A comparison between McGrath MAC videolaryngoscopy and Macintosh laryngoscopy in children.

BACKGROUND: This prospective, randomised, controlled study was performed to evaluate the usefulness of the McGrath VL compared with Macintosh laryngoscopy in children with expected normal airway during endotracheal intubation, by comparing the time to intubation and difficulty of intubation. METHODS: Eighty-four patients aged 1-10 years who underwent endotracheal intubation for elective surgery were randomly assigned to the McGrath group (n = 42) or the Macintosh group (n = 42). Anaesthesia was induced with 2.5-3.0 mg/kg of propofol and sevoflurane 5-8 vol%. Orotracheal intubation was performed 2 min after injection of rocuronium 0.6 mg/kg with McGrath VL or Macintosh laryngoscope; the primary outcome was the time to intubation. The Cormack and Lehane glottic grade, intubation difficulty score (IDS), and success rate on intubation were assessed. Haemodynamic changes were also recorded. RESULTS: As the primary outcome, median time to intubation [interquartile range] did not differ between the McGrath group and the Macintosh group (25.0 [22.8-28.3] s vs. 26.0 [24.0-29.0] s, P = 0.301). The incidence of grade I glottic view was significantly higher in the McGrath group than in the Macintosh group (95% vs. 74%, P = 0.013). Median IDS was lower in the McGrath group than in the Macintosh group (0 [0-0] vs. 0 [0-1], P = 0.018). There were no significant differences in success rate on intubation or haemodynamics between the two groups. CONCLUSIONS: McGrath VL provides better laryngeal views and lower IDS but similar intubation times and success rates compared with the Macintosh laryngoscope in children with normal airway.

The effect of low-volatile organic compounds, water-based paint on aggravation of allergic disease in schoolchildren.

Whether indoor painting aggravates preexisting allergic diseases remains unclear. We aimed to evaluate the impact of new classroom painting on aggravation of asthma, allergic rhinitis (AR), and atopic dermatitis (AD) in children. Studied school was previously painted with conventional water-based paint 20 years ago and had natural ventilation system. We identified a total of 172 children aged 10-12 years with allergic diseases in 17 classrooms, which were allocated to newly painted rooms with low-volatile organic compounds (VOC), water-based paint, or existing rooms. After painting, there was no intervention or internal airflow to influence indoor air environment in both classrooms. We prospectively assessed the symptom severity and serious events of allergic diseases between both classrooms at baseline and after one and eight weeks after painting. At one and eight weeks, there were no significant changes in the Childhood Asthma Control Test scores, the fractional nitric oxide levels, lung function in asthmatic children in either classroom. There were also no significant changes in the severity score of AR or AD, or serious events in all allergic diseases. These findings suggest classroom painting with this new paint at the levels encountered in this study might not be a major aggravating factor for school-aged children with allergic diseases.

The median effective dose of dexmedetomidine for laryngeal mask airway insertion with propofol 2.0 mg/kg.

BACKGROUND: Dexmedetomidine can be used as a co-induction agent to facilitate laryngeal mask airway (LMA) insertion with minimal effect on respiratory function. The purpose of the study was to determine the median effective dose (ED50) of dexmedetomidine to facilitate LMA insertion during anaesthesia induction with propofol 2.0 mg/kg without neuromuscular blockade. METHODS: Twenty-two patients, whose American Society of Anesthesiologists physical status was I or II with ages between 18 and 60 years undergoing minor orthopaedic or gynaecological surgery, were enrolled. After an injection of pre-determined bolus dose of dexmedetomidine over 2 min, anaesthesia was induced with propofol 2.0 mg/kg. The modified Dixon's up-and-down method was used to determine the bolus dose of dexmedetomidine, starting from 0.5 µg/kg (step size; 0.1 µg/kg). LMA insertion was conducted 90 s after the propofol injection, and the response of patients was categorized as either 'success' or 'failure.' RESULTS: Insertion of the LMA was unsuccessful in 12 of 22 patients. The ED50 (95% confidence interval) of dexmedetomidine for successful LMA insertion with propofol 2.0 mg/kg was 0.55 (0.44-0.66) µg/kg. Bradycardia occurred in four patients, and seven patients had an apneic episode. CONCLUSION: The single dose of dexmedetomidine for successful LMA insertion to be feasible in 50% of patients was 0.55 µg/kg during anaesthesia induction with propofol 2 mg/kg.

