[A child with Klippel-Feil syndrome in whom GlideScope was effective for tracheal intubation].

GlideScope videolaryngoscope (GlideScope, herein-after referred to as "GS", Verathon Medical, Bothell, WA, USA), with a high-resolution camera positioned on a blade, enables operators to confirm the position of the larynx and a tube through clear view, thereby conducting intubation safely in a patient whose neck is difficult to be bent back. As the blade is slim, GS is indicated for use in children whose oral cavity is narrow. We herein report safe and smooth intubation with GS in a child with Klippel-Feil syndrome in whom difficult intubation was predicted.

Cogan syndrome presenting after uneventful laser in situ keratomileusis.

We report 2 cases of Cogan syndrome that developed after uneventful laser in situ keratomileusis. In the first case, an 8-month postoperative biomicroscopy revealed bilateral interface neovascularization, white intrastromal deposits, and anterior chamber cells and flare. In the second case, white cell infiltration and neovascularization were observed in the deep corneal stroma of the patient's right eye 18 months postoperatively. Based on these observations, which are consistent with typical interstitial keratitis, and the patients' history of Meniere-like disease, such as vertigo and mild hearing loss, Cogan syndrome was diagnosed in both patients. Topical steroids were prescribed. Intensive treatments with corneal irrigation and topical steroids showed effective outcomes in both cases.

Evaluation of LASIK treatment with the Femto LDV in patients with corneal opacity.

PURPOSE: To evaluate the relative effectiveness and safety of LASIK using the Femto LDV (Ziemer Ophthalmic Systems AG) and IntraLase FS 60 (Abbott Medical Optics Inc) femtosecond lasers in patients with corneal opacity. METHODS: Patients with corneal opacity were retrospectively selected between March and July 2009. For this study, 205 eyes with 90-µm corneal flaps created using the Femto LDV (LDV group) and 200 eyes with corneal flaps created using the IntraLase FS 60 (Intra-Lase group) were selected. The flap thickness of the IntraLase group was determined by observation with slit-lamp microscopy. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest refraction spherical equivalent (MRSE) were measured pre- and postoperatively and were statistically evaluated using the Student t test and Mann-Whitney U-test. RESULTS: Regardless of the levels of opacity, eyes in the LDV group experienced uneventful procedures with no complications. Eyes in the IntraLase group had corneal flaps of 100- to 130-µm thickness and uneventful procedures; however, gas breakthrough was observed in 27 eyes. Of all eyes, 117 eyes from the LDV group and 109 eyes from the IntraLase group were available for 3-month follow-up. Mean 3-month postoperative UDVA, CDVA, and MRSE for the LDV group were 20/12.5, 20/12.5, and 0.17±0.32 diopters (D), respectively, and for the IntraLase group were 20/12.5, 20/12.5, and 0.11±0.34 D, respectively. No statistically significant differenes were noted in UDVA, CDVA, or MRSE between groups (P>.05 for all). CONCLUSIONS: Laser in situ keratomileusis with the Femto LDV created thin flaps regardless of level of opacity and induced no complications as compared to the IntraLase FS 60, where gas breakthrough was significantly more common.

[Use of the airway scope for rapid sequence induction in the emergency operation].

Rapid sequence intubation is a common procedure in emergency patients at risk for pulmonary gastric aspiration. However, in some of these cases may accompany a difficult airway. The Airway Scope (AWS) has been shown to be useful for difficult airway. We used AWS for rapid sequence intubation in 19 such patients. All patients were successfully intubated without any complication. We believe that AWS is a useful device for rapid sequence intubation.

[Awake fiberoptic nasal intubation using a Parker spiral tube in a patient with a giant thyroid tumor].

A 62-year-old man was scheduled for resection of a giant thyroid tumor. We planned awake fiberoptic nasotracheal intubation using a Parker spiral tube. Because a Parker spiral tube may improve endotracheal tube passage with fiberoptic intubation when compared to a standard endotracheal tube. After inserting the bronchial fiberscope, his trachea was intubated easily. The operation was performed without any complications. We conclude that a Parker spiral tube is useful for fiberoptic awake nasal intubation in a patient with a giant thyroid tumor.

[Use of the Airway Scope for awake intubation in five cases].

Several case reports have shown that the Airway Scope is useful in patients with difficult airways. We experienced five patients with known or predicted difficult airways who underwent awake intubation using the Airway Scope. The patients were known or predicted as having a difficult airway due to the following factors: limited head and neck movement (2 cases), risk for aspiration of gastric contents (1 case), and the thyroid tumor causing displacement of the trachea (2 cases). After the desired sedation with fentanyl and topical anesthesia of the airway, awake intubation was performed using the Airway Scope. All patients were successfully intubated without any complications. This experience suggests that the technique has the following advantages. First, the Airway Scope allows detection of regurgitation and vomiting during intubation and avoids accidental esophageal intubation. Second, the Airway Scope provides a useful means of teaching and supervising tracheal intubation compared with the conventional Macintosh laryngoscope. We believe that this method can achieve effective, safe and successful awake intubation in patients with known or predicted difficult airways.

