A refractory head tremor appearing after volatile anesthesia combined with epidural anesthesia in a patient with spinocerebellar ataxia type 6.

A 64-year-old female patient with spinocerebellar ataxia type 6 was referred to our department for pancreatic cancer and anesthetized with volatile anesthesia combined with epidural anesthesia for pancreaticoduodenectomy. No complications arose during surgery. On postoperative day 4, a head tremor was noticed at the time of mobilization. The tremor was a postural and "no-no" tremor rather than an intention or resting tremor. The head tremor caused difficulty in eating and in other activities of daily living. No abnormal results were obtained by magnetic resonance imaging of the brain. The tremor was resistant to drugs, including anti-Parkinson drugs and benzodiazepines, and was therefore difficult to treat.

Predictors for incidence of increased time spent in hospital after ambulatory surgery in children: a retrospective cohort study.

PURPOSE: Recently, pediatric ambulatory surgery has become common. However, for some of these patients, unplanned admission or prolonged hospital stay is also necessary, which can increase the mental burden on these patients. The aim of this study was to identify the predictors of the incidence of increased time spent in hospitals associated with pediatric ambulatory surgery. METHODS: Data were obtained from the medical and anesthetic records of 1087 consecutive patients aged < 18 years who underwent ambulatory surgery under general anesthesia. We defined the incidence of increased time spent in a hospital as a composite outcome of unplanned admission and prolonged hospital stay. Multivariate logistic regression analysis was used to examine the associations between the incidence of increased time spent in a hospital and 14 parameters including patient characteristics, anesthesia, and operative factors. RESULTS: Multivariate analysis identified American Society of Anesthesiologist Physical Status (ASA-PS), type of regional block, intraoperative fluid volume, and type of surgery as predictors for the incidence of increased time spent in a hospital. Specifically, caudal block compared to no regional block [odds ratio (OR) (95% confidence interval (CI)) = 0.44 (0.22-0.90)]; increasing intraoperative fluid volume [OR (95% CI) = 0.71 (0.55-0.92) in every increment of 5 ml/kg/h); and ear, nose, and throat (ENT) and urology surgery compared to other types of surgery [OR (95% CI) = 0.13 (0.03-0.64), and 3.93 (1.99-7.77), respectively] were identified as strong predictors. CONCLUSIONS: This study found that the incidence of increased time spent in a hospital in pediatric ambulatory surgery was affected by the type of regional block, intraoperative fluid volume, type of surgery. Potentially modifiable factors, such as intraoperative fluid volume or type of regional block, should be further investigated in future prospective studies.

Self-Exposure to the Male Pheromone ESP1 Enhances Male Aggressiveness in Mice.

Exocrine gland-secreting peptide 1 (ESP1) released into male tear fluids is a male pheromone that stimulates sexually receptive behavior in female mice via the vomeronasal sensory system. ESP1 also induces c-Fos expression in male brain regions distinct from those in females. However, behavior in males following ESP1 exposure has not been examined. In the present study, we show that ESP1, in conjunction with unfamiliar male urine, enhances male aggression via the specific vomeronasal receptor V2Rp5. In addition, male mice that secrete ESP1 but lack V2Rp5 exhibit a lower level of aggressiveness than do mice that express V2Rp5. These results suggest that ESP1 not only acts as a male pheromone in both sexes but also serves as an auto-stimulatory factor that enhances male aggressiveness by self-exposure. Finally, re-activation of ESP1-induced c-Fos-positive neurons by using the designer receptor exclusively activated by designer drug (DREADD) approach resulted in enhancement of sexual and aggressive behaviors in female and male mice, respectively, indicating that sexually dimorphic activation in the brain is a neural basis for the sex-specific behavioral responses to ESP1.

[Perioperative fibrinogen concentrations in cardiac surgery with cardiopulmonary bypass].

BACKGROUND: Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) need many blood products due to deficiency of coagulation factors. Blood transfusion therapy in patients with excessive bleeding after CPB is generally empiric. We checked and studied the fibrinogen concentration and transfusion, as well as bleeding amount in the perioperative period. METHODS: The study was approved by our institutional ethics committee. Thirty patients were studied. Blood samples were obtained at the induction of anesthesia (before CPB), at the end of CPB, at the end of operation, and on the next morning, or before the patient was given fresh frozen plasma in the intensive care unit. RESULTS: For all cases, fibrinogen concentration and platelet concentration were lowest at the end of CPB. Fibrinogen concentration rose up to before CPB level on the next morning. The group in which fibrinogen concentration was less than 150 mg x dl(-1) at the end of CPB consumed more blood products than the group with fibrinogen concentration of over 150 mg x dl(-1). CONCLUSIONS: Blood transfusion therapy based on fibrinogen concentration is needed to maintain adequacy of the perioperative blood transfusion and blood conservation in cardiac surgery.

Vestibular evoked myogenic potential induced by bone-conducted stimuli in patients with conductive hearing loss.

CONCLUSIONS: Bone-conducted vestibular evoked myogenic potentials (B-VEMPs) showed high specificity for the presence of vertigo in patients with unilateral chronic otitis media (COM). These results suggest that vestibular function can be evaluated with B-VEMPs, even in patients with conductive hearing loss. OBJECTIVE: The purpose of this study was to investigate the VEMPs induced by bone-conducted stimuli (B-VEMPs) in patients with conductive hearing loss due to perforated COM. SUBJECTS AND METHODS: The subjects were 48 patients with unilateral perforated COM and conductive hearing loss. The disequilibrium group consisted of 25 patients, and the non-disequilibrium group consisted of 23 patients. The control group comprised 35 healthy volunteers. B-VEMPs were stimulated with tone burst sound of 60 dB nHL and 250 Hz delivered from a bone vibrator and were recorded for each subject. The results of B-VEMP were compared between disequilibrium and non-disequilibrium groups. RESULTS: The mean interaural ratio was 16.5+/-12.1% in the control group, thus the normal range was <40.7%. Abnormal results were not found in any subject in the non-disequilibrium group but were found in 13 patients (54.0%) in the disequilibrium group (p<0.001). The ear with COM showed lower responses than the intact ear in all subjects with abnormal results.

[Case of toxic shock-like syndrome affecting the neck].

Toxic shock-like syndrome (TSLS) is a form of rapidly progressing septic shock that can lead to multiple organ failure and has a high mortality rate of 30%. We report a rare case of TSLS affecting the head and neck. A 40-year-old man complained of redness and swelling of the neck with vomiting and diarrhea. His blood pressure dropped, and multiple organ failure occurred. Streptcoccus pyogenes, Group A, was identified in a blood culture, and he was diagnosed as having TSLS. He was treated with high-dose carbapenem, clindamysin, and gamma globulin. Continuous hemodiafiltration (CHDF) and PMX-DHP was applied to prevent sepsis and multiple organ failure. Debridement of the neck was performed on day 16. He recovered gradually and was discharged from hospital on day 45. A total resection is required to treat TSLS, but such a procedure is difficult to perform in the head and neck region. Our case improved without resection but after debridement and general control. TSLS should be first treated by medication and then by surgery, consisting of either debridement or resection.