distribution of areas and individuals vulnerable to extreme heat are quite different. The only area found among the most vulnerable on both indices has the largest agglomeration of age- and income-restricted rental housing in the metropolitan area. DISCUSSION AND IMPLICATIONS: Due to spatial variations in heat-related risk at the individual and area scales, measures addressing heat risk should not be spatially uniform. By focusing resources on older adult individuals and areas in particular need of assistance, heat risk management policies can be both highly efficient and cost effective.

Color Routing of the Emission from Magnetic and Electric Dipole Transitions of Eu3+ by Broken-Symmetry TiO2 Metasurfaces.

Manipulation of magnetic dipole emission with resonant photonic nanostructures is of great interest for both fundamental research and applications. However, obtaining selective control over the emission properties of magnetic dipole transitions is challenging, as they usually occur within a manifold of spectrally close emission lines associated with different spin states of the involved electronic levels. Here we demonstrate spectrally selective directional tailoring of magnetic dipole emission using designed photonic nanostructures featuring a high quality factor. Specifically, we employ a hybrid nanoscale optical system consisting of a Eu3+ compound coupled to a designed broken-symmetry TiO2 metasurface to demonstrate directional color routing of the compound's emission through its distinct electric and magnetic-dominated electronic transition channels. Using low numerical aperture collection optics, we achieve a fluorescence signal enhancement of up to 33.13 for the magnetic-dominated dipole transition at 590 nm when it spectrally overlaps with a spectrally narrow resonance of the metasurface. This makes the, usually weak, magnetic dipole transition the most intense spectral line in our recorded fluorescence spectra. By studying the directional emission properties for the coupled system using Fourier imaging and time-resolved fluorescence measurements, we demonstrate that the high-quality-factor modes in the metasurface enable free-space light routing, where forward-directed emission is established for the magnetic-dominated dipole transition, whereas the light emitted via the electric dipole transition is mainly directed sideways. Our results underpin the importance of magnetic light-matter interactions as an additional degree of freedom in photonic and optoelectronic systems. Moreover, they facilitate the development of spectrometer-free and highly integrated nanophotonic imaging, sensing, and probing devices.

Ketamine as an Alternative Anesthetic for Augmenting Seizure Durations During Electroconvulsive Therapy: A Retrospective Observational Study.

OBJECTIVE: Electroconvulsive therapy (ECT) is highly effective for severe psychiatric disorders; however, short seizure durations may lead to ineffective therapy. This retrospective study aimed to examine the risks and benefits of switching to ketamine anesthesia to augment seizure durations during an acute course of ECT. METHODS: We included 33 patients who underwent ketamine anesthesia due to suboptimal seizures during an acute course of ECT. We assessed seizure duration, stimulus dose, hemodynamic variability, and postseizure complications before and after switching to ketamine. RESULTS: Age was significantly associated with suboptimal seizures during ECT (P = 0.040). After switching to ketamine, 32 patients (97%) experienced prolonged seizure duration. Ketamine significantly prolonged both electroencephalogram and motor seizure durations with a mean difference of 34.6 seconds (95% confidence interval [CI], 26.4-42.7 seconds; P < 0.001) and 26.6 seconds (95% CI, 19.6-33.6 seconds; P < 0.001), respectively. It also significantly reduced stimulus dose (mean difference, -209.5 mC [95% CI, -244.9 to -174.1 mC]; P < 0.001). In addition, maximum changes in systolic blood pressure and heart rate during ECT sessions significantly increased with ketamine (mean difference, 27.2 mm Hg [95% CI, 12.0-42.4 mm Hg; P = 0.001]; 25.7 beats per minute [95% CI, 14.5-36.8 beats per minute; P < 0.001], respectively). Patients reported more headaches with ketamine (P = 0.041). CONCLUSIONS: Our results provide evidence that ketamine as an alternative anesthetic can augment seizure durations in specific patients experiencing suboptimal seizures during an acute course of ECT. However, its use requires greater attention to circulatory management and postseizure complications.

