Effects of early tooth loss on chronic stress and progression of neuropathogenesis of Alzheimer's disease in adult Alzheimer's model AppNL-G-F mice.

Introduction: Alzheimer's disease (AD), the most common neurodegenerative disease, is characterized by accumulated amyloid-ß (Aß) plaques, aggregated phosphorylated tau protein, gliosis-associated neuroinflammation, synaptic dysfunction, and cognitive impairment. Many cohort studies indicate that tooth loss is a risk factor for AD. The detailed mechanisms underlying the association between AD and tooth loss, however, are not yet fully understood. Methods: We explored the involvement of early tooth loss in the neuropathogenesis of the adult AppNL-G-F mouse AD model. The maxillary molars were extracted bilaterally in 1-month-old male mice soon after tooth eruption. Results: Plasma corticosterone levels were increased and spatial learning memory was impaired in these mice at 6 months of age. The cerebral cortex and hippocampus of AD mice with extracted teeth showed an increased accumulation of Aß plaques and phosphorylated tau proteins, and increased secretion of the proinflammatory cytokines, including interleukin 1ß (IL-1ß) and tumor necrosis factor α (TNF-α), accompanied by an increased number of microglia and astrocytes, and decreased synaptophysin expression. AD mice with extracted teeth also had a shorter lifespan than the control mice. Discussion: These findings revealed that long-term tooth loss is a chronic stressor, activating the recruitment of microglia and astrocytes; exacerbating neuroinflammation, Aß deposition, phosphorylated tau accumulation, and synaptic dysfunction; and leading to spatial learning and memory impairments in AD model mice.

Successful Nerve Block Therapy for Lateral Cutaneous Nerve Entrapment Syndrome (LACNES) Triggered by Exercise.

This report presents a case of a 59-year-old man who experienced pain in the left abdomen during abdominal exercises, which gradually improved. Pain recurred in the same area one year later and gradually worsened, rendering him unable to work. The strongest tender point, with a positive Carnett's sign, was noted on the flank. Ultrasonography revealed a 5 × 10 mm mass shadow in the internal oblique muscle. Trigger point injection at the same site was remarkably effective. Lateral cutaneous nerve entrapment syndrome caused by a crush injury due to abdominal exercises was diagnosed. Nerve block therapy provided effective pain relief.

Comparison of postoperative analgesic effects of thoracic epidural analgesia and rectus sheath block in laparoscopic abdominal surgery: A randomized controlled noninferiority trial.

INTRODUCTION: In the Enhanced Recovery After Surgery program, abdominal wall blocks are strongly recommended as postoperative multimodal analgesia for laparoscopic abdominal surgery. The purpose of this study was to compare the efficacy of single-shot rectus sheath block (RSB) with that of thoracic epidural analgesia (TEA) as a method of multimodal analgesia in patients receiving conventional laparoscopic abdominal surgery. METHODS: A noninferiority comparison was performed. Patients scheduled for laparoscopic gastric or colorectal surgery were enrolled in this study. Patients were divided randomly into two groups: TEA and RSB. The primary endpoint was the numerical rating scale (NRS) score upon coughing as of 24 hours after surgery. RESULTS: In total, 80 patients were randomly assigned to receive TEA (n = 42) or RSB (n = 38). Three patients were excluded from the TEA group after randomization. The NRS score on coughing as of 24 hours after surgery was significantly lower in the TEA group than in the RSB group (least square mean: 3.59 vs 6.39; 95% confidence interval for the difference: 1.87 to 3.74, P < .001). The NRS scores upon coughing and at rest were significantly lower in the TEA group than in the RSB group as of 4, 24 and 48 hours after surgery. Patient satisfaction with postoperative analgesia was significantly higher in the TEA group. Postoperative adverse events were not significantly different between groups. CONCLUSION: This is the first report of comparing RSB with TEA in laparoscopic surgery. TEA may be recommended as a multimodal analgesia protocol for laparoscopic gastric and colorectal surgery.

Correlation between Antimicrobial Resistance and the Hospital-Wide Diverse Use of Broad-Spectrum Antibiotics by the Antimicrobial Stewardship Program in Japan.

