Remimazolam Anesthesia for Thyroid Surgery.

Background: Critical upper airway obstruction, hematoma formation, and recurrent laryngeal nerve palsy have been reported as postoperative complications of thyroid surgery. Although remimazolam may reduce the risk of these complications, the efficacy of flumazenil with remimazolam has not been reported. We present the successful anesthesia management of thyroid surgery using remimazolam and flumazenil. Case Presentation. A 72-year-old woman was diagnosed with a goiter and scheduled for a partial thyroidectomy under general anesthesia. We used remimazolam for induction and maintenance using a neural integrity monitor, electromyogram, and endotracheal tube under the bispectral index monitor. At the end of the surgery, spontaneous respiration was confirmed after the intravenous administration of sugammadex, and the patient was extubated under mild sedation. In the operating room, we administered flumazenil intravenously to confirm recurrent laryngeal nerve palsy and active postoperative hemorrhage. The patient was confirmed to have no recurrent laryngeal nerve palsy under full wakefulness but developed active postoperative hemorrhage with normal blood pressure. The patient required reoperation and was reintubated under intravenous administration of propofol. The anesthesia was maintained using 5% of desflurane, and the patient was extubated without any postoperative problems. The anesthesia was then terminated. The patient had no recall of the procedure. Conclusion: Maintenance of general anesthesia using remimazolam allowed the use of a neurostimulator with minimal muscle-relaxant effects, and extubation under sedation reduced the risk of abrupt and unexpected changes in blood pressure, body movement, and coughing. Furthermore, after extubation, the patient was rendered fully awake using flumazenil to confirm the presence of recurrent laryngeal nerve palsy and active postoperative hemorrhage. In addition, the patient had no memory of the reoperation, suggesting that the anterograde amnesic effect of remimazolam had a favorable psychological outcome associated with the reoperation. We safely managed thyroid surgery using remimazolam and flumazenil.

A green cellulose nanofiber-based printed electrode for practical highly sensitive amoxicillin detection.

Simple electrochemical detection of the antibiotic amoxicillin (AMX) in water is crucial to mitigate health and environmental risks; however, the process requires single-use electrodes, which can increase the waste generated as well as the cost. Cellulose nanofibers (CNFs) are biodegradable materials that can be used as electrode frameworks. In this study, a sensitive single-use CNF-based printed electrode modified with polybenzimidazole (PBI)-wrapped multi-walled carbon nanotubes (MWCNTs) is developed for AMX detection. The CNF-based printed electrode achieved a detection limit of 0.3 µM and exhibited a wider detection range of 0.3-500 µM compared with electrodes developed in previous studies. In addition, the electrode reactions of AMX were electrochemically investigated and found to primarily involve the adsorbed species at low AMX concentrations and be diffusion-controlled at high AMX concentrations. Finally, the printed electrodes were used for the easy and practical determination of AMX in seawater and tap water by a soaking method. Satisfactory results were obtained, and the final concentrations of AMX were determined using simple calibration equations. Therefore, this CNF-based electrode exhibits great potential for practical real-time AMX detection in the field.

Cellulose nanofiber-based electrode as a component of an enzyme-catalyzed biofuel cell.

Many types of flexible, wearable, and disposable electronic devices have been developed as chemical and physical sensors, and many solar cells contain plastics. However, because of environmental pollution caused by microplastics, plastic use is being reduced worldwide. We have developed an enzyme-catalyzed biofuel cell utilizing cellulose nanofiber (CNF) as an electrode component. The electrode was made conductive by mixing multi-walled carbon nanotubes with the CNF. This prepared biofuel cell was wearable, flexible, hygroscopic, biodegradable, eco-friendly, and readily disposable like paper. The CNF-based enzyme-catalyzed biofuel cell contained a flavin adenine dinucleotide-dependent glucose dehydrogenase bioanode and laccase biocathode. The maximum voltage and maximum current density of the biofuel cell were 434 mV and 176 µA cm-2, respectively, at room temperature (15-18 °C). The maximum power output was 27 µW cm-2, which was converted to 483 (±13) µW cm-3.

Hydrothermal preparation of a platinum-loaded sulphated nanozirconia catalyst for the effective conversion of waste low density polyethylene into gasoline-range hydrocarbons.

A platinum-loaded sulphated nanozirconia (Pt/nano ZrO2-SO4) bifunctional metal-acid catalyst was synthesized using a hydrothermal process. The nano ZrO2-SO4 was initially prepared by dispersing the nano ZrO2 in H2SO4, followed by wet impregnation via heating in an aqueous PtCl4 solution. This material was subsequently calcined and reduced under hydrogen gas to produce the catalyst. The Pt/nano ZrO2-SO4 was found to be a highly active, selective and stable solid acid catalyst for the conversion of waste low density polyethylene (LDPE) to high value hydrocarbons. The catalytic activity and stability of this material were evaluated during the hydrocracking of waste LDPE while optimizing the reaction temperature, time and catalyst-to-feed ratio. The activity of catalyst prepared by hydrothermal was attributed to highly dispersion of Pt species interacting with the support and inhibition of the agglomeration process. The impregnation method of hydrothermal generated highly active and selective catalyst with Pt loads of 1 wt%. The hydrocracking of waste LDPE over Pt/nanoZrO2-SO4 at 250 °C for 60 min with a catalyst-to-feed proportion of 1 wt% gave the largest gasoline fraction.

