66-year-old woman with amyotrophic lateral sclerosis was scheduled for closed reduction and external fixation of left tibio-fibula. Total intravenous anesthesia using 2% propofol and remifentanil was done without muscle relaxant to avoid possible postoperative respiratory complication and pulmonary aspiration. The surgery had done without difficulty and she recovered from anesthesia promptly without respiratory complication and pulmonary aspitation. She discharged satisfactorily 15 days after surgery.
Aged ; Amyotrophic Lateral Sclerosis* ; Anesthesia ; Anesthesia, Intravenous* ; Female ; Humans ; Muscle Relaxation* ; Propofol

Purpose: Deregulation of SNCA encoding α-synuclein (α-SYN) has been associated with both the familial and sporadic forms of Parkinson disease (PD). Epigenetic regulation plays a crucial role in PD. The intron1 of SNCA harbors a large unmethylated CpG island. Ten-eleven translocation methylcytosine dioxygenase 1 (TET1), a CpG island binding protein, can repress gene expression by occupying hypomethylated CpG-rich promoters, and therefore SNCA could be a target for TET1. We investigated whether TET1 binds to SNCA-intron1 and regulates gene expression. Methods: The dopaminergic neuronal cell line, ReNcell VM, was used. Reverse transcription-polymerase chain reaction (RT-PCR), real time-quantitative PCR, Western blot, dot-blot, and Chromatin immunoprecipitation were conducted. The substantia nigra tissues of postmortem PD samples were used to confirm the level of TET1 expression. Results: In the human dopaminergic cell line, ReNcell VM, overexpression of the DNA-binding domain of TET1 (TET1-CXXC) led to significant repression of α-SYN. On the contrary, knocking down of TET1 led to significantly higher expression of α-SYN. However, overexpression of the DNA-hydroxymethylating catalytic domain of TET1 failed to change the expression of α-SYN. Altogether, we showed that TET1 is a repressor for SNCA, and a CXXC domain of TET1 is the primary mediator for this repressive action independent of its hydroxymethylation activity. TET1 levels in PD patients are significantly lower than that in the controls. Conclusions We identified that TET1 acts as a repressor for SNCA by binding the intron1 regions of the gene. As a high level of α-SYN is strongly implicated in the pathogenesis of PD, discovering a repressor for the gene encoding α-SYN is highly important for developing novel therapeutic strategies for the disease.

OBJECTIVE: Many studies have demonstrated that carbon dioxide has direct depressive effects on the myocardium and dilates the vascular bed. However, it leads to an increase in arterial blood pressure and cardiac output because of sympathetic stimulating effect. Extensive epidural block may impair the sympathetic innervation to the heart as well as to the adrenal gland. The present study was set up in order to investigate how an extensive epidural block would affect the hemodynamic response to sympathetic stimulation induced by hypercapnia. METHODS: Twenty patients were mechanically ventilated under general anesthesia after epidural catheter insertion on T6–T7 intervertebral space. Hypercapnia was obtained by CO2 breathing. PaCO2 (partial pressure of CO2, arterial) was adjusted to 30, 45, and 60 mm Hg with each concentration being maintained for 10 minutes. In each period, hemodynamic variables were monitored by pulmonary artery catheter. After returning to normocarbia for 15 minutes, 20 mL of 0.375% ropivacaine was injected epidurally and PaCO2 was adjusted in the same manner, and then, the hemodynamic variables of each period were checked. RESULTS: There were no changes in mean arterial pressure and heart rate by hypercapnia after combined epidural anesthesia compared with general anesthesia only. Hypercapnia increased cardiac output and cardiac index. Systemic vascular resistance was decreased significantly. Pulmonary artery pressure was increased but not significantly. The degrees of hemodynamic changes were similar between in general anesthesia alone and in combined epidural anesthesia. CONCLUSION: In spite of an extensive epidural block, hemodynamic changes induced by hypercarbnia were not changed. There are some ‘escaped’ sympathetic nerve fibers.
Adrenal Glands ; Anesthesia* ; Anesthesia, Epidural* ; Anesthesia, General ; Arterial Pressure ; Carbon Dioxide ; Cardiac Output ; Catheters ; Heart ; Heart Rate ; Hemodynamics* ; Humans ; Hypercapnia* ; Myocardium ; Nerve Fibers ; Pulmonary Artery ; Respiration ; Vascular Resistance

