Conjoined twins are one of the most intriguing malformations in human beings. This report describes the anesthetic management of a two-day-old pretermomphalopagus conjoined twins posted for an emergency diverting colostomy for imperforate anus. These conjoined twins were born to a primigravid via cesarean section for fetal indication. They were born preterm at 36 weeks age of gestation with a collective birth weight of4.1 kg and an APGAR score 89. Computerized tomography scan of the chest and abdomen revealed Omphalopagus twins with left lower lobe atelectasis for Twin 2, fused liver, separate stomach and small intestines with distal fusion, imperforate anus, horseshoe kidney, bladder fistula, and the shared lower extremity appears to derive its blood supply from Twin 1. Evaluation of cross-circulation between the twins was done pre-induction by giving atropine IV to Twin 1. Atropine flush and increase in heart rate were noted in Twin 1, however, were not appreciated in Twin 2. Anesthesia for conjoined twins can be the most daunting and intimidating procedure that an anesthesiologist can handle in his lifetime. We highlight the challenges encountered with anesthesia preparation, preoperative planning, positioning, airway management, preservation of hemodynamic stability, as well as monitoring in an emergency setting.
Twins, Conjoined ; Cross Circulation

In the first paper of this experiment, the author reported no significant changes in NPN, urea nitrogen and creatinine blood levels resulting from cross circulation between normal dogs. In this experiment cross circulations between Nephrectemized dogs and normal ones were performed and the rate of removal of waste products from the blood of bilaterally nephrectomized dogs through the kidneys of normal dogs as well as the state of improvement of a general condition were observed. Blood levels of NPN, urea nitrogen and creatinine were determined. Sixty to seventy-two hours after both kidneys were removed, the dogs developed anorexia, nausea, vomiting and apathy. Cross circulation as previously described was instituted when blood concentration of NPN varied from 139.2 to 193 mg%; urea nitrogen, from 86.7 to 137.8 mg; and creatinine, from 4.8 to 6.8 mg%. All procedures were carried out under an aseptic technique and penicillin or streptomycin were given to prevent infection. Using the indirect cross circulation in two pairs of dogs, 2080 cc and 3520 cc of blood was cross transfused for periods of 100 minutes and 5 hours respectively. Blood was exchanged by the direct cross circulation in four pairs of dogs for periods ranging from four hours 35 minutes to eight hours. The results obtained are as follows: During cross circulation between the nephrectomized dogs and the normal ones, the former exhibited improvement in their vitality, ceased nausea and vomiting and began to eat. During the indirect cross circulation the NPN of the nephrectomized dogs was lowered 13.8 mg% and 27.2 mg; whereas when using the direct cross circulation a decrease of 57.6 mg% to 84.6mg% and obtained. Decreases in urea nitrogen and creatinine blood concentrations were observed to be 10.2 mg% to 22.6 mg% and O.6 mg% respectively by the indirect cross circulation. whereas 32.7mg% to 65.1 mg% and 2.2 mg% to 3.O mg% respectively by the direct method. The lowered blood concentrations of the waste products, however, rose again and the general condition of the nephrectomized dogs became worse one or two days after the completion of the experiment. The normal dogs receiving blood from the nephrectomized dogs developed a rapid pulse, frequent and irregular respirations, a weakened general condition and elevation of blood concentrations of NPN. urea nitrogen and creatinine. The general condition and the blood concentrations, however, returned to normal one to four days after the completion of the experiments. The direct method of cross circulation between bilaterally nephrectomized dogs and healthy ones is superior to the indirect method in respect to the animals general condition and to the removal of waste products from the blood of the nephrectomized animal.
Animals ; Anorexia ; Apathy ; Creatinine* ; Cross Circulation* ; Dogs* ; Kidney* ; Nausea ; Nitrogen* ; Penicillins ; Streptomycin ; Urea* ; Vomiting ; Waste Products

