A Case of a Pregnant Woman With Primary Aldosteronism and Superimposed Preeclampsia Treated With Esaxerenone.

During pregnancy, there is no established treatment for idiopathic hyperaldosteronism (IHA), the most common form of primary aldosteronism due to bilateral adrenal hyperplasia. Here, we report the case of a pregnant patient with IHA who was successfully treated with esaxerenone, a nonsteroidal mineralocorticoid receptor (MR) antagonist. A 39-year-old woman was diagnosed with IHA and commenced on nifedipine 20 mg daily because she desired to be pregnant. After 1 year, she became pregnant. Her blood pressure was well controlled until 34 weeks of gestation when her home blood pressure became elevated up to 140/90 mmHg. Although the dose of nifedipine was increased to 80 mg daily, her blood pressure increased to 151/97 mmHg, and urinary test showed proteinuria of 2+ in 35 weeks of gestation. She was diagnosed with superimposed preeclampsia (SPE) and additionally treated with esaxerenone. Her blood pressure decreased to 120-140/98-100 mmHg and the proteinuria improved to ±. A successful cesarean section at 37 weeks resulted in the delivery of a healthy baby boy. Her blood pressure was well controlled although esaxerenone was discontinued 2 weeks after the delivery. This is the first case of a pregnant woman who was safely treated with esaxerenone despite being a female at advanced maternal age who had been diagnosed with IHA and developed SPE. Further studies are needed to investigate the efficacy and safety of nonsteroidal selective MR antagonist in similar pregnant patients with IHA to establish better treatment strategy for these patients.

Influence of Abutment Angle on Implant Strain When Supporting a Distal Extension Removable Partial Dental Prosthesis: An In Vitro Study.

PURPOSE: This study evaluated the impact of angled abutments on strain in implants supporting a distal extension removable partial denture. MATERIALS AND METHODS: An in vitro model of an implant supporting a distal extension removable partial denture was developed. The implant was positioned with a 17- or 30-degree mesial inclination, with either a healing abutment or a corrective multiunit abutment. Levels of strain under load were compared, and the results were compared using t test (P = .05). RESULTS: Correcting angulation with a multiunit angled abutment significantly decreased strain (P < .05) when compared with a healing abutment. CONCLUSION: An angled abutment decreased the strain on an inclined implant significantly more than a healing abutment when loaded under a distal extension removable partial denture.

Loading Variables on Implant-Supported Distal-Extension Removable Partial Dentures: An In Vitro Pilot Study.

PURPOSE: The aim of this study was to investigate strain on implants used for adjunctive support of distal extension removable partial dentures. MATERIALS AND METHODS: An implant with strain gauges was used for testing purposes in two positions, parallel and inclined. Three loading scenarios--loading apparatus (LA), artificial teeth via cotton roll (CR), and artificial teeth (UT)--were studied and strains compared via the Kruskal-Wallis test (P=.05). RESULTS: Strain under CR was significantly larger than UT in parallel (P<.05). However, the opposite was observed in inclined. CONCLUSIONS: Strain in parallel was smallest for UT, whereas in inclined it was largest for CR.

The Influence of Loading Variables on Implant Strain When Supporting Distal-Extension Removable Prostheses: An In Vitro Study.

PURPOSE: The purpose of this study was to determine the implant stress under distalextension removable prostheses (DERPs). MATERIALS AND METHODS: A mandibular distal-extension cast and denture were fabricated. Strain gauges were attached to the implant, which was placed either parallel to the distal abutment or perpendicular to the ridge crest (inclined). Occlusal load was applied in five directions, and strains were compared using the Kruskal-Wallis test (P = .05). RESULTS: When the implant was parallel, the strain was maximum at 20 degrees applied load direction. When the implant was inclined, the strain was minimum at 20 degrees mesial and maximum at 20 degrees applied distal load direction. CONCLUSIONS: Implant bending strain is reduced when the implant is loaded on its long axis and oriented parallel with the long axis of the most distal tooth.

Gastric lavage guided by ultrathin transnasal esophagogastroduodenoscopy in a life-threatening case of tobacco extract poisoning: a case report.

