[Anesthetic Management of a Patient with Langerhans Cell Histiocytosis during Cesarean section].

Langerhans cell histiocytosis is a rare disease, associated with histiocyte increases, and granuloma, in various organs. About 160 patients are reported in Japan. A pregnant patient with a pulmonary Langerhans cell histiocytosis underwent cesarean section under spinal anesthesia. She had repeated pneumothorax with bilateral pulmonary cysts rapidly becoming worse during pregnancy. She was treated with continuous oxygen after 28 weeks of the pregnancy. On 34 weeks of the pregnancy, spinal anesthesia with 0.5% hyperbaric bupivacaine (2 ml) and fentanyl (25 µg) for cesarean section was performed, and provided excellent analgesia without any side-effects.

Optimization of enrichment conditions on TiO2 chromatography using glycerol as an additive reagent for effective phosphoproteomic analysis.

Metal oxide affinity chromatography (MOAC) represented by titanium dioxide (TiO2) chromatography has been used for phosphopeptide enrichment from cell lysate digests prior to mass spectrometry. For in-depth phosphoproteomic analysis, it is important for MOAC to achieve high phosphopeptide enrichment efficiency by optimizing purification conditions. However, there are some differences in phosphopeptide selectivity and specificity enriched by various TiO2 materials and procedures. Here, we report that binding/wash buffers containing polyhydric alcohols, such as glycerol, markedly improve phosphopeptide selectivity from complex peptide mixtures. In addition, the elution conditions combined with secondary amines, such as bis-Tris propane, made it possible to recover phosphopeptides with highly hydrophobic properties and/or longer peptide lengths. To assess the practical applicability of our improved method, we confirmed using PC3 prostate cancer cells. By combining the hydrophilic interaction chromatography (HILIC) with the optimized TiO2 enrichment method prior to LC-MS/MS analysis, over 8300 phosphorylation sites and 2600 phosphoproteins were identified. Additionally, some dephosphorylations of those were identified by treatment with dasatinib for a kinase inhibitor. These results indicate that our method is applicable to understanding the profiling of kinase inhibitors such as anticancer compounds, which will be useful for drug discovery and development.

The effect of intravenous glucose solutions on neonatal blood glucose levels after cesarean delivery.

PURPOSE: Intravenous solutions are often administered to the mother on the day of a cesarean delivery to minimize the effect of preoperative fasting or to stabilize the hemodynamics. Different intravenous solutions contain varying amounts of glucose, and rapid administration may lead to hypoglycemia in the neonate. We conducted a study to compare blood glucose levels of the mother and the fetus/neonate after they were rapidly given a Ringer's solution containing 0, 1, or 5 % glucose. The effect of the glucose load that these intravenous solutions impose during cesarean delivery has not been fully reported. Therefore, we compared the effect of 0 % (Group I, n = 15), 1 % (Group II, n = 15), and 5 % (Group III, n = 15) glucose acetated Ringer's solutions on maternal and umbilical blood glucose levels to determine the optimal glucose concentration. METHODS: Once the patients were in the operating room, the intravenous solutions were administered before delivery. The primary endpoint was changes in umbilical blood glucose levels and minimum neonatal blood glucose levels, and the secondary endpoint was the proportion of neonates who received a glucose infusion. RESULTS: Maternal blood glucose levels before and after intravenous infusion were 79.2 ± 12.2 and 74.6 ± 4.6 in Group I, 81.2 ± 12.9 and 103.3 ± 11.2 in Group II (P < 0.001), and 82.3 ± 8.7 and 252.5 ± 41.8 in Group III (P < 0.001). Umbilical blood glucose levels were 53.9 ± 10.2 in Group I, 80.8 ± 13.7 in Group II, and 181.8 ± 22.2 in Group III (P < 0.01: Group I vs. Group II and P < 0.01: Group II vs. Group III) (P < 0.001: Group I vs. Group III). Minimum neonatal blood glucose levels measured up to 8 h after birth were 35.7 ± 9.6 in Group I, 49.8 ± 10.8 in Group II, and 29.2 ± 7.5 in Group III. Neonatal hypoglycemia requiring glucose before the first milk feeding occurred in 6 neonates whose mothers were in Group I, 3 in Group II, and 9 in Group III, indicating a trend towards less neonatal hypoglycemia in Group II. CONCLUSIONS: The use of 1 % glucose acetated Ringer's solution did not induce hyperglycemia in the mother and it was able to maintain appropriate blood glucose levels in the fetus.