BACKGROUND: The cerebral blood flow velocity (CBFV) and rate pressure product (RPP) have been reported to benefit hemodynamics more during exercise in the recumbent position than during that in the upright position. However, it is unclear which angle is of the greatest benefit to hemodynamics during exercise in the recumbent position. This study aimed to evaluate the effect of the recumbent angle on CBFV and RPP during exercise. METHODS: In a balanced crossover study, 15 healthy volunteers (age, 18.7±1.1 years) were asked to perform the bicycle exercise four times in the upright and at recumbent angles of 67° (R), 47°R, and 15°R, with weekly intervals between each condition. The exercise intensity was set initially at 50 W and increased by 25 W every 2 minutes up to 150 W. CBFV in the middle cerebral artery (MCA) was measured using transcranial doppler sonography. All data were analyzed using two-way repeated-measures analysis of variance. RESULTS: CBFV at 15°R was significantly higher than that in the upright position and at 67°R at 10 minutes recovery (69±16 vs. 56±7 and 58±10 cm/s, respectively; P<0.05). The RPP was significantly lower at 67°R, 47°R, and 15°R than in the upright position immediately after exercise (176±23, 177±22, and 173±26, respectively, vs. 241±42 mmHg×beats/min×10⁻²; P<0.001). CONCLUSIONS: At an angle of less than 67°R, exercise increases CBFV and reduces RPP, relative to those during exercise in the upright position. This hemodynamic effect was most prominent at 15°R, where cerebral circulation was further increased in the recovery phase.
Cerebrovascular Circulation ; Cross-Over Studies ; Healthy Volunteers ; Hemodynamics ; Middle Cerebral Artery ; Posture ; Ultrasonography, Doppler, Transcranial

BACKGROUND: The cerebral blood flow velocity (CBFV) has been known to increase in response to acute hypoxia. However, how CBFV might respond to exercise in hypoxic conditions and be associated with electroencephalogram (EEG) remains unclear. The purpose of this study was to evaluate the effect of exercise in hypoxic conditions corresponding to altitudes of 4,000 m on CBFV and EEG. METHODS: In a randomized, double-blind, balanced crossover study, ten healthy volunteers (19.8±0.4 years) were asked to perform the incremental bicycle ergometer exercise twice in hypoxic and control (sea level) conditions with a 1-week interval, respectively. Exercise intensity was set initially at 50 W and increased by 25 W every 2 minutes to 125 W. Acute normobaric hypoxic condition was maintained for 45 minutes using low oxygen gas mixture. CBFV in the middle cerebral artery (MCA) and EEG were measured at rest 5 minutes, rest 15 minutes, immediately after exercise, and 15 minutes recovery using transcranial-Doppler sonography and EEG signal was recorded from 6 scalp sites leading to analysis of alpha and beta wave relative activities. All data were analyzed using two-way repeated-measures analysis of variance and Pearson's correlation. RESULTS: CBFV in the MCA in the hypoxic condition was significantly higher than that in the control condition at rest 5 minutes (83±9 vs. 69±9 cm/s, P<0.01), rest 15 minutes (87±8 vs. 67±7 cm/s, P<0.001), immediately after exercise (112±9 vs. 97±9 cm/s, P<0.01), and 15 minutes recovery (91±11 vs. 74±7 cm/s, P<0.01). However, no significant correlation was found between the changes of CBFV and EEG wave activities. CONCLUSIONS: These results suggest that the drastic change of CBFV observed during exercise with hypoxia might appear independently with EEG wave activities.
Altitude ; Anoxia ; Cerebrovascular Circulation ; Cross-Over Studies ; Electroencephalography ; Healthy Volunteers ; Middle Cerebral Artery ; Oxygen ; Scalp

Normal adult Korean dogs (Mongrel) were used for these experiments. Operations and cross circulations were performed under sterile conditions and anesthesia with intravenous sodium pentothal injection. Heparin was used as the anticoagulant before and during cross circulation. Two dogs were placed on operating tables so that their legs were together. The femoral arteries and veins in adjacent legs were isolated and cannulated with tubes of 1.0mm inside diameter. The arterial cannule of each animal was connected to the venous cannule of the other dog, and cross circulation was started and continued for 2 to 13 hours. This method is referred as direct cross circulation. A second method, indirect cross circulation, was devised to connect the arterial cannule of each dog to the venous cannule of the other dog through a glass bottle containing 20cc of ACD solution elevated one meter above the animals. With the venous tubing clamped, arterial blood flowed into the bottles. When 100cc of arterial blood had been collected, blood flow was reversed by clamping the arterial tubings and removing the venous clamps. The procedures were repeated for 5 hours. General condition, pulse, respiration, NPN. BUN and creatinine of blood content were observed and determined before, during and after cross circulation. The experiments were done in 7 pairs of animals by the direct method, and in 2 pairs by the indirect method. During the experiment, pulse and respiration became frequent and irregular. They showed sign of weakness. But dogs returned to normal in 1 to 3 days after the experiment. No significant differences were noted in the amount of blood NPN, BUN and creatinine content during and after cross circulation by both animals. However, the indirect method appears safer for the animals but less blood volume can be exchanged than in using the direct method.
Adult ; Anesthesia ; Animals ; Blood Volume ; Constriction ; Creatinine ; Cross Circulation* ; Dogs* ; Femoral Artery ; Glass ; Heparin ; Humans ; Kidney* ; Leg ; Operating Tables ; Respiration ; Sodium ; Thiopental ; Veins