Increased antibiotic use and antibiotic homogeneity cause selective pressure. This study investigated the correlation between antibiotic diversity and antimicrobial resistance (AMR) in Gram-negative organisms. The days of therapy/100 patient-days (DOT) for four broad-spectrum antibiotic classes were evaluated for 2015-2022. The antibiotic heterogeneity index (AHI) for the equal use of four classes (25%) and the modified AHI for the equal use of three classes (30%), excluding fluoroquinolones (10%), were measured (target: 1.0). Quarterly antibiotic use markers and the resistance rates against ≥2 anti-Pseudomonas antibiotics were compared. The DOT value was 9.94, and the relative DOT were 34.8% for carbapenems, 32.1% for piperacillin/tazobactam, 24.3% for fourth generation cephalosporins/ceftazidime/aztreonam, and 8.9% for fluoroquinolones. Although no correlation was found between the total DOT and the resistance rate for any bacterium, a significant negative correlation was found between the heterogeneity indices and resistance rates for Pseudomonas aeruginosa and Klebsiella pneumoniae. The significant cutoffs that discriminate the risk of resistance were 0.756 for the AHI and 0.889 for the modified AHI for K. pneumoniae. Antibiotic diversity is more important in preventing AMR than overall antibiotic use. The ideal ratio of broad-spectrum antibiotics should be studied for diversified use to prevent AMR.

Correction of thrombocytopenia caused by linezolid with scheduled sequential tedizolid use in patients with vertebral osteomyelitis by antibiotic resistant Gram-positive organisms.

INTRODUCTION: Because of thrombocytopenia, linezolid treatment tends to be stopped before the completion of therapy for complicated infections that require prolonged antimicrobial administration. In contrast, tedizolid shows a favorable hematologic profile. The primary end-point of this study was to evaluate the efficacy of switching treatment to tedizolid in patients who developed thrombocytopenia during linezolid therapy. METHODS: This retrospective study was conducted in patients with vertebral osteomyelitis (VO) caused by antibiotic-resistant Gram-positive bacteria. Treatment failure was defined as the reappearance of infection signs within 2 weeks after stopping tedizolid and discontinuation of tedizolid because of continued thrombocytopenia or other adverse effects. RESULTS: Eight patients with native VO (n = 3) and postoperative VO (n = 5) were included in the study. The causative organisms were MRSA in all patients except one. Platelet counts decreased from 35.2 ± 11.5 × 104/mm3 to 17.8 ± 6.2 × 104/mm3 during linezolid therapy and improved without washout period in all patients after switching to tedizolid on days 5-7 (28.6 ± 4.9 × 104/mm3, p = 0.002). Tedizolid therapy was completed and treatment failure was not observed in any patient. The duration of treatment was 20.0 ± 11.2 days for linezolid and 30.3 ± 9.5 days for tedizolid (total, 50.3 ± 10.7 days). One patient died because of underlying disease, and there was no recurrence in the remaining 7 patients (median follow-up 501 days). CONCLUSIONS: Switching therapy to tedizolid improved thrombocytopenia that occurred during linezolid therapy, and it enabled the completion of therapy for VO patients.

Validation of Vancomycin Area under the Concentration-Time Curve Estimation by the Bayesian Approach Using One-Point Samples for Predicting Clinical Outcomes in Patients with Methicillin-Resistant Staphylococcus aureus Infections.

Area under the concentration-time curve (AUC)-guided vancomycin treatment is associated with decreased nephrotoxicity. It is preferable to obtain two samples to estimate the AUC. This study examined the usefulness of AUC estimation via trough concentration (Cmin)-only sampling of 260 adults infected with methicillin-resistant Staphylococcus aureus (MRSA) who received vancomycin. The exact Cmin sampling time was used for Bayesian estimation. A significantly higher early treatment response was observed in patients with a day 2 AUC ≥ 400 µg·h/mL than those with <400 µg·h/mL, and a significantly higher early nephrotoxicity rate was observed in patients with a day 2 AUC ≥ 600 µg·h/mL than those with <600 µg·h/mL. These AUC cutoff values constituted independent factors for each outcome. In sub-analysis, the discrimination ability for early clinical outcomes using these AUC cutoffs was confirmed only in patients with q12 vancomycin administration. A significant difference in early treatment response using the 400 µg·h/mL cutoff was obtained only in patients with low-risk infections. The usefulness of the vancomycin AUC target to decrease nephrotoxicity while assuring clinical efficacy was even confirmed with a single Cmin measurement. However, assessment with two samples might be required in patients with q24 administration or high/moderate-risk MRSA infections.