Wider Dissemination of Simplified Chest Compression-Only Cardiopulmonary Resuscitation Training Combined With Conventional Cardiopulmonary Resuscitation Training and 10-Year Trends in Cardiopulmonary Resuscitation Performed by Bystanders in a City.

BACKGROUND: Little is known about how to effectively increase bystander cardiopulmonary resuscitation (CPR), so we evaluated the 10-year trend of the proportion of bystander CPR in an area with wide dissemination of chest compression-only CPR (CCCPR) training combined with conventional CPR training.Methods and Results: We conducted a descriptive study after a community intervention, using a prospective cohort from September 2010 to December 2019. The intervention consisted of disseminating CCCPR training combined with conventional CPR training in Toyonaka City since 2010. We analyzed all non-traumatic out-of-hospital cardiac arrest (OHCA) patients resuscitated by emergency medical service personnel. The primary outcome was the trend of the proportion of bystander CPR. We conducted multivariate logistic regression models and assessed the adjusted odds ratio (AOR) using a 95% confidence interval (CI) to determine bystander CPR trends. Since 2010, we have trained 168,053 inhabitants (41.9% of the total population of Toyonaka City). A total of 1,508 OHCA patients were included in the analysis. The proportion of bystander CPR did not change from 2010 (43.3%) to 2019 (40.0%; 1-year incremental AOR 1.02 [95% CI: 0.98-1.05]). CONCLUSIONS: The proportion of bystander CPR did not increase even after wider dissemination of CPR training. In addition to continuing wider dissemination of CPR training, other strategies such as the use of technology are necessary to increase bystander CPR.

Remimazolam's Effects on Postoperative Nausea and Vomiting Are Similar to Those of Propofol after Laparoscopic Gynecological Surgery: A Randomized Controlled Trial.

(1) Background: Remimazolam is a novel benzodiazepine that prevents postoperative nausea and vomiting (PONV), is more effective than volatile anesthetics, and was recently approved for use in Japan. (2) Methods: This prospective, double-blind, randomized controlled trial study aimed to compare the efficacy of remimazolam and propofol as general anesthetics in terms of the incidence of PONV after laparoscopic gynecological surgery (UMIN000046237). High-risk female patients who underwent general anesthesia with either remimazolam or propofol for the maintenance of anesthesia were enrolled. The primary outcome was the incidence of PONV in the two groups (i.e., REM versus PROP) 2 h and 24 h after surgery. The incidence of vomiting without nausea, rescue antiemetic use, and the severity of nausea were also evaluated. (3) Results: No significant differences in PONV were identified between the REM and PROP groups at 2 h or 24 h. Furthermore, no differences were observed in any of the measured parameters, and no adverse events were reported. (4) Conclusions: The results of the present study suggest that remimazolam may be as effective as propofol in preventing PONV; however, further investigation is necessary to identify possible differences between these two agents.

Hemodynamic impact of ephedrine on hypotension during general anesthesia: a prospective cohort study on middle-aged and older patients.

BACKGROUND: Ephedrine is a mixed α- and ß-agonist vasopressor that is frequently used for the correction of hypotension during general anesthesia. ß-responsiveness has been shown to decrease with age; therefore, this study aimed to determine whether aging would reduce the pressor effect of ephedrine on hypotension during general anesthesia. METHODS: Seventy-five patients aged ≥ 45 years were included in this study, with 25 patients allocated to each of the three age groups: 45-64 years, 65-74 years, and ≥ 75 years. All patients received propofol, remifentanil, and rocuronium for the induction of general anesthesia, followed by desflurane and remifentanil. Cardiac output (CO) was estimated using esCCO technology. Ephedrine (0.1 mg/kg) was administered for the correction of hypotension. The primary and secondary outcome measures were changes in the mean arterial pressure (MAP) and CO, respectively, at 5 min after the administration of ephedrine.  RESULTS: The administration of ephedrine significantly increased MAP (p < 0.001, mean difference: 8.34 [95% confidence interval (CI), 5.95-10.75] mmHg) and CO (p < 0.001, mean difference: 7.43 [95% CI, 5.20-9.65] %) across all groups. However, analysis of variance revealed that the degree of elevation of MAP (F [2, 72] = 0.546, p = 0.581, η2 = 0.015 [95% CI, 0.000-0.089]) and CO (F [2, 72] = 2.023, p = 0.140, η2 = 0.053 [95% CI, 0.000-0.162]) did not differ significantly among the groups. Similarly, Spearman's rank correlation and multiple regression analysis revealed no significant relation between age and the changes in MAP or CO after the administration of ephedrine. CONCLUSION: The administration of ephedrine significantly increased MAP and CO; however, no significant correlation with age was observed in patients aged > 45 years. These findings suggest that ephedrine is effective for the correction of hypotension during general anesthesia, even in elderly patients. TRIAL REGISTRATION: UMIN-CTR (UMIN000045038; 02/08/2021).