Effects of high positive end-expiratory pressure on haemodynamics and cerebral oxygenation during pneumoperitoneum in the Trendelenburg position.

We investigated the effects of 10 cmH2O positive end-expiratory pressure on cerebral haemodynamics and cerebral oxygenation in patients undergoing laparoscopic lower abdominal surgery in the 30° Trendelenburg position during desflurane anaesthesia. Twenty-six patients were enrolled in this study. After anaesthesia induction, pneumoperitoneum was applied in Trendelenburg position. Twenty minutes later, positive end-expiratory pressure was applied. There was no change in regional cerebral oxygen saturation (p = 0.376). Cerebral perfusion pressure decreased significantly over time (p < 0.001) and positive end-expiratory pressure caused a further decrease in cerebral perfusion pressure (p = 0.036). The application of 10 cmH2O positive end-expiratory pressure during pneumoperitoneum in the Trendelenburg position preserved regional cerebral oxygen saturation, but cerebral perfusion pressure decreased significantly due to its secondary haemodynamic effects.

Acid-base alterations during laparoscopic abdominal surgery: a comparison with laparotomy.

BACKGROUND: Carbon dioxide insufflation during laparoscopic surgery results in an acid-base imbalance. The purpose of this study was to investigate the effect of pneumoperitoneum on the acid-base status using Stewart's approach. METHODS: Thirty patients undergoing abdominal surgery were allocated to the laparotomy group (n=15) or the laparoscopy group (n=15). The acid-base parameters were measured 10 min after the induction (T1), 40 min after opening the peritoneum or pneumoperitoneum according to the group (T2), at the end of the surgery (T3), and 1 h after the surgery (T4). RESULTS: There were no significant differences in the standard base excess (SBE), strong ion gap, or anion gap between the two groups. In both groups, the SBE decreased at T2, T3, and T4 compared with baseline value. At T3 and T4 in the laparotomy group, the apparent strong ion difference (SIDa) and pH were decreased whereas the lactate and chloride were increased compared with their baseline values. At T2 in the laparoscopy group, the pH was decreased whereas Pa(CO(2)) was increased compared with their baseline values. CONCLUSIONS: The decrease in the pH during the pneumoperitoneum was affected by the increase in Pa(CO(2)), which promptly returned to a normal value after the desufflation. On the other hand, the decrease in the pH after laparotomy was affected by the metabolic factors, which persisted an hour after the surgery.

Optimal bolus dose of alfentanil for successful tracheal intubation during sevoflurane induction with and without nitrous oxide in children.

BACKGROUND: The goals of this study were to determine the effective bolus dose of alfentanil required for successful tracheal intubation during inhalation induction using sevoflurane 5% without neuromuscular block in children, and whether nitrous oxide reduces these doses. METHODS: Fifty paediatric patients, aged 3-10 yr, were randomly assigned to one of the two groups. Subjects received either sevoflurane 5% in oxygen 100% (O(2) group, n=25) or sevoflurane 5% in oxygen 40% and nitrous oxide 60% (N(2)O group, n=25) through a face mask. One minute after inhalation induction, a predetermined dose of alfentanil was injected over 15 s. The alfentanil dose was determined using Dixon's up-and-down method, starting from alfentanil 14 microg kg(-1). The trachea was intubated 3 min after inducing anaesthesia. RESULTS: The ED(50) [95% confidence interval (CI)] of alfentanil for successful tracheal intubation was 11.5 (9.9-13.1) and 8.6 (7.4-9.8) microg kg(-1) in the O(2) and N(2)O groups, respectively. The ED(50) of the N(2)O group was significantly lower than that of the O(2) group (P=0.0146)(.) From isotonic regression, 50% effective dose (ED(50)) (95% CI) of alfentanil in the O(2) and N(2)O groups was 11.4 (9.9-13.0) and 6.5 (5.0-8.1) microg kg(-1), respectively. CONCLUSIONS: The effective bolus dose of alfentanil for successful tracheal intubation was 11.5 microg kg(-1) in 50% of children during inhalation induction using sevoflurane 5% without neuromuscular blocking agent. Addition of nitrous oxide 60% in oxygen reduced the effective alfentanil dose by 25%.