Enhanced loading dose of teicoplanin for three days is required to achieve a target trough concentration of 20 µg/mL in patients receiving continuous venovenous haemodiafiltration with a low flow rate.

INTRODUCTION: Because of its lower risk of renal toxicity than vancomycin, teicoplanin is the preferred treatment for methicillin-resistant Staphylococcus aureus infection in patients undergoing continuous venovenous haemodiafiltration (CVVHDF) in whom renal function is expected to recover. The dosing regimen for achieving a trough concentration (Cmin) of ≥20 µg/mL remains unclear in patients on CVVHDF using the low flow rate adopted in Japan. METHODS: The study was conducted in patients undergoing CVVHDF with a flow rate of <20 mg/kg/h who were treated with teicoplanin. We adopted three loading dose regimens for the initial 3 days: the conventional regimen, a high-dose regimen (four doses of 10 mg/kg), and an enhanced regimen (four doses of 12 mg/kg). The initial Cmin was obtained at 72 h after the first dose. RESULTS: Overall, 60 patients were eligible for study inclusion. The proportion of patients achieving the Cmin target was significantly higher for the enhanced regimen than for the high-dose regimen (52.9% versus 8.3%, p = 0.003). In multivariate analysis, the enhanced regimen (odds ratio [OR] = 39.93, 95% confidence interval [CI] = 5.03-317.17) and hypoalbuminaemia (OR = 0.04, 95% CI = 0.01-0.44) were independent predictors of the achievement of Cmin ≥ 20 µg/mL. CONCLUSIONS: An enhanced teicoplanin regimen was proposed to treat complicated or invasive infections by methicillin-resistant Staphylococcus aureus in patients receiving CVVHDF even with a low flow rate.

Patient-controlled epidural analgesia, patient-controlled intravenous analgesia, and conventional intravenous opioids for gynecologic interstitial brachytherapy: A single-center retrospective study.

PURPOSE Interstitial brachytherapy for gynecologic malignancies is stressful physically and mentally; however, optimal analgesic methods remain unclear. We investigated the effect of analgesic methods on pain and adverse events during interstitial brachytherapy for gynecologic malignancies. METHODS The data of 73 patients who underwent interstitial brachytherapy for gynecologic malignancies between April 2015 and March 2020 were retrospectively analyzed. Patient-controlled epidural analgesia (PCEA), patient-controlled intravenous analgesia (PCIA), and conventional intravenous opioid administration were used for analgesia during treatment. We compared the analgesic effects based on a numerical rating scale (NRS), the number of additional analgesics, and the adverse events associated with analgesia. The NRS score was calculated as an average value for every 12 h (NRS1: treatment on the 1st day from 12 to 24 o'clock; NRS2: treatment on the 2nd day from 0 to 12 o'clock; NRS3: treatment on the 2nd day from 12 to 24 o'clock). The mean NRS score differences between the methods were evaluated using mixed models for repeated-measures analyses. RESULTS The NRS score was significantly lower at all times for PCEA (NRS1: p = 0.003; NRS2: p = 0.011; NRS3: p < 0.001). NRS2 and NRS3 were significantly lower for PCIA (NRS2: p = 0.043; NRS3: p < 0.001) than for the conventional method. The NRS scores for PCEA and PCIA were not significantly different. Moreover, additional analgesics and adverse events did not differ between the three treatments. CONCLUSION PCEA and PCIA were superior to conventional intravenous opioids for analgesia in interstitial brachytherapy for gynecologic malignancies. However, adverse events associated with PCEA and PCIA were not reduced.

