Paradoxical increase in the PPG amplitude

Background : Although an increase in sympathetic nerve activity is generally associated with a decrease in the photoplethysmography (PPG) amplitude, the present case study demonstrates that nociceptive stimuli, such as tracheal intubation, paradoxically induce an increase in PPG amplitude. To the best of our knowledge, this is the first study to capture an increase in the PPG amplitude in response to sympathetic nerve activation. Case presentation : A 73-year-old woman underwent open surgery. Following anesthesia induction, tracheal intubation was performed, which resulted in increased heart rate and raised blood pressure. While nociception usually decreases the PPG amplitude, the opposite was found. Conversely, the vascular stiffness K value, our research group’s unique monitoring method to quantify the strength of sympathetic activity, increased reflecting increased peripheral vascular resistance. Conclusions : We report a paradoxical case of increased PPG amplitude following tracheal intubation. It is important to note that the PPG amplitude does not always decrease with nociceptive stimuli

Inflammatory Polyp of the Gallbladder Mimicking Early Polypoid Carcinoma

We treated a 69-year-old male with a 16-mm polyp of the gallbladder. Enhanced computed tomography demonstrated marked enhancement. With a tentative diagnosis of early polypoid cancer of the gallbladder, open cholecystectomy was performed. Intraoperative ultrasound showed hyperechoic spots on the surface of the polyp with an inner echopenic area. The histological diagnosis was an inflammatory polyp that manifested nonneoplastic, edematous stroma, and infiltration of lymphcytes and plasmacytes

Branched-chain amino acids-induced cardiac protection against ischemia/reperfusion injury

Aims: Amino acids, especially branched chain amino acids (BCAAs), have important regulatory roles in protein synthesis. Recently studies revealed that BCAAs protect against ischemia/reperfusion (I/R) injury. We studied the signaling pathway and mitochondrial function affecting a cardiac preconditioning of BCAAs. Main methods: An in vivo model of I/R injury was tested in control, mTOR+/+, and mTOR+/−. Mice were randomly assigned to receive BCAAs, rapamycin, or BCAAs + rapamycin. Furthermore, isolated cardiomyocytes were subjected to simulated ischemia and cell death was quantified. Biochemical and mitochondrial swelling assays were also performed. Key findings: Mice treated with BCAAs had a significant reduction in infarct size as a percentage of the area at risk compared to controls (34.1 ± 3.9% vs. 44.7 ± 2.6%, P = 0.001), whereas mice treated with the mTOR inhibitor rapamycin were not protected by BCAA administration (42.2 ± 6.5%, vs. control, P = 0.015). This protection was not detected in our hetero knockout mice of mTOR. Western blot analysis revealed no change in AKT signaling whereas activation of mTOR was identified. Furthermore, BCAAs prevented swelling which was reversed by the addition of rapamycin. In myocytes undergoing simulated I/R, BCAA treatment significantly preserved cell viability (71.7 ± 2.7% vs. 34.5 ± 1.6%, respectively, p < 0.0001), whereas rapamycin prevented this BCAA-induced cardioprotective effect (43.5 ± 3.4% vs. BCAA, p < 0.0001). Significance: BCAA treatment exhibits a protective effect in myocardial I/R injury and that mTOR plays an important role in this preconditioning effect.This work was supported by JSPS KAKENHI, Japan [grant number 19K09353]

Genetic screening for malignant hyperthermia and comparison of clinical symptoms in Japan

Malignant hyperthermia (MH) is an anaesthetic complication that causes an abnormal hypermetabolic state. RYR1 encoding ryanodine receptors of the sarcoplasmic reticulum and CACNA1S encoding α subunits of dihydropyridine receptors are known to be associated with MH pathogenicity. We performed genetic screening using next-generation sequencing to evaluate the prevalence of genes associated with MH pathogenicity and clinical symptoms. This was a retrospective cohort study wherein next-generation sequencing data of 77 families diagnosed with MH predisposition by calcium-induced calcium release (CICR) tests from 1995 to 2019 was used to search for RYR1 and CACNA1S variants. Furthermore, the clinical symptoms and predisposition tests in participants with RYR1 and CACNA1S variants were compared. In the 77 families, 44.2%, 7.8%, and 48.1% individuals had RYR1, CACNA1S, and neither RYR1 nor CACNA1S variants, respectively. Clinically significant differences were found in the maximum body temperature, maximum elevated body temperature for 15 min, creatinine kinase level, and CICR rate between the RYR1 and CACNA1S groups. The prevalence of pathogenic CACNA1S variants appears to be prominent in Japan. The severity of clinical symptoms and the CICR rate were greater in individuals with RYR1 variants than in those with CACNA1S variants, likely due to more direct regulation of calcium levels by ryanodine receptors than by dihydropyridine receptors. Genetic analysis of MH in future studies may help identify other genes associated with MH, which will further clarify the relationship between genotypes and MH symptoms and contribute to safer anaesthesia practice.This study was supported by a Grant-in-Aid for Young Scientists (grant number: 17K16733 to Y.N. and 20K17783 to R.K.) from the Japan Society for the Promotion of Science and by the Takeda Science Foundation (H.K.)