Small bowel diseases comprised of neoplasm, inflammatory disease, vascular abnormality, absorption dysfunction, and iatrogenic causes. Among those, vascular abnormality is perhaps the most important clinical disease entity. Obscure gastrointestinal bleeding accounts for 5% of chronic gastrointestinal bleeding, but conventional endoscopy and radiologic study may fail to diagnose the cause in certain cases. Patients with neurofibromatosis type 1 have a lot of gastrointestinal tumor, with a high incidence of small bowel involvement. We experienced a case presenting with chronic bleeding due to jejunal gastrointestinal stromal tumor diagnosed by capsule endoscopy in a seventy-two year old female patient with sporadic neurofibromatosis type 1.
Absorption ; Capsule Endoscopy* ; Endoscopy ; Female ; Gastrointestinal Stromal Tumors ; Hemorrhage* ; Humans ; Incidence ; Neurofibromatoses* ; Neurofibromatosis 1* ; Vascular Diseases

BACKGROUND: Previous studies have shown that measuring the distance from the skin to the ligamentum flavum by ultrasound preceding cervical epidural block can be beneficial in excluding false loss of resistance. However, the measurement value using ultrasound may vary depending on the degree of operator experience. Therefore, we aimed to determine the depth from skin to cervical epidural space by using lateral cervical spine X-ray, which is a more intuitive method. METHODS: We enrolled 102 adult patients who were scheduled to undergo cervical epidural anesthesia for vascular bypass surgery of upper arm. After attaching a steel rod on the needle insertion site, lateral cervical spine X-ray was taken before the epidural procedure. We measured the distance from the steel rod to the midpoint of interlaminar space on the spinolaminar line. The X-ray depth was compared with needle depth. RESULTS: Of the 102 enrolled patients, 18 patients including 13 in whom we were unable to measure X-ray depth were excluded from the analysis. In total, 84 patients were included in the analysis. Concordance correlation coefficient between the X-ray-measured depth and needle depth was 0.925. Bland-Altman analysis indicated a mean difference of ± 1.96 SD with 0.06 ± 0.56 cm. CONCLUSIONS: Lateral cervical spine X-ray can be useful for prediction of the midline depth from skin to epidural space, particularly for operators who are not skilled at spine ultrasound or the use the C-arm fluoroscopy.
Adult ; Anesthesia ; Anesthesia, Epidural ; Arm ; Cervical Vertebrae ; Epidural Space* ; Female ; Fluoroscopy ; Humans ; Ligamentum Flavum ; Methods ; Neck ; Needles ; Skin* ; Spine* ; Steel ; Ultrasonography

BACKGROUND: The purpose of this study was to evaluate the effect of intraoperative dexmedetomidine sedation on patient's and surgeon's satisfaction during retinal surgery under sub-tenon's anesthesia. METHODS: Forty-four patients scheduled for elective retinal surgery under sub-tenon's anesthesia were enrolled in this randomized controlled trial. The patients were divided into Dexmedetomidine (n = 22) and Control (n = 22) groups. Intravenous dexmedetomidine or 0.9% saline via infusion pump were administered continuously to the dexmedetomidine or control group, respectively. Ramsay sedation scale with a target level of 3-4 was used to assess adequacy of sedation. Perioperative pain, hemodynamic and respiratory data were collected, while satisfaction from patients and surgeon were assessed post-surgery using a 5-point satisfaction scale. RESULTS: Patient and surgeon satisfaction was higher in the dexmedetomidine group (P < 0.001, P = 0.002, respectively). The pain associated with sub-tenon's anesthesia and peripheral vitrectomy was lesser in the dexmedetomidine group than in the control group (P = 0.020). There was significant reduction of heart rate in the dexmedetomidine group (P = 0.001), but only one patient needed treatment with atropine. There was no respiratory effect on both groups. CONCLUSIONS: Dexmedetomidine sedation during retinal surgery improved satisfaction from both patient and surgeon without respiratory complication. It is a safe and preferable choice of sedation for retinal surgery.
Anesthesia* ; Atropine ; Conscious Sedation ; Dexmedetomidine* ; Heart Rate ; Hemodynamics ; Humans ; Infusion Pumps ; Patient Satisfaction ; Retinaldehyde* ; Vitrectomy ; Vitreoretinal Surgery