[Hypotonic Versus Isotonic Electrolyte Solution for Perioperative Fluid Therapy in Infants].

BACKGROUND: This study was designed to evaluate the effects of perioperative administration of an isotonic electrolyte solution with 1% glucose (IT) on blood sodium (Na+) and blood glucose (BG) concentrations in pediatric patients < 1-year-old undergoing plastic surgery in comparison with a conventional hypotonic electrolyte solution with 2.6% glucose (HT). METHODS: Fifty Patients were randomly allocated to HT group and IT group. Na+ and BG were measured at induction of anesthesia (Tind), the end of surgery (Tend), and 4 hours after surgery (T4h). RESULTS: Patient characteristics were similar for the 2 groups. In the HT group, Na+ at Tend insignificantly dropped compared with that at Tind, whereas in the IT group Na+ was significantly elevated. Na+ at T4h significantly increased compared with that at Tend in each group. No cases developed new dysnatremia or dysglycemia in IT group. The incidence of hyponatremia at Tend was significantly lower in the IT group. A positive correlation between intraoperative Na+ concentration changes and the infusion duration was observed in the IT group. CONCLUSIONS: Isotonic solution with 1% glucose is suggested to be safe in infants during and after surgery.

MAOA, MTHFR, and TNF-ß genes polymorphisms and personality traits in the pathogenesis of migraine.

Migraine is a multifactorial disease with various factors, such as genetic polymorphisms and personality traits, but the contribution of those factors is not clear. To clarify the pathogenesis of migraine, the contributions of genetic polymorphisms and personality traits were simultaneously investigated using multivariate analysis. Ninety-one migraine patients and 119 non-headache healthy volunteers were enrolled. The 12 gene polymorphisms analysis and NEO-FFI personality test were performed. At first, the univariate analysis was performed to extract the contributing factors to pathogenesis of migraine. We then extracted the factors that independently contributed to the pathogenesis of migraine using multivariate stepwise logistic regression analysis. Using the multivariate analysis, three gene polymorphisms including monoamine oxidase A (MAOA) T941G, methylenetetrahydrofolate reductase (MTHFR) C677T, and tumor necrosis factor beta (TNF-ß) G252Α, and the neuroticism and conscientiousness scores in NEO-FFI were selected as significant factors that independently contributed to the pathogenesis of migraine. Their odds ratios were 1.099 (per point of neuroticism score), 1.080 (per point of conscientiousness score), 2.272 (T and T/T or T/G vs G and G/G genotype of MAOA), 1.939 (C/T or T/T vs C/C genotype of MTHFR), and 2.748 (G/A or A/A vs G/G genotype of TNF-ß), respectively. We suggested that multiple factors, such as gene polymorphisms and personality traits, contribute to the pathogenesis of migraine. The contribution of polymorphisms, such as MAOA T941G, MTHFR C677T, and TNF-ß G252A, were more important than personality traits in the pathogenesis of migraine, a multifactorial disorder.

Association of the A-1438G polymorphism in serotonin 2A receptor in migraine with aura among Japanese patients.

We investigated the possible association of serotonin (5-HT) 2A receptor gene A-1438G polymorphism in Japanese patients with migraine. Genotyping of 5-HT(2A) A-1438G polymorphism was performed by polymerase chain reaction-restriction fragment length polymorphism in patients with migraine (male 17 : 3 with aura and 14 without aura, female 65 : 17 with aura and 48 without aura) and controls (male 31, female 84). The distribution of 5-HT(2A) A-1438G genotype frequency between migraine patients and controls did not differ. These results suggest that the A-1438G polymorphism of the 5-HT(2A) receptor gene is not a direct risk factor for migraine; however, the incidence of the A/A genotype between migraine with aura (MA) and without aura (MO) was significantly different. The 5-HT(2A) A-1438G polymorphism may be involved in determining the subtypes of migraine in Japanese.

Early oral feeding should be resumed following the resolution of gastric ileus.