Comparison of the incidence and severity of cough after alfentanil and remifentanil injection.

BACKGROUND: Intravenous administration of fentanyl derivatives can induce cough paradoxically. This study examined the incidence and severity of cough after a bolus of alfentanil and remifentanil. METHODS: Four hundred and sixty-five patients, aged 18-70 years, were allocated randomly to three groups to receive alfentanil 10 microg/kg, remifentanil 1 microg/kg or an equal volume of 0.9% saline intravenously over 10 s. Any episode of cough was classified as coughing and graded as mild (1-2), moderate (3-4) or severe (5 or more). RESULTS: The overall incidence of cough was higher in the opioid groups than in the saline group. The remifentanil group [39/150 patients; 26.0% (95% CI, 19.6-33.6%)] showed a higher incidence than the alfentanil group [11/152 patients; 7.2% (95% CI, 0.4-12.6%)] (P<0.001). There was no significant difference in the severity of cough between the alfentanil group and the remifentanil group. CONCLUSION: This study demonstrated that equipotent boluses of alfentanil and remifentanil induced coughing, even though the incidence of cough after alfentanil administration was lower than that after remifentanil administration.

Automated Detection of TMJ Osteoarthritis Based on Artificial Intelligence.

The purpose of this study was to develop a diagnostic tool to automatically detect temporomandibular joint osteoarthritis (TMJOA) from cone beam computed tomography (CBCT) images with artificial intelligence. CBCT images of patients diagnosed with temporomandibular disorder were included for image preparation. Single-shot detection, an object detection model, was trained with 3,514 sagittal CBCT images of the temporomandibular joint that showed signs of osseous changes in the mandibular condyle. The region of interest (condylar head) was defined and classified into 2 categories-indeterminate for TMJOA and TMJOA-according to image analysis criteria for the diagnosis of temporomandibular disorder. The model was tested with 2 sets of 300 images in total. The average accuracy, precision, recall, and F1 score over the 2 test sets were 0.86, 0.85, 0.84, and 0.84, respectively. Automated detection of TMJOA from sagittal CBCT images is possible by using a deep neural networks model. It may be used to support clinicians with diagnosis and decision making for treatments of TMJOA.

Prevention of propofol-induced pain in children: combination of alfentanil and lidocaine vs alfentanil or lidocaine alone.

BACKGROUND: Pain from a propofol injection is a common side-effect in paediatric patients. This prospective, randomized, double-blind study evaluated the efficacy of a combined pretreatment of alfentanil with lidocaine on the incidence and severity of propofol injection pain in children. METHODS: After obtaining parental consent, 120 paediatric patients were allocated randomly into one of the three groups (n=40, in each). The patients in the alfentanil group received alfentanil 15 microg kg(-1) 90 s before the propofol injection. The patients in the lidocaine group received propofol 3 mg kg(-1) premixed with lidocaine 0.1% over a 15 s period. The patients in the combination group received both alfentanil and lidocaine. RESULTS: The incidence of propofol injection pain (severity 2 or more) in the combination group (2.6%) was significantly lower than that in the alfentanil and lidocaine groups (30% and 38.5%, respectively) (P=0.001 and <0.001, respectively). No patient in the combination group complained of moderate or severe pain from propofol injection. CONCLUSIONS: Our study demonstrated that the combination treatment of two different analgesic modalities, alfentanil and lidocaine, could prevent the moderate and severe pain on propofol injection, and reduce the incidence of mild pain compared with each drug alone.

Post-induction alfentanil reduces sevoflurane-associated emergence agitation in children undergoing an adenotonsillectomy.

