Feasibility of trauma-focused cognitive behavioral therapy for traumatized children in Japan: a Pilot Study.

BACKGROUND: Trauma-focused cognitive behavioral therapy is used to treat children who have experienced traumatic events and suffer from trauma-related disorders. Its effectiveness has been demonstrated in several randomized controlled studies. However, most of these studies have been performed in the United States, with few studies conducted in Asian countries. Therefore, we aimed to evaluate the feasibility of trauma-focused cognitive behavioral therapy in children who have experienced traumatic events and who suffer from trauma-related disorders in Japan. FINDINGS: Thirty-five traumatized children (mean age = 10.9 years; range = 3-17 years; 74.3% girls) who received trauma-focused cognitive behavioral therapy were included. The effectiveness of the program was evaluated in each case using the University of California at Los Angeles Post-Traumatic Stress Disorder Reaction Index for DSM-IV for trauma-related symptoms and the Children's Global Assessment Scale for social functioning. Pre- and post-treatment outcome measures were analyzed using two-tailed paired t tests. The results for 35 participants indicate that post-traumatic stress symptoms were significantly improved following therapy [t(35) = 8.27; p < 0.01], whereas the assessment of social functioning supported the effectiveness of the program [t(35) = -14.68; p < 0.01]. The pre- to post-treatment effect sizes (Glass's delta) were 1.24 for the University of California at Los Angeles Post-Traumatic Stress Disorder Reaction Index and 1.96 for the Children's Global Assessment Scale. CONCLUSIONS: Our findings indicate that trauma-focused cognitive behavioral therapy is feasible for treating traumatized children of an Asian population. We discuss the implications of this result for clinical practice and future research.

[Anesthetic management for mitral valve replacement in a patient with mitral stenosis and dilated cardiomyopathy].

A 69-year-old man who has mitral stenosis concomitantly with dilated cardiomyopathy underwent mitral valve replacement. The preoperative left ventricular ejection fraction was 23%. Preoperative dobutamine stress echocardiography showed poor response. High dose fentanyl was administered for induction and maintenance of general anesthesia, and blood pressure was kept with vasoconstrictors. Circulatory assist with milrinone and intraaortic balloon pumping after the cardiopulmonary bypass enabled us to obtain stable hemodynamics.

Pharmacokinetics of lidocaine, bupivacaine, and levobupivacaine in plasma and brain in awake rats.

BACKGROUND: We have compared the pharmacokinetics and brain distribution of lidocaine, racemic bupivacaine (bupivacaine), and levobupivacaine in awake, spontaneously breathing rats. METHODS: Lidocaine (0.5 mg x kg x min), bupivacaine (0.1 mg x kg x min), or levobupivacaine (0.1 mg x kg x min) was continuously administered to rats for 2 h (n = 12, each anesthetic). Blood samples and cerebral dialysate were collected during infusion and for 2 h after termination of infusion. Concentrations of anesthetics in the cerebral extracellular fluid were measured by microdialysis using the retrodialysis calibration method. Tissue-to-plasma partition coefficients calculated from the total (protein-bound and unbound) and unbound concentrations in plasma and brain as well as pharmacokinetic parameters in plasma and cerebral extracellular fluid were compared among the three anesthetics. RESULTS: There were no differences in plasma total or unbound concentrations between bupivacaine and levobupivacaine. Concentrations of bupivacaine in the cerebral extracellular fluid were significantly higher than levobupivacaine (P < 0.001). Despite no differences in the ratio of total brain concentration to total plasma concentration among the three anesthetics, the ratio of cerebral extracellular fluid concentration to plasma unbound fraction of bupivacaine was significantly higher than lidocaine and levobupivacaine (0.58 +/- 0.09, 0.47 +/- 0.18, and 0.40 +/- 0.09, respectively; P = 0.03 and 0.003, respectively). CONCLUSIONS: Although the ratio of total brain concentration to total plasma concentrations of lidocaine, bupivacaine, and levobupivacaine was similar, concentration ratio of bupivacaine in the cerebral extracellular fluid to plasma unbound fraction was significantly higher than lidocaine and levobupivacaine.

Electroencephalographic response following midazolam-induced general anesthesia: relationship to plasma and effect-site midazolam concentrations.