BACKGROUND/AIMS: The main aim of the study was to assess the feasibility of early mobilization and early feeding following the resolution of gastric ileus in patients who have elective open colonic surgery. METHODOLOGY: This was a randomized controlled trial of patients who were assigned to one of the following two groups. Group 1: patients were encouraged to mobilize postoperatively. A radiopaque marker was given orally on the first postoperative morning and X-ray film was taken daily until more than 70% of the markers had been emptied out of the stomach. Then patients received a diet regardless of flatus or defecation. Group 2: patients were not enforced to mobilize and allowed a diet following flatus or defecation. RESULTS: No significant differences were noted in age, sex, and type of procedures in either group. No patient in group 1 vomited postoperatively, while postoperative time to oral diet was significantly shorter than that to the resumption of bowel function. No significant difference was seen in the incidence of complications. The time to first flatus in group 1 (median, 48 hours) was significantly shorter than that in group 2 (median, 67 hours). The length of hospitalization in group 1 (median, 7 days) was significantly shorter than that in group 2 (median, 10 days). CONCLUSIONS: Early mobilization and early feeding following the resolution of gastric ileus is safe and feasible without vomiting in patients who have elective colonic surgery.

Usefulness of fractional flow reserve guidance for PCI in acute myocardial infarction.

Objectives. After conventional balloon angioplasty (PTCA) for acute myocardial infarction in 77 patients (77 lesions), we used myocardial fractional flow reserve (FFR(myo)) to assess the endpoint of percutaneous coronary intervention (PCI) and to determine whether adjunctive stenting was required. Of these, a total of 37 lesions with FFR > or = 0.94 after PTCA received no further treatment (FFR-PTCA group), while the remaining 40 lesions (FFR < 0.94) underwent adjunctive stenting (FFR-stent group). A further 78 patients (78 lesions) comprised the control group; these patients underwent direct stenting without FFR measurement (stent-only group). The restenosis rate at 14-day discharge (mean time to discharge) was 5.1% in the two groups treated with FFR guidance (FFR-PTCA and FFR-stent), but was 0% in the control group (p = ns). There were no significant differences in reocclusion rates between the FFR-guided patients (1.7%) and the controls (0%). There was no incidence of in-hospital mortality or reinfarction in any of the groups. The number of balloons used (mean, 1.3 0.6 balloons for FFR patients versus 1.8 0.5 balloons for control patients) and the total cost of hospitalization and treatment ($16,213 versus $19,730 in U.S. currency; 1,945,571 998,726 yen versus 2,367,656 538,444 yen in Japanese currency) were both higher in the control group. Long-term survival rates were comparable in the two groups. These findings indicate that FFR guidance for PCI of acute myocardial infarction is a useful, low-cost technique that results in similar clinical outcomes as primary stenting.

[Anesthesia in a patient with relapsing polychondritis].

A 46-year-old female with relapsing polychondritis (RP) was scheduled for surgical repair of saddle-nose and peri-chondritic ear. RP is a rare systemic, inflammatory, and destructive disease of the cartilaginous structures leading to multiple functional disorders in the affected organs. Preoperatively, her chest radiogram of the trachea showed narrowing in diameters which altered about 2 mm with expiration and inspiration. Propofol administered intravenously was given as induction and anesthesia was maintained with nitrous oxide-oxygen-sevoflurane with spontaneous ventilation using laryngeal mask airway. The operation was over uneventfully. Anesthesiologic management requires careful preoperative evaluation of vital organ functions, in particular, respiration.

[The development of methicillin-resistant Staphylococcus aureus sepsis in a patient with herpes zoster during treatment with continuous epidural infusion].

A 79-year-old man with herpes zoster was referred to our hospital for pain control. He was a survivor of the atomic bombing of Hiroshima, and had a history of cerebral infarction and hypertension. A cervical epidural catheter was placed for continuous analgesic infusion. After 20 days of catheterization, he gradually developed a high fever and confusion, and complained of nausea and headaches. An urgent blood examination revealed a white blood cell count of 15,200 mm-3 and a C-reactive protein of 32.4 mg.dl-1. The catheter was removed and antibiotic therapy was started. Repeated magnetic resonance imaging could not confirm epidural abscess formation. The bacterial culture of the cerebrospinal fluid was negative, but the cultures of the blood, the catheter tip, and the nasal cavity swab were positive for methicillin-resistant Staphylococcus aureus. Although intravenous vancomycin was administered, systemic inflammation persisted. The patient consecutively suffered varied disorders such as acute renal failure, disseminated intravascular coagulation, and gastrointestinal bleeding. Although symptomatic treatment had been prolonging his life, 58 days after the catheter removal, the patient suddenly developed cerebellopontine infarction, which made mechanical ventilation necessary. He remained unconscious until his death 117 days after the catheter removal. We discussed the possible pathogenetic mechanisms of the present case.

[Oxygen embolism after intraoperative use of hydrogen peroxide].

Hydrogen peroxide is widely used for irrigation of surgical wounds. However, its administration has been associated with gas embolism. We report a case of gas embolism after wound irrigation with hydrogen peroxide in a 11-year-old boy undergoing extraction of the extra-traumatic splint under general anesthesia. When 3% hydrogen peroxide 12 ml was applied to wound of the left femur after extraction of the splint, the patient showed clinical signs of pulmonary embolism. Symptomatic treatment was initiated immediately. When the patient awoke from anesthesia, he showed tonic convulsion. But he recovered without any complications. The administration of hydrogen peroxide into a closed tissue is contraindicated during surgery.