Objectives: To evaluate microvascular perfusion and left ventricular function in patients with acute ST-segment elevation myocardial infarction after revascularization using myocardial contrast echocardiography (MCE), and to explore clinical influencing factors of abnormal microvascular perfusion in these patients. Methods: This is a cross-sectional study. The analysis was performed among patients admitted to Peking University People's Hospital for acute ST-segment elevation myocardial infarction (STEMI) from June 2018 to July 2021. All patients underwent percutaneous coronary intervention (PCI) and completed MCE within 48 hours after PCI. Patients were divided into normal myocardial perfusion group and abnormal perfusion group according to the myocardial perfusion score. The echocardiographic indexes within 48 hours after PCI, including peak mitral valve flow velocity (E), mean value of early diastolic velocity of left ventricular septum and lateral mitral annulus (Em), left ventricular global longitudinal strain (GLS) and so on, were analyzed and compared between the two groups. Multivariate logistic regression analysis was used to evaluate the influencing factors of myocardial perfusion abnormalities. Results: A total of 123 STEMI patients, aged 59±13 years with 93 (75.6%) males, were enrolled. There were 50 cases in the normal myocardial perfusion group, and 73 cases in the abnormal myocardial perfusion group. The incidence of abnormal myocardial perfusion was 59.3% (73/123). The left ventricular volume index ((62.3±18.4)ml/m² vs. (55.1±15.2)ml/m², P=0.018), wall motion score index (WMSI) (1.59 (1.44, 2.00) vs. 1.24(1.00, 1.47), P<0.001) and mitral E/Em (17.8(12.0, 24.3) vs. 12.2(9.2, 15.7), P<0.001) were significantly higher whereas left ventricular global longitudinal strain (GLS) ((-10.8±3.4)% vs. (-13.8±3.5)%, P<0.001) was significantly lower in the abnormal myocardial perfusion group than those in the normal myocardial perfusion group. Multivariate logistic regression analysis showed that left anterior descending (LAD) as culprit vessel (OR=3.733, 95%CI 1.282-10.873, P=0.016), intraoperative no/low-reflow (OR=6.125, 95%CI 1.299-28.872, P=0.022), and peak troponin I (TnI) (OR=1.018, 95%CI 1.008-1.029, P=0.001) were independent risk factors of abnormal myocardial perfusion. As for ultrasonic indexes, deceleration time of mitral E wave (OR=0.979, 95%CI 0.965-0.993, P=0.003), mitral E/Em (OR=1.100, 95%CI 1.014-1.194, P=0.022) and WMSI (OR=7.470, 95%CI 2.630-21.222, P<0.001) were independently related to abnormal myocardial perfusion. Conclusions: The incidence of abnormal myocardial perfusion after PCI is high in patients with acute STEMI. Abnormal myocardial perfusion is related to worse left ventricular systolic and diastolic function. LAD as culprit vessel, intraoperative no/low-reflow and peak TnI are independent risk factors of abnormal myocardial perfusion.
Male ; Humans ; Female ; ST Elevation Myocardial Infarction/diagnostic imaging* ; Percutaneous Coronary Intervention ; Cross-Sectional Studies ; Coronary Circulation ; Echocardiography ; Anterior Wall Myocardial Infarction/etiology* ; Ventricular Function, Left ; Perfusion

OBJECTIVETo compare the clinical effect of acupuncture treatment and western medicine Carbamazepine for thalamic pain.

METHODSCrossover trial design was used, 11 cases diagnosed as thalamic pain were randomly divided into two groups according to the mini-unbalance-index method, group I (with 6 cases received acupuncture first and then western medicine) and group II (with 5 cases received western medicine first and then acupuncture). When the effects were evaluated, the two groups were named as acupuncture group and western medicine group, 11 cases in each group. The method of clearing away the heart fire, regulating the spirit, activating blood and relieving pain was adopted in acupuncture treatment, Ximen (PC 4), Yinxi (HT 6), Xuehai (SP 10) and Zhaohai (KI 6) were selected; the western medicine group was treated with oral administration of Carbamazepine, and one course as well as the eluting period were both 10 days. The effects were evaluated with visual analogue scale (VAS) and evaluation scale of Anderson Cancer Center pain in US (MD Pain Evaluation value) respectively.