Effect of 10-minute prewarming plus intraoperative co-warming on core temperature maintenance during breast surgery compared to intraoperative co-warming alone: a randomized controlled trial.

PURPOSE: We evaluated the effect of 10-min prewarming on core temperature maintenance during general anesthesia. PATIENTS: We randomized 40 women scheduled for breast cancer surgery into 10-min Prewarming and Control groups. In the Prewarming group, a forced-air warming system was used to warm the patients at 43℃ for 10 min immediately before general anesthesia induction. In the Control group, the patients were kept warm using cotton thermal blankets for 10 min. We measured tympanic temperature every 15 min from anesthesia induction for 90 min. FINDINGS: Since two patients deviated from the protocol, we used the data of 38 patients (Prewarming [n?=?18] and Control [n?=?20]). There was a significant between-group difference in changes in core temperature (P?=?0.03), including a significant difference in core temperature decrease during the first 60 min from anesthesia induction (Prewarming : -0.3 [0.3] ℃ vs. Control : -0.6 [0.2] ℃, P=0.02). In addition, the duration of normal core temperature maintenance was significantly longer in the Prewarming group (66 [34] min vs. 39 [32] min, P?=?0.01). CONCLUSIONS: Ten-min prewarming decreases core temperature loss and contribute to maintaining normal core temperature during breast surgery. J. Med. Invest. 70 : 74-79, February, 2023.

The Impact of International Conservation Agreements on Protected Areas: Empirical Findings from the Convention on Biological Diversity Using Causal Inference.

Although 30 years have passed since the Convention on Biological Diversity (CBD) was adopted in 1992, few attempts have been made to evaluate its impact on protected areas. This study investigates the relationship between participation in the CBD and conservation effort in member countries, using an original dataset of 169 countries from 1992 to 2015. Our measure of conservation effort is the percentage of a country's terrestrial area under protection, which is the primary mechanism for achieving the CBD's conservation as distinct from its sustainable use or access and benefit-sharing objectives. We consider how protected area expansion relates to membership of the CBD, and a set of socio-economic and political variables that measure both the opportunity cost of conservation and national responsiveness to the demand for public goods. We find a positive and significant relationship between the area under protection, membership of the CBD, and a dummy for the Aichi biodiversity targets-Nagoya protocol. We also find that the area under protection is negatively related to measures of economic development and education (proxies for the opportunity cost of conservation), and positively associated with forest area (a proxy for species richness and endemism). We conclude that, at least for this measure of conservation effort, the CBD has had a significant impact, albeit moderated in predictable ways by the opportunity cost of conservation.

The Safety and Strategies for Reinitiating Electroconvulsive Therapy After ECT-Induced Takotsubo Cardiomyopathy: A Case Report and Systematic Review.