BACKGROUND: Emergence agitation is a common problem in paediatric anaesthesia, especially after volatile induction and maintenance anaesthesia (VIMA) with sevoflurane. The purpose of this study was to investigate the effect of alfentanil to prevent emergence agitation without delayed recovery after VIMA with sevoflurane in children undergoing an adenotonsillectomy. METHODS: One hundred and five children, aged 3-10 years, were randomly allocated to receive normal saline (control group), alfentanil 10 microg/kg (A10) or 20 microg/kg (A20) 1 min after loss of the eyelash reflex. Anaesthesia was induced and maintained with sevoflurane. Time to tracheal extubation, recovery time, Paediatric Anaesthesia Emergence Delirium (PAED) scale and emergence behaviour were assessed. RESULTS: The incidence of severe agitation was significantly lower in the A10 and A20 groups compared with those in the control group (11/32 and 12/34 vs. 24/34, respectively) (P=0.007, 0.006, respectively). PAED scales were significantly different between the three groups (P=0.008), and lower in the A10 and A20 groups than that in the control group (P=0.044, 0.013, respectively). However, the incidence of severe agitation and PAED scale was not different between the A10 and the A20 groups. Time to tracheal extubation and recovery time were similar in all three groups. CONCLUSION: The administration of alfentanil 10 microg/kg after induction of anaesthesia for children undergoing an adenotonsillectomy under VIMA reduced the incidence of emergence agitation without delaying the recovery time or causing significant hypotension.

The optimal bolus dose of alfentanil for tracheal intubation during sevoflurane induction without neuromuscular blockade in day-case anaesthesia.

BACKGROUND: The purpose of this study was to determine the optimal bolus dose of alfentanil required to provide successful intubating conditions following inhalation induction of anaesthesia using 5% sevoflurane and 60% nitrous oxide without neuromuscular blockade in adult day-case anaesthesia. METHODS: Twenty-four adults, aged 18-60 years, undergoing general anaesthesia for short ambulatory surgery were enroled into the study. After vital capacity induction, with sevoflurane 5% and 60% nitrous oxide in oxygen, pre-determined dose of alfentanil was injected over 30 s. The dose of alfentanil was determined by modified Dixon's up-and-down method (2 microg/kg as a step size). Ninety seconds after the end of bolus administration of alfentanil, the trachea was intubated. Systolic blood pressure, heart rate and SpO2 were recorded at anaesthetic induction, before, 1 min and 3 min after intubation. RESULTS: The bolus dose of alfentanil for successful tracheal intubation was 10.7+/-2.1 microg/kg in 50% of patients during inhalation induction. From probit analysis, 50% effective dose (ED(50)) and ED(95) values (95% confidence limits) of alfentanil were 10.7 microg/kg (8.0-12.9 microg/kg) and 14.9 microg/kg (12.9-31.1 microg/kg), respectively. CONCLUSIONS: Using the modified Dixon's up-and-down method, the bolus dose of alfentanil for successful tracheal intubation was 10.7+/-2.1 microg/kg in 50% of adult patients during inhalation induction using 5% sevoflurane and 60% nitrous oxide in oxygen without neuromuscular blocking agent in day-case anaesthesia.

The optimum bolus dose of remifentanil to facilitate laryngeal mask airway insertion with a single standard dose of propofol at induction in children.

The purpose of this study was to determine the optimal bolus dose of remifentanil required for the successful insertion of the laryngeal mask airway during propofol induction in children without a neuromuscular blocking agent. Twenty-six paediatric patients, aged 3-10 years, requiring anaesthesia for short ambulatory surgery were recruited. A predetermined bolus dose of remifentanil was injected over 30 s, followed by propofol 2.5 mg.kg(-1) over 10 s. The bolus dose of remifentanil was determined by a modified Dixon's up-and-down method, starting from 0.5 microg.kg(-1) (0.1 microg.kg(-1) as a step size). Laryngeal mask insertion was attempted 90 s after the end of remifentanil injection and the response of patients was classified as either 'movement' or 'no movement'. The bolus dose of remifentanil at which there was a 50% probability of successful laryngeal mask insertion (ED(50)) during induction with 2.5 mg.kg(-1) propofol was 0.56 (0.07) microg.kg(-1) in children without a neuromuscular blocking agent. From probit analysis, the ED(50) and ED(95) of remifentanil were 0.52 microg.kg(-1) (95% confidence limits, 0.42-0.62 microg.kg(-1)) and 0.71 microg.kg(-1) (95% confidence limits, 0.61-1.40 microg.kg(-1)), respectively.

