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Eisenmenger's syndrome (ES) is considered as the most severe form of pulmonary arterial hypertension related to congenital cardiac anomalies [1]. Due to high maternal mortality rate in these patients (30-50%) [2], termination of pregnancy is generally recommended. However, in the case of continuing gestation, a multidisciplinary approach with cardiologists, cardiac surgeons, obstetricians, and anesthesiologists should be required for the safe pregnancy and delivery [3]. A 27-year-old patient of multigravida (height 164 cm, weight 71 kg) with known ES was scheduled for cesarean section. When she was pregnant at the first time, she terminated pregnancy according to cardiologist's advice. However, after 4 months, she revisited the hospital at 8 weeks of gestation and refused the second termination of pregnancy. At 26 weeks of gestation, she was admitted for the management of worsening pulmonary arterial hypertension and heart failure. On physical examination, heart rate was 88 bpm and blood pressure was 100/51 mmHg. Oxygen saturation was maintained between 88 and 92%. Transthoracic echocardiography showed complicated atrioventricular septal defect with bidirectional shunt, severe pulmonary hypertension (mean pulmonary artery pressure of 66 mmHg measured by maximum velocity of pulmonary regurgitation), dilated right ventricle with mildly depressed right ventricular systolic function, right ventricular hypertrophy, right atrial enlargement, and preserved left ventricular function (ejection fraction of 68%). With O2 supplement using facial mask, the continuous infusion of treprostinil (10 ng/kg/min) was started. At 32 weeks of gestation, non-sustained ventricular tachycardia (NSVT) was frequently developed. After discussing about the optimal managements with a cardiologist, an obstetrician, and an anesthesiologist, an emergent cesarean section under general anesthesia was decided. Extracorporeal membrane oxygenation was prepared in case of developing biventricular dysfunction before starting anesthesia. On the arrival at the operating room, 5-lead electrocardiography, non-invasive blood pressure monitoring, and pulse oxymetry were applied on the patient, and continuous infusion of amiodarone was initiated at 20 mg/hr to prevent NSVT. After applying the elastic stockings for the prophylaxis of deep vein thrombosis, a radial artery catheter and a right internal jugular venous catheter were placed before inducing anesthesia. A dedicated transducer (FloTrac, Edwards Lifesciences, Irvine, CA, USA) was connected to the radial arterial line on one side and to the Vigileo system (Edwards Lifesciences, Irvine, CA, USA) on the other side for the continuous monitoring of cardiac output. The pre-induction blood pressure, central venous pressure, oxygen saturation, and cardiac index were 120/62 mmHg, 6 mmHg, 89%, and 3.5 L/min/m2, respectively. After preoxygenation, anesthesia was induced using 2 mg of midazolam, 10 mg of etomidate, and continuous infusion of remifentanil with cricoid pressure. Neuromuscular block was achieved using 70 mg of rocuronium. Transesophageal echocardiography (TEE) was then inserted. There was no significant change compared to preoperative echocardiography finding. Mechanical ventilation was set with a tidal volume of 450 ml and an inspired oxygen fraction of 0.5. The respiratory rate was adjusted to maintain the pressure of end-tidal carbon dioxide at 30 to 35 mmHg. Mean airway pressure and oxygen saturation were maintained at 20 cmH2O and at 93 to 94%, respectively. Anesthesia was maintained with a continuous infusion of propofol and remifentanil to prevent the increasing of PVR so that the target bispectral index was between 40 and 60. A live male baby at 1.84 kg with Apgar score of 4 at 1 minute and 8 at 5 minutes was extracted and transferred to neonatal intensive care unit. During the whole course of anesthesia, acidosis, hypercarbia, and hypoxemia which require corrections did not occur, and no hemodynamic instability developed (Table 1). Table 1 Preinduction, Intraoperative and Postoperative Hemodynamics After surgery, the patient was transferred to an intensive care unit with endotracheal tube and was taken to the cardiologist. Postoperative pain was managed with intravenously infused opioid. Anticoagulation with heparin was started from postoperative day (POD) 1 and was continued for the next 1 week. Extubation was performed on POD 1. She was transferred to the general ward on POD 10. On POD 14, she was discharged without any specific complications. In a normal pregnancy, plasma volume increases and the systemic and pulmonary vascular resistances decrease. However, in patients with ES, an irreversibly increased pulmonary vascular resistance restricts blood flow to the lungs. Therefore, an increased plasma volume adds burden to the already compromised right ventricle [3,4]. Moreover, systemic vasodilation with pre-existing pulmonary hypertension increases the right-to-left shunt, which worsens the hypoxia [3,4]. These series of changes occur in a vicious cycle of increases in the pulmonary hypertension, right ventricular strain, and right-to-left shunt [3]. In this case, we chose the method of general anesthesia, due to the patient's request and for the monitoring of intraoperative TEE. Unfortunately, the conduction of anesthesia can increase the right-to-left shunt in these patients, regardless of the choice between general and regional anesthesia. Therefore, maintaining the stable hemodynamics is more important than the choice of anesthesia. The use of appropriate invasive monitoring devices such as direct arterial catheter, central venous catheter, pulmonary arterial catheter, and TEE might be helpful [5]. However, we did not use pulmonary arterial catheter for several reasons. Firstly, cardiac output by thermodilution technique would be unpredictable in the presence of large intracardiac shunt. Secondly, the risk of pulmonary artery rupture would be high. Lastly, arrhythmia induced by the catheter could be risky in the case of our patient. Instead, we chose Vigileo monitor (Vigileo/FloTrac, Edwards Lifesciences, Irvine, CA, USA) for the continuous monitoring of cardiac output. In addition, we did our best to avoid the conditions that would increase pulmonary arterial resistance (i.e., hypothermia, acidosis, hypercarbia, and hypoxemia). We did not use preoperative anticoagulation. An obstetrician was concerned about the postoperative bleeding. Considering that any hypovolemia could result in a sudden death in the case of our patient [4], our team decided to follow the obstetrician's suggestion. The postoperative pain could also increase the systemic vascular resistance. Therefore, we decided to wake the patient up after achieving the appropriate postoperative analgesia. In conclusion, maintaining the balance between systemic vascular resistance and pulmonary vascular resistance without myocardial depression would be the key to safe anesthetic management in a pregnant patient with ES.