An optimal epidural catheter placement site for post-cesarean section analgesia with double-space technique combined spinal-epidural anesthesia: a retrospective study.

BACKGROUND: Epidural anesthesia affects lower extremities, which often prevents early mobilization postoperatively. The incidence of numbness and motor weakness in the lower extremities with respect to epidural catheter placement site in cesarean section (CS) is uncertain. We aimed to investigate the effect of catheter placement site on postoperative lower extremities numbness and motor weakness in patients who received combined spinal-epidural anesthesia (CSEA) for CS including analgesic effects and optimal epidural placement site in CS. METHODS: We retrospectively included 205 patients who underwent CS with CSEA at the University of Tsukuba Hospital between April 2018 and March 2020, and assessed numbness and motor weakness in the lower extremities. We also examined whether differences in the intervertebral space of epidural catheter placement and epidural effect on the lower extremities are related to analgesic effects. ANOVA and Mann-Whitney U test were used for statistical analysis. RESULTS: The incidence of numbness and motor weakness were 67 (33%) and 28 (14%), respectively. All patients with motor weakness had numbness. A more caudal placement was associated with increased incidence of affected lower extremities. There was no significant difference in the analgesic effect depending on the catheter placement site. When the lower extremities were affected, the number of additional analgesics increased (p < 0.001). Patient-controlled epidural analgesia was used for fewer days in patients with motor weakness (p = 0.046). CONCLUSION: In CS, epidural catheter placement at T10-11 or T11-12 interspace is expected to reduce effect on the lower extremities and improve quality of postoperative analgesia.

Minimum effective volume of ropivacaine for ultrasound-guided supra-inguinal fascia iliaca compartment block.

Supra inguinal fascia iliaca compartment block (FICB) is increasingly used in elderly patients with hip fractures. However, the minimum effective volume of local anesthetics required for ultrasound-guided supra-inguinal FICB has not been determined. With ethical committee approval and written informed consent from patients, we studied 21 consecutive patients of ASA physical status I-III undergoing surgery for hip fracture who met the inclusion criteria. Blocks were performed before going to the operation room. We determined the injection volumes of 0.25% ropivacaine for consecutive patients from the preceding patient's outcome. The initial volume was 30 ml. The testing interval was set at 10 ml, and the lowest volume was 5 ml. An effective block was defined as loss of sensation of pinprick in the territory of the femoral nerve and lateral cutaneous nerve of the thigh 30 min after the injection. The aim of this study was to determine the 50% effective volume (EV50) and the 95% effective volume (EV95) of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB using Logistic regression analysis. EV50 and EV95 of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB calculated with logistic regression analysis were 15.01 ml (95% confidence interval, 6.53-22.99 ml) and 26.99 ml (95% confidence interval, 20.54-84.09 ml), respectively. EV50 and EV95 of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB were 15.01 ml and 26.99 ml, respectively.Clinical trial number: UMIN000027277 (URL https://www.umin.ac.jp/ctr/index-j.htm ).

Clinical efficacy and safety in patients treated with teicoplanin with a target trough concentration of 20 µg/mL using a regimen of 12 mg/kg for five doses within the initial 3 days.

BACKGROUND: A trough concentration (Cmin) ≥20 µg/mL of teicoplanin is recommended for the treatment of serious methicillin-resistant Staphylococcus aureus (MRSA) infections. However, sufficient clinical evidence to support the efficacy of this target Cmin has not been obtained. Even though the recommended high Cmin of teicoplanin was associated with better clinical outcome, reaching the target concentration is challenging. METHODS: Pharmacokinetics and adverse events were evaluated in all eligible patients. For clinical efficacy, patients who had bacteremia/complicated MRSA infections were analyzed. The primary endpoint for clinical efficacy was an early clinical response at 72-96 h after the start of therapy. Five dosed of 12 mg/kg or 10 mg/kg was administered as an enhanced or conventional high loading dose regimen, respectively. The Cmin was obtained at 72 h after the first dose. RESULTS: Overall, 512 patients were eligible, and 76 patients were analyzed for treatment efficacy. The proportion of patients achieving the target Cmin range (20-40 µg/mL) by the enhanced regimen was significantly higher than for the conventional regimen (75.2% versus 41.0%, p < 0.001). In multivariate analysis, Cmin ≥ 20 µg/mL was an independent factor for an early clinical response (odds ratio 3.95, 95% confidence interval 1.25-12.53). There was no significant difference in the occurrence of adverse events between patients who did or did not achieve a Cmin ≥ 20 µg/mL. CONCLUSION: A target Cmin ≥ 20 µg/mL might improve early clinical responses during the treatment of difficult MRSA infections using 12 mg/kg teicoplanin for five doses within the initial 3 days.