Angiopoietin-2 at high concentration can enhance endothelial cell survival through the phosphatidylinositol 3'-kinase/Akt signal transduction pathway.

The angiopoietin-Tie2 system in endothelial cells is an important regulator of vasculogenesis and vascular integrity. High levels of angiopoietin-2 (Ang2) mRNA are observed in vascular activation during tumorigenesis. Although Ang2 is known to be a naturally occurring antagonist of angiopoietin-1 (Ang1) in vivo, the exact function of Ang2 itself is not known. Here, we found that a high concentration of Ang2 (800 ng/ml) acts as an apoptosis survival factor for endothelial cells during serum deprivation apoptosis. The survival effect of high concentration Ang2 was blocked by pre-treatment with soluble Tie2 receptor and the PI 3'-kinase-specific inhibitors, wortmannin and LY294002. Accordingly, 800 ng/ml of Ang2 induced phosphorylation of Tie2, the p85 subunit of phosphatidylinositol 3'-kinase (PI 3'-kinase), and serine-threonine kinase Akt at Ser473 in the human umbilical vein endothelial cells; lower concentrations of Ang2 (50 - 400 ng/ml) did not produce notable effects. These findings indicate that at high concentrations, Ang2, like Ang1, can be an apoptosis survival factor for endothelial cells through the activation of the Tie2 receptor, PI 3'-kinase and Akt, and thus may be a positive regulator of tumor angiogenesis. Oncogene (2000) 19, 4549 - 4552.

Angiopoietin-1 inhibits irradiation- and mannitol-induced apoptosis in endothelial cells.

BACKGROUND AND PURPOSE: Angiopoietin-1 (Ang1) is a vasculogenic factor that signals through the endothelial cell-specific Tie2 receptor tyrosine kinase. We recently reported that Ang1 prevented apoptosis induced by serum deprivation in endothelial cells. In this study, we examined whether Ang1 prevents apoptosis in endothelial cells treated with irradiation or clinical concentrations of mannitol. METHODS AND RESULTS: ++Ang1 prevented irradiation- and mannitol-induced apoptosis in human umbilical vein endothelial cells in a dose-dependent manner. Pretreatment with soluble Tie2 receptor, but not Tie1 receptor, blocked the antiapoptotic effect of Ang1. Two phosphatidylinositol 3'-kinase (PI3-kinase)-specific inhibitors, wortmannin and LY294002, blocked the Ang1-induced antiapoptotic effect. The antiapoptotic potency of Ang1 was similar to or greater than that of vascular endothelial growth factor, basic fibroblast growth factor, and endothelin-1. Ang1 also prevented apoptosis in cultured endothelial cells from porcine pulmonary and coronary arteries and in endothelial cells of explanted rat aorta. CONCLUSIONS: Ang1 promotes the survival of endothelial cells in irradiation- and mannitol-induced apoptosis through Tie2 receptor binding and PI3-kinase activation. Pretreatment with Ang1 could be beneficial in maintaining normal endothelial cell integrity during intracoronary irradiation or systemic mannitol therapy.

Effect of angiotensin-converting enzyme inhibitors on phenylephrine responsiveness in patients with valvular heart disease.

We studied patients with valvular heart disease to investigate whether chronic preoperative treatment with angiotensin-converting enzyme (ACE) inhibitors modulates the effect of phenylephrine (PE) on anaesthesia-induced hypotension. Sixty-five patients were enrolled in the study and hypotension developed after anaesthesia in 36 (18 in the control group and 18 in the ACE inhibitor group). These patients received PE infusions, which were increased in a stepwise fashion at 10-min intervals. Increased mean arterial pressure due to PE infusion was significant only in the control group. There was no significant difference in pressor response or change in haemodynamic variables with PE infusion between the two groups. Treatment with ACE inhibitors did not increase the incidence of hypotensive episodes or significantly modify pressor response after anaesthesia in patients with valvular heart disease.