Purpose: We report a case of treatment of acute central retinal artery occlusion (CRAO) with ocular ischemic syndrome (OIS). Case summary: A 72-year-old man presented with acute loss of vision in the right eye on that day. At initial examination, visual acuity tested positive for light sensitivity in the right eye. Fundus examination demonstrated a visible embolus at the central retinal artery overlying the optic disc head and a cherry-red spot in the fovea. Fluorescein angiography revealed that filling of the choroidal circulation was delayed, and the arteriovenous transit time was even further delayed. Carotid angiography showed marked stenosis within the right internal carotid artery. Laboratory tests included blood tests for hypercoagulability evaluation, for which the results were non-specific. To treat acute CRAO with OIS in the right eye, transluminal Nd:YAG laser embolectomy (TYE) was performed twice, and carotid angioplasty with stenting was conducted within the stenosed internal carotid artery. One month after the TYE procedure and carotid stenting, the patient’s visual acuity improved to 0.06 and the arteriovenous transit time was within normal limits on fluorescein angiography. Conclusions: The visual prognosis in eyes with CRAO plus an associated choroidal circulatory disturbance is extremely poor. However, we experienced and reported a case of CRAO with OIS treated successfully through a prompt TYE procedure and carotid angioplasty with stenting. J Korean Ophthalmol Soc 2014;55(8):1242-1247