PURPOSE: To examine the relationships between effect-site concentrations and electroencephalographic parameters after the induction of general anesthesia with midazolam. METHODS: Twenty-four patients with American Society of Anesthesiologists status I or II were randomly allocated to receive either an intravenous (i.v.) bolus of midazolam 0.2 mg kg(-1) (small-dose group, n = 12) or 0.3 mg kg(-1) (large-dose group, n = 12) for induction of general anesthesia in a double-blind experimental design. The bispectral index (BIS), 95% spectral edge frequency (SEF95), spectral power density, and plasma concentrations of midazolam were measured for 60 min following the induction of general anesthesia. RESULTS: Plasma and simulated effect-site concentrations of midazolam were significantly higher in the large-dose group than in the small-dose group (P = 0.005 and <0.001, respectively). There was a correlation between the relative beta ratio and BIS (r (2) = 0.30, P < 0.001; n = 168); however, effect-site concentrations of midazolam showed no association with BIS, relative beta ratio, or SEF95 (r (2) = 0.07, 0.11 and 0.01, respectively; n = 168). The electroencephalographic spectral power density in the beta-band (>/=13 and <30 Hz) was significantly increased after induction and was significantly larger in the large-dose group than in the small-dose group (P = 0.009). CONCLUSION: Following the induction of general anesthesia with i.v. midazolam 0.2 or 0.3 mg kg(-1), the BIS was positively correlated with the relative beta ratio. Despite a rapid decrease in the plasma and effect-site concentrations of midazolam, the average BIS remained >60 for 60 min after induction, reflecting an increased power of the electroencephalographic high-frequency band.

Effect of remifentanil on cardiovascular and bispectral index responses following the induction of anesthesia with midazolam and subsequent tracheal intubation.

PURPOSE: We examined the hypothesis that remifentanil decreases the bispectral index (BIS) as well as blunts cardiovascular responses to tracheal intubation during anesthesia with midazolam. METHODS: Sixty patients were randomly allocated to three groups according to the dose of remifentanil-0.1 (S), 0.2 (M), or 0.5 (L) microg kg(-1) min(-1), respectively. Infusion of remifentanil was started 5 min before the induction of general anesthesia with midazolam 0.2 mg/kg in all groups. Following the administration of vecuronium 0.1 mg/kg, the trachea was intubated 5 min after induction, and the infusion rate of remifentanil was then reduced to 0.05 microg kg(-1) min(-1) in all groups. Mean arterial blood pressure (MAP), heart rate (HR), BIS, and 95% spectral edge frequency (SEF95) were measured until 10 min after tracheal intubation. RESULTS: Infusion of remifentanil alone before the induction of anesthesia did not affect the hemodynamic or electroencephalographic parameters. MAP was significantly decreased after induction in all groups of patients (P < 0.01), with no differences among the three groups, while it was significantly increased after tracheal intubation in the patients of groups S and M, but not in those of group L. The HR did not change after induction in any of the groups, but it was also significantly increased after tracheal intubation of group S and M patients, although not in those of group L. The BIS decreased after induction, and both the BIS and SEF95 were significantly lower in group L patients than in those of group S (P < 0.01). All patients were unconscious after induction, and none complained of intraoperative awareness. CONCLUSION: In our patient cohort, remifentanil 0.5 microg kg(-1) min(-1) effectively decreased the BIS after the induction of general anesthesia with midazolam 0.2 mg/kg and suppressed the increase of MAP and HR in response to subsequent laryngoscopy and tracheal intubation.

[Prolonged pain after left hepatectomy].

We have experienced a patient complaining of the prolonged pain after left hepatectomy. The patient was a 53-year-old man. He underwent left hepatectomy for cholangiocellular carcinoma, and complained of prolonged abdominal pain for more than 10 days after the operation. After detailed examinations, we noticed duodenal perforation. After the conservative treatment, his pain was improved. In this case, the causes of the prolonged pain might be peritoneal irritation caused by gastric contents and duodenal perforation. The peritoneal irritation was caused by bile leakage and the deformity of the stomach that might be due to the enlarged dead space after left hepatectomy. We should be cautious of possible pyloric obstruction as the cause of prolonged pain after left hepatectomy.