Angiopoietin-1 is an apoptosis survival factor for endothelial cells.

We examined the effect of angiopoietin-1 (Ang1) on apoptosis in human umbilical vein endothelial cells (HUVECs). Ang1 (5-1000 ng/ml) dose-dependently inhibited apoptosis under a serum-deprived state. A significant apoptotic inhibition occurred with as low as 50 ng/ml. Two hundred ng/ml of Ang1 inhibited to approximately 50% of the control apoptotic rates for 96 h. Furthermore, an augmented antiapoptotic effect of Ang1 by the addition of 20 ng/ml vascular endothelial growth factor was observed. This Ang1-induced strong antiapoptotic effect in endothelial cells is a novel and intriguing finding and could be an additional description of Ang1-induced direct biological function.

Molecular cloning and characterization of a novel angiopoietin family protein, angiopoietin-3.

Using homology-based PCR, we have isolated cDNA encoding a novel member (491 amino acids) of the angiopoietin (Ang) family from human adult heart cDNA and have designated it angiopoietin-3 (Ang3). The NH2-terminal and COOH-terminal portions of Ang-3 contain the characteristic coiled-coil domain and fibrinogen-like domain that are conserved in other known Angs. Ang3 has a highly hydrophobic region at the N-terminus (approximately 21 amino acids) that is typical of a signal sequence for protein secretion. Ang3 mRNA is most abundant in adrenal gland, placenta, thyroid gland, heart and small intestine in human adult tissues. Additionally, Ang3 is a secretory protein, but is not a mitogen in endothelial cells.

Comparison of biological phenotypes according to midkine expression in gastric cancer cells and their autocrine activities could be modulated by pentosan polysulfate.

We studied biological phenotypes of gastric cancer cell lines based on a novel heparin-binding growth/differentiation factor (midkine (MK)) expression. MK expression was found in 67% (6/9) of the gastric cancer cell lines and 56% (14/25) of the primary cancer tissues. Gastric cancer cell lines with MK expression showed higher colony forming activity in soft agar assay and endothelial cell growth stimulatory effect in cross-feeding assay than cells which did not express MK. However, urokinase-type plasminogen activator (uPA) expression and tumor invasiveness did not correlate with MK expression. Growth of MK expressing cells was inhibited by a heparin-binding blocking agent, pentosan polysulfate (PPS). In cancer tissues, MK expression correlated with tumor size, suggesting in vivo autocrine and paracrine activity. This proliferation promoting activity of MK can be targeted by an anti-heparin binding agent as a biotherapy model in gastric cancer.

Induction of granulocytic differentiation in acute promyelocytic leukemia cells (HL-60) by water-soluble chitosan oligomer.

Water-soluble chitosan oligomer (WSCO) has been reported to have anticancer activity, immuno-enhancing effect and antimicrobial activity. However, other biological activities are unknown. Herein, we have shown that WSCO is able to inhibit proliferation of human leukemia HL-60 cells and induce these cells to differentiate. Treatment with WSCO for 4 days resulted in a concentration-dependent reduction in HL-60 cell growth as measured by cell counting and MTT assay. This effect was accompanied by a marked increase in the proportion of G(0)/G(1) cells as measured by flow cytometry. WSCO also induced differentiation of the cells as measured by phorbol ester-dependent reduction of NBT, morphological changes as examined by Wright-Giemsa staining and expression of CD11b but not of CD14 as analysed by flow cytometry, indicating differentiation of HL-60 cells toward granulocyte-like cells. A combination of low dose of WSCO with all-trans retinoic acid, a differentiating agent toward granulocyte-like cells, exhibited a synergistic effect on the differentiation. In addition, treatment of HL-60 cells with WSCO for 6 or 8 days resulted in the induction of apoptosis as assayed qualitatively by agarose gel electrophoresis and quantitatively by Annexin V technique using flow cytometry. Collectively, there is a potential for WSCO in the treatment of myeloid leukemia.