Vancomycin loading dose is associated with increased early clinical response without attainment of initial target trough concentration at a steady state in patients with methicillin-resistant Staphylococcus aureus infections.

WHAT IS KNOWN AND OBJECTIVE: Vancomycin therapeutic guidelines suggest a loading dose of 25-30 mg/kg for seriously ill patients. However, high-quality data to guide the use of loading doses are lacking. We aimed to evaluate whether a loading dose (a) achieved a target trough concentration at steady state and (b) improved early clinical response. METHODS: Patients with an estimated glomerular filtration rate ≥ 90 mL/min/1.73 m2 were included. A loading dose of 25 mg/kg vancomycin followed by 15 mg/kg twice daily was compared with traditional dosing. A Cmin sample was obtained before the fifth dose. An early clinical response 48-72 hours after the start of therapy and clinical success at end of therapy (EOT) was evaluated in patients with methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase-negative Staphylococci or Enterococcus faecium. RESULTS: There was no significant difference in Cmin between the regimen with and without a loading dose (median: 10.4 and 10.2 µg/mL, P = .54). Proportions of patients achieving 10-20 and 15-20 µg/mL were 56.9% and 5.6%, respectively, in patients with a loading dose. Although there was no significant difference in success rate at EOT between groups, a loading dose was associated with increased early clinical response for all infections (adjusted odds ratio [OR]: 4.588, 95% confidence interval [CI]: 1.373-15.330) and MRSA infections (OR: 12.065, 95% CI: 1.821-79.959). Study limitations included no Cmin measurements within 24 hours and the inclusion of less critically ill patients. WHAT IS NEW AND CONCLUSION: A loading dose of 25 mg/kg followed by 15 mg/kg twice daily did not achieve the optimal Cmin at steady state in patients with normal renal function. However, more early clinical responses were obtained with a loading dose compared with traditional dosing, possibly because of a prompt albeit temporary achievement of a more effective concentration.

Pasteurella multocida-induced endophthalmitis after a cat scratch.

PURPOSE: To report the case of a Japanese girl with a perforating ocular injury caused by a cat scratch, resulting in Pasteurella multocida-induced endophthalmitis. OBSERVATIONS: A 10-year-old girl presented with a red eye, eye pain, and blurred vision in her right eye immediately after receiving a cat scratch. We performed lensectomy and vitrectomy for endophthalmitis 4 hours after her arrival. After culturing a sample of the vitreous humor, Pasteurella multocida was identified, and the antibiotic was changed to ampicillin. The best-corrected visual acuity of her right eye improved to 20/20 6 months after surgery. CONCLUSIONS AND IMPORTANCE: We present a rare case of Pasteurella multocida-induced endophthalmitis after a cat scratch. Our findings suggest the great importance of identifying the responsible bacterium and using matched antibiotics as soon as possible in such cases to prevent vision loss.

Clinical efficacy of teicoplanin in the treatment of bloodstream infection caused by methicillin-resistant coagulase-negative staphylococci.