OBJECTIVES: Takotsubo cardiomyopathy (TCM) is a life-threatening complication of electroconvulsive therapy (ECT). We report the case of a 66-year-old woman who was rechallenged with ECT after ECT-induced TCM. Moreover, we have made a systematic review to assess the safety of and strategies for reinitiating ECT after TCM. METHODS: We searched for published reports on ECT-induced TCM since 1990 in MEDLINE (PubMed), Scopus, Cochrane Library, ICHUSHI, and CiNii Research. RESULTS: A total of 24 ECT-induced TCM cases were identified. Patients who developed ECT-induced TCM were predominantly middle-aged and older women. There was no specific trend in anesthetic agents used. Seventeen (70.8%) cases developed TCM by the third session in the acute ECT course. Eight (33.3%) cases developed ECT-induced TCM despite the use of ß-blockers. Ten (41.7%) cases developed cardiogenic shock or abnormal vital signs related to cardiogenic shock. All cases recovered from TCM. Eight (33.3%) cases tried to receive ECT retrial. The duration until ECT retrial was between 3 weeks and 9 months. The most common preventive measures during ECT retrial were related to ß-blockers; however, the type, dose, and route of administration of ß-blockers varied. In all cases, ECT could be reperformed without TCM recurrence. CONCLUSIONS: Electroconvulsive therapy-induced TCM is more likely to cause cardiogenic shock than nonperioperative cases; nevertheless, it has good prognosis. Cautious reinitiation of ECT after TCM recovery is possible. Further studies are required to determine preventive measures for ECT-induced TCM.

Comparison of hemodynamics during induction of general anesthesia with remimazolam and target-controlled propofol in middle-aged and elderly patients: a single-center, randomized, controlled trial.

BACKGROUND: Remimazolam confers a lower risk of hypotension than propofol. However, no studies have compared the efficacy of remimazolam and propofol administered using target-controlled infusion (TCI). This study aimed to investigate hemodynamic effects of remimazolam and target-controlled propofol in middle-aged and elderly patients during the induction of anesthesia. METHODS: Forty adults aged 45-80 years with the American Society of Anesthesiologists Physical Status 1-2 were randomly assigned to remimazolam or propofol group (n = 20 each). Patients received either remimazolam (12 mg/kg/h) or propofol (3 µg/mL, TCI), along with remifentanil for inducing anesthesia. We recorded the blood pressure, heart rate (HR), and estimated continuous cardiac output (esCCO) using the pulse wave transit time. The primary outcome was the maximum change in mean arterial pressure (MAP) after induction. Secondary outcomes included changes in HR, cardiac output (CO), and stroke volume (SV). RESULTS: MAP decreased after induction of anesthesia in both groups, without significant differences between the groups (- 41.1 [16.4] mmHg and - 42.8 [10.8] mmHg in remimazolam and propofol groups, respectively; mean difference: 1.7 [95% confidence interval: - 8.2 to 4.9]; p = 0.613). Furthermore, HR, CO, and SV decreased after induction in both groups, without significant differences between the groups. Remimazolam group had significantly shorter time until loss of consciousness than propofol group (1.7 [0.7] min and 3.5 [1.7] min, respectively; p < 0.001). However, MAP, HR, CO, and SV were not significantly different between the groups despite adjusting time until loss of consciousness as a covariate. Seven (35%) and 11 (55%) patients in the remimazolam and propofol groups, respectively, experienced hypotension (MAP < 65 mmHg over 2.5 min), without significant differences between the groups (p = 0.341). CONCLUSIONS: Hemodynamics were not significantly different between remimazolam and target-controlled propofol groups during induction of anesthesia. Thus, not only the choice but also the dose and usage of anesthetics are important for hemodynamic stability while inducing anesthesia. Clinicians should monitor hypotension while inducing anesthesia with remimazolam as well as propofol. TRIAL REGISTRATION: UMIN-CTR (UMIN000045612).

Authorship by gender in anesthesiology journals: a retrospective cross-sectional study for Japan.

PURPOSE: Although it is important to recognize gender disparities in publishing to achieve gender diversity, women's authorship in Japan remains unclear. Therefore, this study aimed to investigate the percentage and analyze the trends of articles authored and published in anesthesiology journals by Japanese female authors. METHODS: The genders of the first and last authors affiliated with Japanese institutions were surveyed in the Journal of Anesthesia (JA) (1990, 1995, and 2000-2022) and 11 international anesthesiology journals (2010-2022). RESULTS: We included 845 and 819 original research articles from JA in the analyses of the first and last authors, respectively. The proportion of female first authors significantly increased from 41 (11.7%) out of 351 before 2009 to 119 (24.1%) out of 494 after 2010 (p < 0.001). The proportion of female last authors was 11 (3.3%) out of 335 before 2009 and 22 (4.5%) out of 484 after 2010, respectively, with no significant difference (p = 0.470). We included 624 and 572 original research articles from international anesthesiology journals in the analyses of first and last authors, respectively. Among these, there were 134 (21.5%) and 23 (4.0%) female first and last authors, respectively. These proportions in international anesthesiology journals did not significantly differ from those in JA (p = 0.334, p = 0.789, respectively). CONCLUSION: The percentage of female first authors has increased, commensurate with the percentage of female anesthesiologists. However, the percentage of female last authors has not increased and remains low in Japan.