We describe a case of a 35-year-old male patient who was scheduled for laparoscopic cholecystectomy and developed a life-threatening anaphylactic reaction 2 min after the administration of sugammadex. He manifested erythematous wheals on the entire body, dyspnea, hypotension, and tachycardia. These symptoms disappeared after the administration of epinephrine. The patient recovered and was discharged at postoperative day 5 without any complications. After 7 weeks, we performed a skin prick test, and there was a weakly positive reaction for sugammadex. This case is suspected anaphylaxis associated with sugammadex, and we need to be aware that the use of sugammadex is associated with a serious risk of anaphylaxis.
Adult ; Anaphylaxis* ; Cholecystectomy, Laparoscopic ; Dyspnea ; Epinephrine ; Humans ; Hypotension ; Male ; Skin ; Tachycardia

BACKGROUND: Corneal abrasion is one of the most common ophthalmic complications that occurs after general anesthesia. Although they can occur by direct contact with surgical drapes or masks, most occur as a result of the drying of the cornea exposed during general anesthesia due to a reduced amount of tear secretions, the loss of light reflex, or the loss of recognition of pain during the procedure. Thus, to prevent corneal abrasions during general anesthesia, proper eye protection is required. METHODS: Seventy-two patients (144 eyes) were divided into four groups as follows: 1) control group: careful manual eye closure; 2) adhesive tape group: a bandage attached over the eyelid; 3) ointment group: eye ointment placed into the eye followed by eye closure; and 4) ointment and tape group: eye ointment placed into the eye followed by a bandage attached over the eyelid, with the patient subjected to both methods for each eye. The National Eye Institute (NEI) scale, conjunctiva hyperemia scale, tear break-up time, and Schmer test were conducted before and after operation. RESULTS: No statistically significant difference was noted between groups regarding the NEI scale, conjunctiva hyperemia scale, tear break-up time, or Schirmer test. CONCLUSIONS: To prevent corneal abrasions in normal patients undergoing general anesthesia, eye taping, eye ointment application, or taping after eye ointment application will not significantly reduce the degree of corneal epithelial damage compared to manual eye closure.
Adhesives ; Anesthesia ; Anesthesia, General* ; Bandages ; Conjunctiva ; Cornea ; Eyelids ; Humans ; Hyperemia ; Intraoperative Complications ; Masks ; Methods* ; National Eye Institute (U.S.) ; Reflex ; Surgical Drapes ; Tears

Monitoring cerebral oxygenation using a near infrared spectroscopy (NIRS) device is useful for estimating cerebral hypoperfusion and is available during liver transplantation (LT). However, high serum bilirubin concentration can interfere with NIRS because bilirubin absorbs near infrared light. We report a patient who underwent LT with a diagnosis of vanishing bile duct syndrome, whose regional cerebral oxygen saturation (rSO₂) remained below 15% even with alert mental status and SpO2₂ value of 99%. The rSO₂ values were almost fixed at the lowest measurable level throughout the intra- and postoperative period. We report a case of erroneously low rSO₂ values during the perioperative period in a liver transplant recipient which might be attributable to skin pigmentation rather than higher serum bilirubin concentration.
Bile Ducts* ; Bile* ; Bilirubin ; Diagnosis ; Humans ; Hyperbilirubinemia ; Hypoxia, Brain ; Liver Transplantation* ; Liver* ; Oxygen* ; Perioperative Period ; Postoperative Period ; Skin Pigmentation ; Spectrum Analysis ; Transplant Recipients

Human reflexes are simple motor responses that are automatically elicited by various sensory inputs. These reflexes can provide valuable insights into the functioning of the nervous system, particularly the brainstem and spinal cord. Reflexes involving the brainstem, such as the blink reflex, laryngeal adductor reflex, trigeminal hypoglossal reflex, and masseter H reflex, offer immediate information about the cranial-nerve functionality and the overall state of the brainstem. Similarly, spinal reflexes such as the H reflex of the soleus muscle, posterior root muscle reflexes, and sacral reflexes provide crucial information about the functionality of the spinal cord and peripheral nerves. One of the critical benefits of reflex monitoring is that it can provide continuous feedback without disrupting the surgical process due to no movement being induced in the surgical field. These reflexes can be monitored in real time during surgical procedures to assess the integrity of the nervous system and detect potential neurological damage.It is particularly noteworthy that the reflexes provide motor and sensory information on the functional integrity of nerve fibers and nuclei. This article describes the current techniques used for monitoring various human reflexes and their clinical significance in surgery. We also address important methodological considerations and their impact on surgical safety and patient outcomes. Utilizing these methodologies has the potential to advance or even revolutionize the field of intraoperative continuous monitoring, ultimately leading to improved surgical outcomes and enhanced patient care.