Potential plasma biomarkers for progression of knee osteoarthritis using glycoproteomic analysis coupled with a 2D-LC-MALDI system.

BACKGROUND: Although osteoarthritis (OA) is a highly prevalent joint disease, to date, no reliable biomarkers have been found for the disease. In this study, we attempted to identify factors the amounts of which significantly change in association with the progression of knee OA. METHODS: A total of 68 subjects with primary knee OA were enrolled in the study. These subjects were followed up over an 18-month period, and plasma and serum samples were obtained together with knee radiographs every 6 months, i.e., 0, 6, 12 and 18 months after the enrollment. Progressors and non-progressors were determined from the changes on radiographs, and plasma samples from those subjects were subjected to N-glycoproteomic 2D-LC-MALDI analysis. MS peaks were identified, and intensities for respective peaks were compared between the progressors and non-progressors to find the peak intensities of which differed significantly between the two groups of subjects. Proteins represented by the chosen peaks were identified by MS/MS analysis. Expression of the identified proteins was evaluated in synovial tissues from 10 OA knee joints by in situ hybridization, western blotting analysis and ELISA. RESULTS: Among the subjects involved in the study, 3 subjects were determined to be progressors, and 6 plasma and serum samples from these subjects were subjected to the analysis together with another 6 samples from the non-progressors. More than 3000 MS peaks were identified by N-glycoproteomic 2D-LC-MALDI analysis. Among them, 4 peaks were found to have significantly different peak intensities between the progressors and non-progressors. MS/MS analysis revealed that these peaks represented clusterin, hemopexin, alpha-1 acid glycoprotein-2, and macrophage stimulating protein, respectively. The expression of these genes in OA synovium was confirmed by in situ hybridization, and for clusterin and hemopexin, by western blotting analysis and ELISA as well. CONCLUSIONS: In this study, 4 potential biomarkers were identified as potential prognostic markers for knee OA through N-glycoproteomic analysis. To the best of our knowledge, this is the first report for the use of glycoproteomic technology in exploring potential biomarkers for knee OA.

[Anesthesia management for cesarean section in a patient with placenta percreta].

Placenta accreta is a placental abnormality with a defect in decidua basalis. Villi tissue invades myometrium and it is difficult to exfoliate the placenta. Placenta percreta is a comparatively rare disorder in placenta accreta. This patient at pregnancy 14 weeks, exploratory laparotomy was performed for acute abdomen. At this time she was diagnosed as placenta percreta, but the pregnancy was continued. Caesarean section was scheduled in 37 weeks 0 days of pregnancy and combined spinal-epidural anesthesia was used. After the operation, we moved the patient to the angiography room to perform uterus artery embolization (UAE). While moving, we monitored maternal hemodynamics using a transportable monitor. During the cesarean section in the operation room, and in moving to the angiography room and in the angiography room, we used the same transportable monitor for secure perioperative management.

[Central venous catheterization complication by a guide wire].