Empirical combination therapy with ß-lactams and glycopeptides is recommended for patients with presumed staphylococcal bloodstream infection (BSI). While coagulase-negative staphylococci (CNS) remain susceptible to vancomycin, such isolates have become less susceptible to teicoplanin. The aim of this retrospective study was to evaluate the clinical efficacy of teicoplanin in the treatment of BSI caused by methicillin-resistant CNS according to teicoplanin susceptibility. Inclusion criteria were patients with intravascular-catheter related BSIs caused by methicillin-resistant CNS (positive for two or more specimens); teicoplanin therapy; and at least one of the signs or symptoms caused by BSI. Antimicrobial resistance was defined as minimum inhibitory concentration (MIC) ≥8 µg/mL. The primary efficacy endpoint was clinical success evaluated 2 weeks after the completion of teicoplanin therapy [test of cure (TOC)]. Resistant rate of CNS was 0% for vancomycin and 22.9% for teicoplanin, and geometric mean MICs were 1.31 µg/mL and 3.41 µg/mL, respectively (p < 0.001). The catheter was removed in all patients except one, and high early clinical response at 72 h after starting therapy was obtained irrespective of teicoplanin susceptibility. The clinical success rate at TOC was 60% in patients with BSIs caused by teicoplanin-resistant strains, while 90% in patients with BSIs caused by susceptible strains (p = 0.052). In multivariate analyses, teicoplanin resistance was significant factor for decreased clinical success at TOC (adjusted odds ratio 0.138, 95% confidence interval 0.020-0.961, p = 0.045). Because of the poor clinical efficacy of teicoplanin against teicoplanin-resistant CNS, combination therapy comprising vancomycin and ß-lactam antibiotics should be considered in presumed staphylococci BSI.

[Emergent Caesarean Section in a Patient with a Mediastinal Tumor and Von Recklinghausen Disease: A Case Report].

It is rare to encounter a pregnant patient with a mediastinal tumor, and if the tumor size increases as the pregnancy progresses, this increase can cause complications such as airway constriction and vascular occlusion. We report a case of a pregnant patient diagnosed with von Recklinghausen disease at the age of seven and diagnosed with a mediastinal tumors just after her present admission. The impending suffocation progressed and fetal heart rate decreased during her hospitalization. Her trachea was intubated and she was moved to an operating room for an emergent cesarean section under general anesthesia. With this rapid response, we could rescue both patient and infant. If the size of mediastinal tumor increases as pregnancy progresses, the tumor will cause suffocation by airway compression from the outside, in addition to specific airway edema on the inward side. The present case demonstrates that appropriate desisoins must be made for airway manegement and initiation of surgery.

The Ropivacaine Concentration Required for Ultrasound-Guided Ilioinguinal/Iliohypogastric Nerve Block in Pediatric Patients.

BACKGROUND: To the best of our knowledge, the ropivacaine concentration required for ultrasound-guided ilioinguinal and iliohypogastric nerve block (INB) has not been reported. We designed this study to examine the 50% effective concentration (EC50) of ropivacaine for ultrasound-guided INB in children anesthetized with 2% sevoflurane. METHODS: We studied 30 consecutive children (age range, 6 months to 11 years) ASA physical status I to II undergoing unilateral open inguinal hernia repair. General anesthesia was induced by sevoflurane and maintained with 2% end-tidal concentration of sevoflurane in air and oxygen (FIO2 = 0.4). Ultrasound-guided INB was performed using a 3 mL ropivacaine solution. The first child received 0.3% ropivacaine, and subsequent concentrations were determined by the response of the previous patient to initial skin incision using Dixon up-and-down method. The testing interval was set at 0.1%, and the lowest concentration was 0.05% (0.05%, 0.1%, 0.2%, 0.3%, 0.4%, or 0.5%). The EC50 for INB of ropivacaine was analyzed using probit test. RESULTS: The concentration at which all patients showed complete block was 0.50%, according to the up-and-down method. The EC50 was 0.21% (95% confidence interval, 0.03-0.34). CONCLUSIONS: The EC50 of ropivacaine for ultrasound-guided INB was 0.21% (95% confidence interval, 0.03-0.34), in pediatric patients anesthetized with 2% sevoflurane.

Effects of Active Mastication on Chronic Stress-Induced Bone Loss in Mice.