[Anesthetic management for a patient with heparin-induced thrombocytopenia (HIT) undergoing off-pump coronary bypass surgery using argatroban, a direct thrombin inhibitor].

HIT type II is one of the severe complications of heparin therapy. The antibody for the heparin-PF 4 complex, which causes thrombocytopenia of less than 100 x 10(3) microl(-1), thrombosis and DIC-like symptoms, is produced. We managed the patient with HIT type II undergoing off-pump CABG. Anesthesia was induced and maintained with fentanyl, midazolam, vecuronium and sevoflurane. The operation was performed using argatroban, a direct thrombin inhibitor, as an anticoagulant. Intraoperative activated coagulation time (ACT) was maintained above 250 sec with 2.5-5.0 microg x kg(-1) x min(-1) of argatroban infusion without bolus injection and all the procedures were successful.

Lack of cytotoxic property in a variant of Epstein-Barr virus latent membrane protein-1 isolated from nasopharyngeal carcinoma.

Latent membrane protein 1 (LMP1) encoded by Epstein-Barr virus (EBV) is a membrane protein that activates multiple signaling pathways and transcription factors, including NF-kappaB. Our recent report demonstrated that expression of LMP1 induced programmed cell death in an NF-kappaB-dependent manner. In this study, we demonstrate that a variant CAO-LMP1 derived from EBV-infected nasopharyngeal carcinoma (NPC) does not induce cell death unlike the prototype B95.8-LMP1, although both types of LMP1 show NF-kappaB activation to a similar extent. Studies with chimeric or mutated proteins identified two amino acids in the transmembrane domain, which are commonly substituted in NPC-derived LMP1 variants, being critical for cell death induction by B95.8-LMP1. Furthermore, we show that the B95.8 transmembrane domain co-operates with NF-kappaB to trigger cell death program. Thus, our results reveal a particular feature of the transmembrane domain of tumor-derived CAO-LMP1 and suggest its possible contribution to the pathogenesis of NPC.

Two carboxyl-terminal activation regions of Epstein-Barr virus latent membrane protein 1 activate NF-kappaB through distinct signaling pathways in fibroblast cell lines.

Latent membrane protein 1 (LMP1), an Epstein-Barr virus transforming protein, is able to activate NF-kappaB through its carboxyl-terminal activation region 1 (CTAR1) and 2 (CTAR2), but the exact role of each domain is not fully understood. Here we show that LMP1 activates NF-kappaB in different NF-kappaB essential modulator (NEMO)-defective cell lines, but not in cells lacking both IkappaB kinase 1 (IKK1) and 2 (IKK2). Mutational studies reveal that CTAR1, but not CTAR2, mediates NEMO-independent NF-kappaB activation and that this process largely depends on IKK1. Retroviral expression of LMP1 mutants in cells lacking either functional NF-kappaB inducing kinase (NIK), NEMO, IKK1, or IKK2 further illustrates distinct signals from the two activation regions of LMP1 for persistent NF-kappaB activation. One originates in CTAR2, operates through the canonical NEMO-dependent pathway, and induces NFKB2 p100 production; the second signal originates in CTAR1, utilizes NIK and IKK1, and induces the processing of p100. Our results thus help clarify how two functional domains of LMP1 persistently activate NF-kappaB through distinct signaling pathways.

NF-kappaB is required for cell death induction by latent membrane protein 1 of Epstein-Barr virus.

NF-kappaB is a transcription factor known to promote or antagonize cell death depending on cell types and stimuli. Here, we demonstrate that expression of latent membrane protein 1 (LMP1), an Epstein-Barr virus (EBV)-encoded membrane protein, triggers programmed cell death in an NF-kappaB-dependent manner. Co-expression of NF-kappaB inhibitors completely prevented activation of NF-kappaB and LMP1-induced cell death. Addition therein of RelA, an active subunit of NF-kappaB, restored the NF-kappaB activation and cell death induction by LMP1, but RelA alone did not induce cell death. These results indicate that the activation of NF-kappaB is required for cell death induced by LMP1. Moreover, LMP1 induced activation of caspase-3 via the activation of NF-kappaB. Studies with z-VAD-fmk, a caspase inhibitor, indicated that NF-kappaB mediated both caspase-dependent and -independent death pathways. In conclusion, the cell death induced by LMP1 uncovered caspase-dependent and -independent death pathways both of which require NF-kappaB.