A hypercoagulable state in antiphospholipid antibody syndrome (APS) may cause many obstetric complications during the pregnancy and postpartum. Therefore, a pregnant woman with APS should be treated with aspirin alone or combined with either unfractionated heparin or low molecular weight heparin [1]. With antithrombotic prophylaxis, thrombocytopenia can often occur in a pregnant woman with APS, and those conditions can cause confusions when conducting regional anesthesia for cesarean section. A 30-year-old woman (height of 160.4 cm and body weight of 73.7 kg) was admitted for the elective repeat cesarean section at gestational age of 39 weeks. She had an obstetric history of 5 recurrent early pregnancy losses, and only one live birth was given 3 years ago with cesarean section under empirical aspirin therapy. The cause of the previous cesarean section was expected to be the low birth weight, and general anesthesia was performed due to the persistent thrombocytopenia unresponsive to platelet transfusions. She was finally diagnosed with APS through laboratory test one year ago at the time of her last abortion. The cesarean section was performed under general anesthesia due to the low platelet count, and further evaluation was not conducted. She took aspirin 100 mg/day and hydroxychlorquine 200 mg twice a day according to the recommendation of a rheumatologist. After confirming her pregnancy at 6 weeks of gestational age, she started to receive enoxaparin 40 mg subcutaneously once daily throughout the pregnancy. There was no significant event during her pregnancy. On the admission for elective repeat cesarean section, her platelet count was 85,000 /µl and there was no significant abnormality in the coagulation tests and liver function profiles. Thrombocytopenia had been observed since third trimester and was maintained stable without bleeding tendency such as bruises and petechiae. After consulting with the obstetrician, we decided to perform combined spinal-epidural anesthesia for her cesarean section. She was administered aspirin until the morning of the surgery, and she was sent to the operating room 10 hours after the last subcutaneous injection of enoxaparin 40 mg. With the patient in the right lateral position, a 19-gauge epidural catheter (FlexTip plus®; Arrow International, Inc., Reading, PA, USA) was inserted via a 17-gauge Tuohy needle at the L2-3 intervertebral space, using a midline approach with the loss-of-resistanceto- air technique and fixed at 10 cm to the skin. Then, spinal tapping was done at the L3-4 interspace with 25-gauge Whitacre needle and 6 mg of 0.5% hyperbaric bupivacaine, and 20 µg of fentanyl were administered intrathecally. An epidural injection of 10 ml of 0.25% levobupivacaine followed thereafter. The sensory block to the T4 level was achieved with additional injection of 10 ml of 2% lidocaine. Her vital signs were maintained stable during the operation with just one dose of phenylephrine (100 µg). A 3.52 kg healthy male infant was delivered (APGAR score of 9 at 1 and 5 min). Total anesthetic time was 101 min, and the cesarean section was completed without any event. T6 sensory block was identified just upon the arrival to the postanesthesia care unit. Then, a patient-controlled epidural analgesia was started with 0.11% ropivacaine and 3.7 µg/ml fentanyl through the epidural catheter, for postoperative pain control (bolus-lockout time-basal, 2 ml - 15 min - 4 ml). Enoxaparin was re-started in the absence of postpartum bleeding on the next morning which was 24 hours after the operation and was scheduled to be used for up to 6 weeks postoperative. The patient didn't have any symptoms or signs of venous thromboembolism during peripartum period. The epidural catheter was removed 2 hours before the regular enoxaparin injection on postoperative day 2. She was discharged on postoperative day 4 without any neurologic complication. Compared with normal pregnant women, the pregnant women with APS are approximately 15 times more likely to develop thromboembolism, and the risk is increased by 24-fold in the cases of thrombosis history [2]. Deep vein thrombosis or pulmonary embolism was seen at a lower incidence in patients under regional anesthesia than general anesthesia [3], and satisfactory postoperative pain control with patient-controlled epidural analgesia would allow early ambulation to decrease the risk of thrombosis. Based on the American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines, even though prophylactic dose of 40 mg of subcutaneous enoxaparin is taken once daily, neuraxial block could be executed 10-12 hours following the last dose. Based on the guideline, the epidural catheter was removed 2 hours before the next dose. Most of the spinal hematoma in patients receiving enoxaparin was reported when prophylactic dose of enoxaparin was 30-40 mg twice daily or higher [4]. Recently, regional anesthesia has been performed safely in pregnant patients with platelet counts between 50-79 × 103 /µl. Normal hemostasis can be maintained until the platelet count decreases to 54 × 103 /µl [5]. Stable mild thrombocytopenia should not be a contraindication for regional anesthesia, as long as there is no bleeding diathesis, significant prolongation of prothrombin time or APTT, decreasing tendency of platelet counts, or association with eclampsia. In this case, we carefully monitored the possible clinical symptoms of spinal hematoma, because a continuous epidural catheter was adopted during postpartum period even though the patient still had bleeding tendency. We didn't consider the thromboelastogram or the platelet function analyzer; however, it would have been more secure if the platelet function was evaluated [5]. A continuous neuraxial block could mask the symptoms of motor or sensory changes from spinal hematoma. Therefore, close observation is essential for early detection of spinal hematoma. APS with thrombosis in pregnancy requires higher dose of anticoagulation (enoxaparin 1 mg/kg). In such case, general anesthesia is much safer to avoid spinal hematoma. General anesthesia might also be favorable in emergent situation such as fetal distress due to placental infarction in a patient with APS, because anesthetic induction time is shorter than the regional anesthesia. Regional anesthesia would also be considered as a safe anesthetic option in a patient with APS syndrome, antithrombotic prophylaxis, and mild thrombocytopenia. Anesthesiologists should consider the use of anticoagulants and practical coagulation state to choose anesthetic technique for cesarean section in a patient with APS, by weighing the benefits and the risks between general or regional anesthesia.

The goal of this study was to determine whether etomidate has protective effect against kainic acid (KA)-induced neurotoxicity. Administration of etomidate (20 mg/kg i.p.) was performed in sequence, first being just 1 h after KA (10 mg/kg i.p.) injection, then three times at 1-h intervals. Neuronal damages in hippocampus were evaluated by using the acid fuchsin stain to detect cell death and the heat shock protein-70 (HSP-70) induction as an index of cell injury at 24 h after the administration of KA. HSP-70 induction and acid fuchsin positive neurons were increased in CA1 and CA3 regions of hippocampus after KA injection but significantly decreased by etomidate-injection. These results suggest that the etomidate hold potential effect on the protection of neurons against KA-induced neurotoxicity.