RESULTSThe VAS and MD value in two groups were obviously decreased after treatment (both P < 0.05), while there was no significant difference between two groups; the markedly effective rate of pain relieving in acupuncture group was 63.6% (7/11), which was higher than that of 36.4% (4/11) in western medicine group, but there was no significant difference between two groups.

CONCLUSIONAcupuncture treatment of regulating spirit, activating blood and relieving pain has a better therapeutic effect for thalamic pain, and can reach to the same therapeutic effect with western medicine Carbamazepine.

Acupuncture Therapy ; Adult ; Aged ; Blood Circulation ; Carbamazepine ; therapeutic use ; Cross-Over Studies ; Female ; Humans ; Male ; Medicine, Chinese Traditional ; Middle Aged ; Pain ; physiopathology ; Pain Management ; Pain Measurement ; Spirituality ; Thalamus ; physiopathology

BACKGROUND AND PURPOSE: Although sleep disturbances are common and considered a major burden for patients with Alzheimer's disease (AD), the fundamental mechanisms underlying the development and maintenance of sleep disturbance in AD patients have yet to be elucidated. The aim of this study was to examine the correlation between regional cerebral blood flow (rCBF) and sleep disturbance in AD patients using technetium-99m hexamethylpropylene amine oxime single-photon emission computed tomography (SPECT). METHODS: A total of 140 AD patients were included in this cross-sectional study. Seventy patients were assigned to the AD with sleep loss (SL) group and the rest were assigned to the AD without SL group. SL was measured using the sleep subscale of the Neuropsychiatric Inventory. A whole-brain voxel-wise analysis of brain SPECT data was conducted to compare the rCBF between the two groups. RESULTS: The two groups did not differ in demographic characteristics, severity of dementia, general cognitive function, and neuropsychiatric symptoms, with the exception of sleep disturbances. The SPECT imaging analysis displayed decreased perfusion in the bilateral inferior frontal gyrus, bilateral temporal pole, and right precentral gyrus in the AD patients with SL group compared with the AD patients without SL group. It also revealed increased perfusion in the right precuneus, right occipital pole, and left middle occipital gyrus in the AD with SL group compared with the AD without SL group. CONCLUSIONS: The AD patients who experienced sleep disturbance had notably decreased perfusion in the frontal and temporal lobes and increased rCBF in the parietal and occipital regions. The findings of this study suggest that functional alterations in these brain areas may be the underlying neural correlates of sleep disturbance in AD patients.
Alzheimer Disease* ; Brain* ; Cerebrovascular Circulation ; Cognition ; Cross-Sectional Studies ; Dementia ; Frontal Lobe ; Humans ; Occipital Lobe ; Parietal Lobe ; Perfusion* ; Prefrontal Cortex ; Rabeprazole ; Temporal Lobe ; Tomography, Emission-Computed ; Tomography, Emission-Computed, Single-Photon