Chronic psychologic stress increases corticosterone levels, which decreases bone density. Active mastication or chewing attenuates stress-induced increases in corticosterone. We evaluated whether active mastication attenuates chronic stress-induced bone loss in mice. Male C57BL/6 (B6) mice were randomly divided into control, stress, and stress/chewing groups. Stress was induced by placing mice in a ventilated restraint tube (60 min, 2x/day, 4 weeks). The stress/chewing group was given a wooden stick to chew during the experimental period. Quantitative micro-computed tomography, histologic analysis, and biochemical markers were used to evaluate the bone response. The stress/chewing group exhibited significantly attenuated stress-induced increases in serum corticosterone levels, suppressed bone formation, enhanced bone resorption, and decreased trabecular bone mass in the vertebrae and distal femurs, compared with mice in the stress group. Active mastication during exposure to chronic stress alleviated chronic stress-induced bone density loss in B6 mice. Active mastication during chronic psychologic stress may thus be an effective strategy to prevent and/or treat chronic stress-related osteopenia.

Chewing ameliorates chronic mild stress-induced bone loss in senescence-accelerated mouse (SAMP8), a murine model of senile osteoporosis.

Chronic mild stress is a risk factor for osteoporosis and chewing inhibits the stress response. We examined the effect of chewing on chronic stress-induced bone loss and bone microstructural deterioration in mice. The senescence-accelerated mouse strain P8 (SAMP8) was randomly divided into control, stress, and stress with chewing groups of fifteen animals each. Mice in the stress and stress with chewing groups were placed in a ventilated restraint tube for 60minutes, twice a day for 4weeks. The restrained mice were simultaneously subjected daily to one of the following stressors: water immersion, physical shaking and flashing lights. Mice in the stress with chewing group were allowed to chew a wooden stick during the experimental period. After the experiment, the bone response was evaluated using quantitative micro computed tomography, bone histomorphometry, and biochemical markers. Exposure of SAMP8 mice to chronic stress resulted in significant increase of the blood corticosterone and noradrenaline levels, and adrenal weight. The bone resorption was activated and the bone formation was suppressed. Trabecular bone volume and trabecular number were decreased in both the vertebra and distal femur of the stress group. Chewing under chronic stress prevented the increase in the blood corticosterone and noradrenaline levels, attenuated the reduced bone formation and increased bone resorption, improved the trabecular bone loss and bone microstructural deterioration induced by chronic mild stress. These findings indicate that chewing can ameliorate chronic stress-induced bone loss in SAMP8 mice. Thus, chewing may represent a useful method preventing and/or treating chronic stress-related osteoporosis.

[Case of ulnar nerve palsy in a patient with a history of total elbow arthroplasty after abdominal surgery under general anesthesia].

Ulnar nerve palsy is a well recognized complication of the general anesthesia. We experienced a case of ulnar nerve palsy after abdominal surgery under general anesthesia in a patient with a history of total elbow arthroplasty and ulnar nerve translocation. It appears that pressure on medial epicondyle caused the palsy and that the position of the ulnar nerve has to be carefully examined before surgery in a patient with a history of total elbow arthroplasty and ulnar nerve translocation.

[Group A streptococcus-induced toxic shock syndrome in pregnancy: a case report of cesarean section].

Group A streptococcus (GAS)-induced toxic shock syndrome (TSS) in pregnancy is rare, but its clinical course is fulminant. The mortality rates of mother and fetus are reported to be 58 and 66%, respectively. We report a case of GAS-TSS after cesarean section. A 38-year-old pregnant woman of 38 weeks gestation was admitted to our hospital because of vomiting, fever of 39 degrees C, and continuous abdominal pain with scanty genital bleeding. She had complained of sore throat several days before. One hour after admission, external fetal monitoring revealed periodic pulse deceleration to 90 x beats min(-1). The emergent cesarean section was performed under general anesthesia. Approximately 8 hours after the cesarean section, she developed coma, shock and respiratory insufficiency requiring intubation. Streptococcus pyogens were isolated from her blood sample and the patient met criteria for GAS-TSS. She was treated with antibiotics (penicillin and clindamycin), antithrombin III, recomodulin, catecholamins, and continuous hemodialysis with filtration of toxins. Although the patient recovered and was discharged on 63rd day, the infant died on postpartum day 4. Early recognition and intensive treatment for GAS is recommended in a late stage pregnancy with an episode of sore throat, vomiting, high fever, strong labor pain, and DIC signs.