Nicotine, which is found in tobacco, is one of the most toxic of all known poisons. A 31-year-old woman was brought to our emergency department 2 hours after ingesting a usually fatal dose of a tobacco extract. Although gastric lavage was once commonly used to treat poisoning cases of this type, lavage can lead to such complications as aspiration, hypoxia, oropharyngeal and gastric trauma, and electrolyte disturbances. Recent guidelines have suggested less-aggressive gastric-emptying procedures as initial treatments. Currently, there are no absolute indications for gastric lavage use. The present patient had a history of depressive episodes and had attempted suicide by ingesting an extract derived from 20 cigarettes mixed with alcohol. There was no evidence of vomiting or seizures occurring before arrival of the ambulance. Physical examination revealed no signs of sweating, although the patient appeared to be confused, which is often seen with nicotine intoxication. She admitted using 2 kinds of cigarette, each of which typically contain 11.2 mg of nicotine. The patient's nicotine level was suspected to be higher than 40 to 60 mg, which is normally fatal. To determine whether gastric lavage was indicated in this case, we performed ultrathin transnasal esophagogastroduodenoscopy, which neither requires sedation nor compromises the airways. Although 2 hours had passed since ingestion, the tobacco extract and food were directly visualized within the stomach. Subsequently, gastric lavage was performed with 2,000 mL of water administered through a nasogastric tube. Ultrathin esophagogastroduodenoscopy made it possible to directly observe the gastric lavage and to ensure the stomach contents had been completely removed. No changes were noted in the vital signs, and no obstruction of the airways was observed. The patient recovered quickly and was discharged the following day. Ultrathin esophagogastroduodenoscopy helped determine the diagnosis and ensure that gastric lavage had been performed without complications.

Adsorption of various antimicrobial agents to endotoxin removal polymyxin-B immobilized fiber (Toraymyxin®).

The presence/absence of adsorption of 9 representative types of antimicrobial agent used in combination with a polymyxin-B immobilized fiber (PMX-F) were determined and the degree of adsorption to PMX-F was quantitatively evaluated. Various antimicrobial agents were dissolved at appropriate concentrations, and PMX-F was added to each solution and incubated at 37°C. Antimicrobial solutions without PMX-F were also similarly incubated as controls. After 2 and 4h, the concentration of each antimicrobial agent was determined using HPLC. To produce an environment closer to the in vivo state, albumin or serum was added, and similar evaluation was performed. In the presence of albumin, the rate of adsorption to PMX-F was relatively high for Cefmetazon(®), Pentcillin(®), Ciproxan(®) and Zyvox(®). In the presence of serum, the adsorption rate was 4.02±2.83% for Pentcillin(®), 5.59±1.00% for Ciproxan(®), and 22.12±3.23% for Zyvox(®). The results of this study suggest that adequate caution is necessary on the clinical use of Zyvox(®), which was adsorbed in the presence of serum as an environment close to the in vivo environment, but the use of other antimicrobial agents in combination with PMX-F may have only slight influences on adsorption to PMX-F.

Pharmacokinetics of antifungal agent micafungin in critically ill patients receiving continuous hemodialysis filtration.

Currently in Japan, the preferred method for blood purification in patients with acute renal failure is continuous hemodiafiltration (CHDF). However, CHDF filters out various antifungal drugs such as fluconazole through large pores in the membrane used. Systemic fungal infection is still one of the main causes of death and complications in critically ill patients in intensive care units (ICUs). Therefore it is important to determine the appropriate use of antifungal agents. This study was designed to evaluate the influence of CHDF on the pharmacokinetics of the antifungal agent micafungin in ICU patients. The pharmacokinetics of micafungin were studied in four ICU patients receiving CHDF and in nine ICU patients not receiving CHDF. To evaluate the pharmacokinetics, the ratio of serum micafungin concentration to dose per body weight (C/D) was used in this study. There was no progressive accumulation or exclusion of micafungin in patients receiving CHDF. The mean (+/-S.D.) extraction rate (%) for micafungin during CHDF was 3.6+/-3.9. There was no significant difference in the serum micafungin C/D-time profiles between the patients receiving and not receiving CHDF. These results show that CHDF does not affect the pharmacokinetics of micafungin. Therefore it is not necessary to adjust the micafungin dose in patients receiving CHDF.