Central venous catheterization using the Seldinger technique is a well known and often used method. On the other hand, there are also well known complications by needle puncture or by indwelling catheter, there are few reports about a guide wire which got hung up around the tricuspid valve. We report a case in which a guide wire got hung up to the chordae tendineae of the tricuspid valve. To insert the AVA 3Xi (Edwards life science Co. Iervine) from the right internal jugular vein, we inserted a guide wire without ease. Resistance appeared when we tried to remove the wire for 20 cm from the inserted state. The X-ray and the transesophageal echocardiography, showed the guide wire in the right ventricle. As actions to be taken, we advanced the central vein catheter of the EXCV catheter kit (Nippon Sherwood Medical Industries Co., Ltd.) to the tip, and a the guide wire was easily removed. There are many reports of the complication by the central venepuncture, but there are few reports about the guide wire which was entrapped in the vicinity of a tricuspid valve. The tip of the guide wire in this case was bent excessively, but the cause of the damage did not become clear by investigation. When a guide wire became hard to withdraw, we should never withdraw a guide wire blindly, but should search a cause and we should use the material which was matched with the cause.

[One case of the basilar invagination that prevented tracheal intubation by Airway Scope].

Airway Scope (AWS, Pentax, Tokyo, Japan) is a very useful intubation assistance tool in the case where intubation is difficult with normal Macintosh laryngoscope. In this case, the operation was planned by general anesthesia in a patient with basilar invagination. We decided to intubate the patient using AWS because difficult tracheal intubation was expected. However, glottis was not confirmed even with AWS in the oral cavity, and we could not intubate with AWS. Therefore, we used a fiberscope, and endotracheal intubation was successful.

[Anesthetic management of thoracoscopic mini maze procedure for atrial fibrillation].

We anesthetized three patients with refractory atrial fibrillation undergoing the new thoracoscopic mini Maze procedure. This minimally invasive surgical procedure provides isolation and ablation of the bilateral pulmonary vein without thoracotomy or cardiopulmonary bypass, which was performed first in the United States in 2003. General anesthesia was administrated with a double lumen tracheal tube for bilateral single lung ventilation, and epidural anesthesia was also administrated. We prepared transesophageal echocardiography, a pulmonary artery catheter with pacing wires, and a 20 G arterial line connected to continuous cardiac output monitor. We also prepared a 14 G peripheral intravenous line and two 4 Fr sheaths on the left femoral artery and vein for bleeding and conversion to cardiopulmonary bypass. One patient required massive transfusion and conversion to open procedure with thoracotomy and cardiopulmonary bypass to control sudden and massive bleeding from the pulmonary vein. Another patient was complicated with dextrocardia, but the procedure was successful. One other patient had no complications and the procedure was performed as planned. Certain anesthetic management is essential for this new procedure and we have to prepare for any predictable events.

[Case of caesarean section using Cell Savers5+ in a patient with the placenta accreta associated with massive hemorrhage].

Placenta accreta which occurs as a complication of total placenta previa is comparatively rare. And the diagnosis of placenta accreta before the caesarean section (C-section) is difficult. We experienced an extremely difficult anesthesia management of placenta accrete because of critical hemorrhage during C-section. We used self-blood collection device Cell Saver5+ (Haemonetics Japan Ltd, Tokyo) for the massive bleeding of 25,500 ml. The Cell Saver could be used to treat life threatening bleeding in C-section without any side effects, although it is thought that the use of the self-blood collection device during C-section had the danger of the amniotic fluid embolism and fetal red cell ontamination. It is necessary to consider using the Cell Saver in the obstetrical operation for life-saving medical treatment in response to unexpected massive bleeding.

[Epidural anesthesia for five caesarian sections in patients with placenta previa percreta combined with placenta accreta].

We gave anesthesia for five cases of caesarian section in patients with placenta previa percreta combined with placenta accreta. Five caesarian sections were performed under epidural anesthesia and placentae remained in the uterus. After surgery, they were transferred to the angiography room and received uterine arterial embolization (UAE). They were given the diagnosis of the placenta accreta. However, during anesthesia in patients with placenta accreta, incomplete separation of the placenta causes atonic bleeding. And, uncleanliness of the abrasive degree may lead to difficulty in a prediction of bleeding, and control of hemodynamics is difficult. In the caesarian section of the placenta accreta, UAE prevents excessive bleeding during the operation and FloTrac monitor makes it easy to control hemodynamics.