Gastric perforation caused by Candida infection：Report of a case

An 89-year-old female was admitted to our hospital because of fever and abdominal pain. The patient had used an antihypertensive agent, but had not used either antibiotics, steroids, or potent antacids. An abdominal CT scan revealed free air and ascites. An emergency operation was performed for acute peritonitis caused by a gastrointestinal perforation. A perforated ulcer was observed at the posterior wall of the gastric body. A distal gastrectomy with intraperitoneal drainage and a Billroth II reconstruction was performed. A histological examination demonstrated a perforated ulcer surrounded by Candida infection. The patient developed an abscess in the abdominal cavity, but was discharged on the 52nd postoperative day. Although gastrointestinal Candida infection is commonly seen in immunocompromised host with diabetics or malignant diseases, habitual use of strong antacids can also cause severe Candida infection of the stomach in healthy persons. In this case, it was thus concluded that there may have been a decrease in immunity in this patient because of her advanced age 89 years old and malnutrition

Limited pancreatectomy for metastatic pancreatic tumors from renal cell carcinoma

Background/Aims: Metastasis of renal cell carcinoma (RCC) to distant organs occurs commonly, even after radical nephrectomy, but metastatic lesions are rarely detected in the pancreas. The present study aim was to improve the postoperative quality of life of a patient with pancreatic metastasis of RCC through limited resection of the pancreas. Methodology: Since therapeutic modalities including chemotherapy or radiation are ineffective for metastatic tumors, surgical intervention is a treatment of choice in selected patients. In patients with multiple pancreatic metastases, however, near-total or total pancreatectomy may result in a lower quality of life postoperatively due to endocrine and exocrine pancreatic insufficiency. Results: We used limited resection of the pancreas combined with removal of the uncinate process and distal pancreatectomy for a 65-year-old woman with multifocal pancreatic metastases located in the uncinate process, body, and tail of the pancreas, which were detected 6 years after radical nephrectomy for RCC. This surgical procedure allowed preservation of about 40% of the pancreatic parenchyma, with complete excision of metastatic tumors in the pancreas. Conclusions: The patient has had an excellent quality of life with well-preserved pancreatic function and no evidence of tumor recurrence for 31 months after pancreatic surgery

A Metastatic Jejunal Tumor from Squamous Cell Carcinoma of the Lung Found in an Intestinal Perforation

An 85-year-old male with advanced squamous cell carcinoma of the lung, who was diagnosed about 10 years prior to his current presentation, suddenly complained of abdominal pain and underwent an abdominal computed tomography scan, which revealed free air and massive ascites. He was admitted to our hospital for acute peritonitis and emergency surgery was performed. During the surgical procedure, a perforation of the jejunum was diagnosed and repaired. He was diagnosed to have a metastatic tumor originating from a squamous cell carcinoma of the lung. He improved and was transferred to the former hospital on the 27th postoperative day. Jejunal metastasis from squamous cell carcinoma of the lung is rare, and the prognosis of peritonitis due to a perforated intestinal metastasis from lung cancer is poor. There have been 10 reports of jejunal metastasis of squamous cell carcinoma of the lung reported in Japan between 2000 and 2011. Therefore, when patients with advanced lung cancer present with acute abdomen, it is necessary to keep in mind the possibility of a gastrointestinal metastatic tumor

Design and scale-up methodology for multi-phase reactors based on non-linear dynamics

Multi-phase reactors exhibit chaotic behaviors due to the highly turbulent motions of bubbles and phase interactions, leading to the formation of a complex spatio-temporal flow structure. The instantaneous motions of bubbles and wakes were studied by local measurements of bubble and particle-velocity fluctuations, bubble-wake structure, bubble shape and orientation. The chaotic dynamics of bubble and particle motions in multi-phase reactors were characterized in terms of the correlation dimension obtained by the deterministic chaos analysis for the series of time intervals between successive bubbles or particles by means of the embedding method. Three different methods, the deterministic chaos analysis, the short-term predictability analysis and the rescaled range (R/S) analysis, were applied to the non-linear dynamics of multi-phase reactors. The scale-up effect in the dynamic behavior of multi-phase reactors was investigated by using columns of different diameters. In addition, the non-linear hydrodynamic motions of bubbles and particles in multi-phase reactors have been modeled by means of an ANN (Artificial Neural Network) trained with time series data of voidage fluctuations for gas and solid phases. By successively adapting its output to input, the ANN can generate time-series data for any superficial gas velocity. The bifurcation diagrams of both bubble and particle motions generated by the trained ANN demonstrated that the ANN is capable of predicting and modeling the chaotic dynamics of multi-phase reactors.

Small Bowel Obstruction Caused by Bezoars

The aim of the present study was a clinical analysis of small bowel obstruction caused by bezoars surgically treated. Seven patients with small bowel obstruction caused by bezoars were retrospectively reviewed. Two patients had undergone gastric surgery. The symptoms before surgery lasted from 1 to 3 days in the non-ileus tube group and from 9 to 30 days in the ileus tube group. Four patients were preoperatively diagnosed with bezoar ileus, and one had intestinal tumor. The remaining two patients were diagnosed with postoperative adhesive ileus. The operative procedure was evacuation of bezoars for all patients. One patient needed incisions of the small intestine and the stomach for the complete evacuation of bezoars. The site of the small bowel obstruction was the ileum in all patients, and bezoars ranged from 30 to 60 mm in diameter. Morbidity was present in one patient who underwent insertion of ileus tube for a long-term treatment. Small bowel obstruction caused by bezoars is not uncommon in patients without any gastric surgery. It is important, preoperatively and intraoperatively, to examine the entire gastrointestinal tract for the presence of bezoars. When bezoars ileus was suspected, insertion of ileus tube should be avoided