The association between initial calculated driving pressure at the induction of general anesthesia and composite postoperative oxygen support.

PURPOSE: Early discontinuation of postoperative oxygen support (POS) would partially depend on the innate pulmonary physics. We aimed to examine if the initial driving pressure (dP) at the induction of general anesthesia (GA) predicted POS prolongation. METHODS: We conducted a single-center retrospective study using the facility's database. Consecutive subjects over 2 years were studied to determine the change in odds ratio (OR) for POS prolongation of different dP classes at GA induction. The dP (cmH2O) was calculated as the ratio of tidal volume (mL) over dynamic Crs (mL/cmH2O) regardless of the respiratory mode. The adjusted OR was calculated using the logistic regression model of multivariate analysis. Moreover, we performed a secondary subgroup analysis of age and the duration of GA. RESULTS: We included 5,607 miscellaneous subjects. Old age, high scores of American Society of Anesthesiologist physical status, initial dP, and long GA duration were associated with prolonged POS. The dP at the induction of GA (7.78 [6.48, 9.45] in median [interquartile range]) was categorized into five classes. With the dP group of 6.5-8.3 cmH2O as the reference, high dPs of 10.3-13 cmH2O and ≥ 13 cmH2O were associated with significant prolongation of POS (adjusted OR, 1.62 [1.19, 2.20], p = 0.002 and 1.92 [1.20, 3.05], p = 0.006, respectively). The subgroup analysis revealed that the OR for prolonged POS of high dPs disappeared in the aged and ≥ 6 h anesthesia time subgroup. CONCLUSIONS: High initial dPs ≥ 10 cmH2O at GA induction predicted longer POS than those of approximately 7 cmH2O. High initial dPs were, however, a secondary factor for prolongation of postoperative hypoxemia in old age and prolonged surgery.

Transition in eye gaze as a predictor of emergence from general anesthesia in children and adults: a prospective observational study.

BACKGROUND: It is useful to monitor eye movements during general anesthesia, but few studies have examined neurological finding of the eyes during emergence from general anesthesia maintained with short-acting opioids and volatile anesthetics. METHODS: Thirty children aged 1-6 years and 30 adults aged 20-79 years were enrolled. Patients received general anesthesia maintained with sevoflurane and remifentanil. The timing of three physical-behavioral responses-eye-gaze transition (the cycle from conjugate to disconjugate and back to conjugate), resumption of somatic movement (limbs or body), and resumption of respiration-were recorded until spontaneous awakening. The primary outcome measure was the timing of the physical-behavioral responses. Secondary outcome measures were the incidence of eye-gaze transition, and the bispectral index, concentration of end-tidal sevoflurane, and heart rate at the timing of eye-gaze transition. RESULTS: Eye-gaze transition was evident in 29 children (96.7%; 95% confidence interval, 82.8-99.9). After the end of surgery, eye-gaze transition was observed significantly earlier than resumption of somatic movement or respiration (472 [standard deviation 219] s, 723 [235] s, and 754 [232] s, respectively; p < 0.001). In adults, 3 cases (10%; 95% CI, 0.2-26.5) showed eye-gaze transition during emergence from anesthesia. The incidence of eye-gaze transition was significantly lower in adults than in children (p < 0.001). CONCLUSION: In children, eye-gaze transition was observed significantly earlier than other physical-behavioral responses during emergence from general anesthesia and seemed to reflect emergence from anesthesia. In contrast, observation of eye gaze was not a useful indicator of emergence from anesthesia in adults.