Treatment with flunitrazepam of continuous spikes and waves during slow wave sleep (CSWS) in children.

We describe our treatment of two boys with continuous spikes and waves during slow wave sleep (CSWS). One of the boys was suffering from non-convulsive status epilepticus and the other from conscious disturbance with automatism. Their ictal EEG readings showed continuous diffuse spike and wave complexes, which were considered to show electrical status. The boys were diagnosed as having CSWS, and were later diagnosed with Landau-Kleffner syndrome (LKS). EEG readings returned to normal on intravenous injection of flunitazepam (FZP) at a dose of 0.02 mg/kg, suggesting that FZP is an effective treatment for CSWS.

Effects of single intratracheal exposure to chlorhexidine gluconate on the rat lung.

Chlorhexidine gluconate (CHX) is an antiseptic that has been widely used for disinfection of cutaneous wound and gingivae. Recently, a patient who inhaled CHX solution died from acute respiratory distress syndrome (ARDS). Although it is highly possible that direct pulmonary damage might be the cause of ARDS, there is no preclinical information about the pulmonary toxicity of CHX. In the current study, the acute direct action of CHX to the lung was evaluated in rats. We successfully exposed the left but not the right lung either to CHX at concentrations of 1%, 0.1%, and 0.01% or to saline using a curved-tip administration tube. At the higher concentrations of CHX (0.1% and 1%), severe congestion to the alveoli and capillaries and perivascular and intra-alveolar hemorrhages were observed 1 day after exposure. Aniline blue-stained collagen fibers with an infiltration of inflammatory cells were present 7 days after exposure. The fibrotic changes and intra-alveolar inflammatory cells had decreased but were still observed sporadically 28 and 84 days after exposure. These detrimental effects were more severe at 1% than at 0.1% CHX. No remarkable effect was observed after exposures to 0.01% CHX and saline. We were able to evaluate the time-course changes in the pulmonary toxicity of CHX by exposures limited to the left lung. It is highly possible that CHX at a concentration of more than 0.1% might directly induce ARDS when aspirated and reaching to the alveoli.

Possibility of influence of midazolam sedation on the diagnosis of brain death: concentrations of active metabolites after cessation of midazolam.

Midazolam and its active metabolites have a depressant effect on respiration and consciousness level, and therefore their effects should be considered in all patients for whom brain death testing is contemplated. The concentrations of midazolam and its active metabolites were measured in critically ill patients on a ventilator during and after continuous intravenous infusion of midazolam. Three days after cessation of midazolam infusion, the concentrations of midazolam and 1-hydroxymidazolam decreased to below the therapeutic range (100-1000 ng/ml) in all patients, although the concentrations of 1-hydroxymidazolam glucuronide remained extremely high in a patient who showed deteriorating renal function. The concentrations of 1-hydroxymidazolam glucuronide (19,497-29,761 ng/ml) were measured in this patient. When it is impossible to confirm factors consistent with irreversible brain death, such as the lack of cerebral blood flow, until 3 days after cessation of midazolam infusion, monitoring of the concentration of these substances should be carried out in all patients in whom suspicion exists prior to the evaluation of brain death. It is particularly imperative that monitoring of the 1-hydroxymidazolam glucuronide concentration be carried out in patients with poor renal function.

Chlorhexidine gluconate ingestion resulting in fatal respiratory distress syndrome.

As ingestion of chlorhexidine gluconate (CHG) usually causes relatively mild symptoms, this chemical has been considered safe. An 80-y-old woman with dementia accidentally ingested approximately 200 ml of Maskin (5% CHG) in a nursing home and then presumably aspirated gastric contents. She was intubated for airway protection in the nearest hospital and referred to our critical care unit because of hypotension and rapid deterioration of consciousness. Despite intensive treatment, the patient died of acute respiratory distress syndrome (ARDS) 12 h after ingestion. The serum concentration of CHG was markedly high, although CHG reportedly has poor enteral absorption. We suspect the CHG was absorbed through the pulmonary alveoli following aspiration, not from the gastrointestinal tract. CHG has the potential for fatal ARDS when aspiration occurs following ingestion.