In vitro evolution of single-chain antibodies using mRNA display.

Here we describe the application of the in vitro virus mRNA display method, which involves covalent linkage of an in vitro-synthesized antibody (phenotype) to its encoding mRNA (genotype) through puromycin, for in vitro evolution of single-chain Fv (scFv) antibody fragments. To establish the validity of this approach to directed antibody evolution, we used random mutagenesis by error-prone DNA shuffling and off-rate selection to improve the affinity of an anti-fluorescein scFv as a model system. After four rounds of selection of the library of mRNA-displayed scFv mutants, we obtained six different sequences encoding affinity-matured mutants with five consensus mutations. Kinetic analysis of the mutant scFvs revealed that the off-rates have been decreased by more than one order of magnitude and the dissociation constants were improved approximately 30-fold. The antigen-specificity was not improved by affinity maturation, but remained similar to that of the wild type. Although the five consensus mutations of the high-affinity mutants were scattered over the scFv sequence, analysis by site-directed mutagenesis demonstrated that the critical mutations for improving affinity were the two that lay within the complementarity determining regions (CDRs). Thus, mRNA display is expected to be useful for rapid artificial evolution of high-affinity diagnostic and therapeutic antibodies by optimizing their CDRs.

Sensitization of transient receptor potential vanilloid 4 and increasing its endogenous ligand 5,6-epoxyeicosatrienoic acid in rats with monoiodoacetate-induced osteoarthritis.

Transient receptor potential vanilloid 4 (TRPV4) receptor modulates pain, and this has been noted in several animal models. However, the involvement of TRPV4 in osteoarthritic (OA) pain remains poorly understood. This study assessed the functional changes in TRPV4 and the expression of its endogenous ligand 5,6-epoxyeicosatrienoic acid (5,6-EET) in a rat monoiodoacetate (MIA)-induced OA pain model (MIA rats). Monoiodoacetate-treated rats showed reduced grip strength as compared to sham-treated rats, and this loss in function could be recovered by the intraarticular administration of a TRPV4 antagonist (HC067047 or GSK2193874). By contrast, the intraarticular administration of the TRPV4 agonist, GSK1016790A, increased the pain-related behaviors in MIA rats but not in sham rats. TRPV4 expression was not increased in knee joints of MIA rats; however, the levels of phosphorylated TRPV4 at Ser824 were increased in dorsal root ganglion neurons. In addition, 5,6-EET was increased in lavage fluids from the knee joints of MIA rats and in meniscectomy-induced OA pain model rats. 5,6-EET and its metabolite were also detected in synovial fluids from patients with OA. In conclusion, TRPV4 was sensitized in the knee joints of MIA rats through phosphorylation in dorsal root ganglion neurons, along with an increase in the levels of its endogenous ligand 5,6-EET. The analgesic effects of the TRPV4 antagonist in the OA pain model rats suggest that TRPV4 may be a potent target for OA pain relief.

Bladder cancer-associated cancer-testis antigen-derived long peptides encompassing both CTL and promiscuous HLA class II-restricted Th cell epitopes induced CD4+ T cells expressing converged T-cell receptor genes in vitro.