In Part II, the authors have reported that cross circulation between normal dogs and bilaterally nephrectomized dogs resulted in decreased blood concentrations of non-protein nitrogen, urea nitrogen and creatinine in the bilaterally nephrectomized dogs and improvement of the dogs' general condition for a short time. In this study the renal arteries of normal dogs were occluded by clamping for varied periods of time to cause reversible renal insufficiency. After renal insufficiency developed cross criculation with untreated normal dogs was instituted to investigate the effects of cross circulation on blood concentrations of NPN, urea nitrogen and creatinine, urinary out-put and in the general condition of the dogs.As a control experiment, renal arteries of dogs were clamped bilaterally for 1, 2, 3, 4, 5 and 6 hours and blood concentrations of NPN, urea nitrogen and creatinine, general condition and urinary out-put of these dogs were studied.In the oliguric phase caused by bilateral clamping of the renal arteries of dogs for 3, 4, 5, and 6 hours, cross circulation between these dogs and normal dogs was performed. One to three cross circulations were done on each dog and one cross circulation lasted for 2 to 4 hours. Changes in the blood concentration of NPN, urea nitrogen and creatinine, the general condition of the dogs and urinary out-put were studied.In the control and cross circulation studies 5 dogs were studied in each of the groups designated by the time interval of clamping renal arteries except one dog was used for the 1 and 2 hour groups. Using normal Korea mongrels weighing 12kg. or more, the kidneys were exposed through a flank incision under pentothal anesthesia. Perirenal fat tissue was freed and vessels supplying the renal capsule were severed and ligated. The upper ureters were freed of abarrent vessels. The right kidney was first exposed and then the left. Clamping of both renal arteries was instituted at the same time. The renal arteries were lightly clamped using a rubber shod clamp to interrrupt the blood stream but bot to damage the arterial wall. Clamping of both renal arteries were released simultaneously and the operative wounds were closed. Direct cross circulation as described previously was used in this study and all procedures were done under aseptic technic. Prophylactic penicillin and streptomycin were also given pre- and postoperatively. All observation and determination of experimental items were done before clamping the arteries and at 12 hours after clamping. Daily determinaton for 5 days followed thereafter. Hourly determinatons were performed during the cross circulation. The results of the experiment are summarized as follows: When bilateral renal arteries of normal dogs were clamped for 1, 2, 3, 4, 5 and 6 hours, oliuria or anuria was observed immediately after clamping. Blood levels of NPN, urea nitrogen and creatinine were increased at 12 hours after clamping. A poor general condition was observed in most dogs one to two days post-experimentally in these and there was gradual exacerbation in the induced kidney insufficiency during oliguric phase. Most experimental animals died except a few did recover after regaining enough renal unction to produce diuresis. During cross circulation, urinary out-put was not altered and the general condition of the dogs was remarkedly improved. A decrease in the blood concentrations of NPN, urea nitrogen and creatinine was observed in all the dogs. For one to seven days after the circulation the condition of these dogs became slightly worse but a diuretic phase soon developed and most dogs in these experimental groups survived except for the few which died during or after the cross circulaton.In each of the six control groups in which the renal arteries were clamped for 1 to 6 hours as described above, 1, 1, 2, 2, 0 and 0 dogs survived. With cross circulation, experimental groups in which the renal arteries were clamped for 3, 4, 5 and 6 hours, had a survival of 4, 3, 3 and 2 dogs, respectively. Of 20 dogs, 12 survived and 8 died.Cross circulation increased the survival rate of dogs with induced renal insufficieney, but it is unlikely that pathological changes and function in these kidneys were changed during the curculation. It, however, is clear that the toxic state of renal insufficiency was relieved markedly during the cross circulation, although temporarily, but long enough to provide better survival condition. Most dogs were supported adequately to overcome the oliguric crisis and return to the diuretic phase.In normal dogs used in the cross circulation the development of an apathetic state, and elevation in blood concentrations of NPN, urea nitrogen and creatinine were observed. These dogs urinated several times during the experiment and experienced frequent pulse and respiratory rates. Arrhythmias of a temporary nature were observed. These dogs returned to normal in one to three days after the cross circulation.
Anesthesia ; Animals ; Anuria ; Arrhythmias, Cardiac ; Arteries ; Constriction ; Creatinine* ; Cross Circulation* ; Diuresis ; Dogs* ; Kidney* ; Korea ; Nitrogen* ; Penicillins ; Renal Artery* ; Renal Insufficiency ; Respiratory Rate ; Rivers ; Rubber ; Streptomycin ; Survival Rate ; Thiopental ; Urea* ; Ureter ; Wounds and Injuries

PURPOSE: Remote ischemic preconditioning (RIPC), induced by repeated bouts of ischemia followed by reperfusion of the arm or leg is a noninvasive strategy to protect a target organ against oxidative stress and injury caused by ischemia and reperfusion. Interestingly, recent evidence suggests that RIPC may also improve exercise performance by increasing maximal oxygen consumption, but such finding remain equivocal. As such, the purpose of the study was to examine the effect of RIPC on exercise performance in healthy individuals. METHODS: In a randomized cross-over design, 17 healthy male participants (age, 23±3 years) were exposed to either a sham control (six cycles of 5 minutes bilateral thigh cuff occlusion at 20 mm Hg) or RIPC (six cycles of 5 minutes bilateral thigh cuff occlusion at 180 mm Hg) an hour before a maximal exercise test. We measured maximal oxygen consumption, power output, heat rate, blood pressure, and blood lactate as exercise performance parameters during a maximal exercise test performed on an upright bicycle. RESULTS: Compared with the sham control, RIPC improved maximal oxygen consumption (7.4%, p=0.025) and maximal power output (11.5%, p=0.010), whereas other exercise performance parameters remained unchanged with RIPC (p>0.05). CONCLUSION: Taken together, the improvements in maximal oxygen consumption and maximal power output induced by RIPC may suggest that RIPC should be considered as a method for improving exercise performance.
Arm ; Blood Circulation ; Blood Pressure ; Cross-Over Studies ; Exercise Test ; Exercise Tolerance* ; Hot Temperature ; Humans ; Ischemia ; Ischemic Preconditioning* ; Lactic Acid ; Leg ; Male ; Methods ; Oxidative Stress ; Oxygen Consumption ; Reperfusion ; Thigh ; Young Adult*