DEP domain containing 1 (DEPDC1) and M-phase phosphoprotein 1 (MPHOSPH1) are human cancer testis antigens that are frequently overexpressed in urinary bladder cancer. In a phase I/II clinical trial, a DEPDC1- and MPHOSPH1-derived short peptide vaccine demonstrated promising efficacy in preventing bladder cancer recurrence. Here, we aimed to identify long peptides (LPs) derived from DEPDC1 and MPHOSPH1 that induced both T-helper (Th) cells and tumor-reactive cytotoxic T lymphocytes (CTLs). Stimulation of peripheral blood mononuclear cells (PBMCs) from healthy donors with the synthetic DEPDC1- and MPHOSPH1-LPs predicted to bind to promiscuous human leukocyte antigen (HLA) class II molecules by a computer algorithm induced specific CD4+ T cells as revealed by interferon-γ enzyme-linked immunospot assays. Three of six LPs encompassed HLA-A2- or -A24-restricted CTL epitopes or both, and all six LPs stimulated DEPDC1- or MPHOSPH1-specific Th cells restricted by promiscuous and frequently observed HLA class II molecules in the Japanese population. Some LPs are naturally processed from the proteins in DCs, and the capacity of these LPs to cross-prime CTLs was confirmed in vivo using HLA-A2 or -A24 transgenic mice. The LP-specific and HLA class II-restricted T-cell responses were also observed in PBMCs from patients with bladder cancer. Repeated stimulation of PBMCs with DEPDC1-LPs and MPHOSPH1-LPs yielded clonal Th cells expressing specific T-cell receptor (TCR)-α and ß genes. These DEPDC1- or MPHOSPH1-derived LPs may have applications in immunotherapy in patients with bladder cancer, and the TCR genes identified may be useful for monitoring of Th cells specific to LPs in vivo.

[Anesthetic management for cesarean section in a patient with moyamoya disease].

A 28-year-old female patient with moyamoya disease after hemorrhage into the cerebral cavity, and a history of an indirect blood-circulation reconstruction surgery at 19 years of age, was scheduled to undergo cesarean section at 34 weeks of gestation because of pregnancy toxemia. No symptoms and no abnormal shadow with MRI were observed preoperatively. To avoid intracranial hemorrhage and cerebral infarction, epidural anesthesia was performed. No complication was observed during and after the cesarean section.

[Comparison of cardiac output measured by pulseCO and that by vigilance during inferior vena cava clamping].

BACKGROUND: PulseCO is a low invasive apparatus to measure cardiac output continuously from arterial pulse waveform (PulseCCO). It is thought that the accuracy of PulseCCO measurement is clinically acceptable with stable hemodynamics. We measured and evaluated PulseCCO during inferior vena cava clamp (IVC clamp). METHODS: Anesthesia was induced with propofol and vecuronium. After induction, an arterial catheter and a pulmonary artery catheter were inserted, and anesthesia was maintained with general anesthesia and continuous epidural anesthesia. At first IVC was clamped for five minutes and after an interval of five minutes IVC was clamped again. During IVC clamp maneuver, we measured PulseCCO and continuous cardiac output with Vigilance (VigilanceCCO). RESULTS: At the time of the first IVC clamp and declamp, VigilanceCCO was unchanged, but Pulse CCO showed a marked change. After the second IVC clamp, both PulseCCO and VigilanceCCO decreased, but the change was slower with VigilanceCCO. CONCLUSIONS: With IVC clamp maneuver which is thought to cause rapid change of cardiac output, PulseCCO showed more rapid change in comparison with VigilanceCCO. In the state where hemodynamics change rapidly, PulseCO can be a more useful monitor.

[Effects of propofol on hepatic venous oxygen saturation--a comparison with isoflurane or sevoflurane anesthesia].

BACKGROUND: We performed a comparative study of propofol versus isoflurane and sevoflurane using continuous monitoring of hepatic venous oxygen saturation (ShvO2) during upper abdominal surgery in 26 patients. METHODS: Anesthesia was induced with propofol 2-2.5 mg x kg(-1) and vecuronium 0.1 mg x kg(-1). Thereafter, Swan Ganz catheters were inserted into the pulmonary artery and hepatic vein. Group P (n=26) patients received continuous propofol infusion and epidural mepivacaine injection for maintenance, while Group I (n=17) received isoflurane and Group S (n=9) received sevoflurane. Systemic oxygen extraction ratio (OERsys) and hepato-splanchnic oxygen extraction ratio (OERspl) were calculated. RESULTS: Heart rate, mean arterial pressure and cardiac index were unchanged after propofol infusion, and isoflurane or sevoflurane inhalation. Propofol at 8 and 10 mg x kg(-1) x h(-1) significantly decreased ShvO2 and increased OERspl, although isoflurane and sevoflurane did not change them. Mixed venous saturation and OERsys were within normal ranges during the studies. CONCLUSIONS: The results suggest that propofol increases the metabolism and oxygen consumption in the liver.

Isolation of actin-encoding cDNAs from symbiotic corals.

A cDNA (named LGfact) encoding actin was identified in planular larvae of the scleractinian coral Galaxea fascicularis, using the reverse transcription-polymerase chain reaction (RT-PCR) and rapid amplification of cDNA ends (RACE) techniques. RNA from the adult coral that was inhabited by symbiotic dinophytes was subjected to a similar RT-PCR, and a cDNA fragment, named AGfact-p, was found to encode an actin form distinct from LGfact. In an expression study, LGfact transcripts were present at similar levels in asymbiotic larvae and symbiotic adults, indicating that LGfact was expressed by the host. On the other hand, the expression of AGfact-p was detected in adults but not in larvae. Partial cDNA sequences of orthologues of LGfact and AGfact-p were detected in another scleractinian coral, Favites chinensis. A sequence identical to a part of AFcact-p (an AGfact-p orthologue) was amplified from the genomic DNA extracted from asymbiotic larvae of F. chinensis, strongly suggesting that AFcact-p was a coral actin cDNA. Thus, we presume that A Gfact-p encodes an adult-specific form of actin in the host. A partial actin-encoding cDNA sequence (named Syact-p) obtained from Symbiodinium sp. did not exhibit high levels of similarity to the coral actin sequences.

Molecular analyses of protein components of the organic matrix in the exoskeleton of two scleractinian coral species.

Biochemical and histological studies on the exoskeleton of scleractinian corals had demonstrated presence of the organic matrix containing proteins, lipids and chitin. Examination at the electron microscopic level had shown that the initial phase of calcification occurred in close association with organic substances secreted by calicoblastic cells. The possibility was thereby proposed that certain organic substances induce formation of calcium carbonate crystals, presumably functioning as templates for nucleation. In search for such a molecule, biochemical and molecular analyses were initiated on protein components of the organic matrix extracted from the calcified exoskeleton of the hermatypic coral, Galaxea fascicularis and the ahermatype, Tubastrea aurea. In SDS-PAGE analyses of the extracts, one major protein and a few other minor bands were detected in each of the two species. A cDNA encoding the major protein (named galaxin) in G. fascicularis was cloned and its primary structure was deduced. It consisted mostly of tandem repeats of a unit sequence of about 30 residues, and its sequence did not exhibit significant similarity to known proteins. Preliminary characterization of the T. aurea proteins showed that two proteins bound Ca(2+), and suggested that the major protein of 46 kDa was not homologous to galaxin.

[A patient with pulmonary thromboembolism after cesarean section, inspite of having a temporary IVC filter inserted].

There are several reports on use of a temporary IVC filter (T-IVC-F) in patients with deep vein thrombosis. They conclude that the preoperative insertion of a T-IVC-F is useful to prevent intraoperative pulmonary thromboembolism (PTE). But there is no report on preoperative insertion of T-IVC-F not preventing PTE in perioperative period. We experienced a patient who had developed PTE perioperatively despite preoperative insertion of a T-IVC-F. There is a report that some thrombi are not trapped by T-IVC-F in vitro. This suggests that intraoperative PTE can occur. Then, even if T-IVC-F has been inserted preoperatively, it may cause minor thromboembolism, but not major. Therefore we have to observe the vital signs carefully on monitors, such as, pulmonary arterial pressure, end tidal CO2, and transesophageal echocardiograph.