Previous studies have shown that okadaic acid (OA) evokes tau phosphorylation and neurofibrillary changes in vivo, and in cultured neurons, that resemble Alzheimer's disease pathogenesis. In order to investigate the mechanism of OA-neurotoxicity, we treated cultured rat neurons with OA and examined nuclear morphology, phosphatidylserine (PS) externalization, alpha-fodrin cleavage, and the effects of cell death inhibitors. Our results demonstrated that cycloheximide (CHX) and the broad-spectrum caspase inhibitor, ZVAD, significantly reduced cell death in a dose-dependent manner. Nuclear fragmentation, a hallmark of apoptosis, occurred after OA treatment and was inhibited by CHX or ZVAD. PS externalization was apparent in 6-12 h in neurites and in cell bodies, and peaked at 24 h after OA treatment. Cleavage of alpha-fodrin as visualized by the appearance of 150- and 120-kDa bands appeared with a time course similar to PS externalization. These results suggest that OA induce CHX and caspase sensitive neuronal apoptosis.

Within neurofibrillary tangles and dystrophic neurites of Alzheimer's disease (AD), tau protein is hyperphosphorylated. In the present study, we provide evidence that acute injection of okadaic acid (1 mM, 0.5 μl) into the dorsal hippocampus induces the formation of paired helical filament (PHF)-1, sternberger monoclonals incorporated (SMI)-31, and amyloid precursor protein (APP) positive dystrophic neurites in the lacunosum-molecular layer of CA1 and molecular layer of dentate gyrus. Okadaic acid evoked a marked loss of microtubule associated protein (MAP)-2 immunoreactivity. PHF-1 immunoreactive terminals were fine, and SMI-31 immunoreactive terminals appeared at granular terminals and at the ring-like or elongated dystrophic neurites. APP positive dystrophic neurites exhibited large bulb-like globular terminals. Interestingly, APP dystrophic neurites were co-localized with SMI-31 immunoreactivity in the core. APP immunoreactivity became stronger over 24 h even in vehicle injected area. These results may provide the morphological evidence for the animal model to study dystrophic neurites formation of AD.

In the telecommunication market smaller and lighter devices are preferred in order to miniaturize devices such as antennas, filters and duplexers, multi-layered microwave devices. The realization of these devices may be accomplished by integration of electromagnetic wave analysis technology and the manufacturing technology of dielectric materials. Furthermore, low-fire microwave ceramics which can be co-fired with good conductors such as silver metal, are needed. The microwave dielectric properties of ZnNb/sub 2/O/sub 6/ and Pb/sub 5/Nb/sub 4/O/sub 15/ (ZNPN ceramics) with additives (CuV/sub 2/O/sub 6/, Sb/sub 2/O/sub 3/ and glass) was investigated. A chip antenna (7.5 mm/spl times/4.5 mm/spl times/0.8 mm) using a multilayered process was designed (1.91 GHz for PCS) and manufactured.

In this paper, a car-mounted microstrip feed L-type aperture coupled circular polarization patch antenna, from which polarization characteristics can be obtained by the new-type coupling method, designed. Further consideration are given to the characteristic changes due to several design parameter changes for this antenna. Before loading the phase shifters on the array antenna, which is comprised of single circular polarization patch antennas, there is a need to design a circular polarization array antenna using a simple single microstrip line feeding method for securing the space sufficient to load the phase shifters, as this antenna, which is car-mounted, is required to have the ability to track a satellite by beam-scanning. For this, the 2/spl times/2 array antenna with in-phase feeding is designed and fabricated with several circular polarization characteristics being measured and evaluated.

Background Adult stem cells have been widely investigated in bioengineering approaches for tissue repair therapy. We evaluated the clinical value and safety of the application of cultured bone marrow-derived allogenic mesenchymal stem cells (MSCs) for treating skin wounds in a canine model. Hypothesis Topical allogenic MSC transplantation can accelerate the closure of experimental full-thickness cutaneous wounds and attenuate local inflammation. Animals Adult healthy beagle dogs (n = 10; 3–6 years old; 7.2–13.1 kg) were studied. Methods Full-thickness skin wounds were created on the dorsum of healthy beagles, and allogenic MSCs were injected intradermally. The rate of wound closure and the degree of collagen production were analysed histologically using haematoxylin and eosin staining and trichrome staining. The degree of cellular proliferation and angiogenesis was evaluated by immunocytochemistry using proliferating cell nuclear antigen-, vimentin- and α-smooth muscle actin-specific antibodies. Local mRNA expression levels of interleukin-2, interferon-γ, basic fibroblast growth factor and matrix metalloproteinase-2 were evaluated by RT-PCR. Results Compared with the vehicle-treated wounds, MSC-treated wounds showed more rapid wound closure and increased collagen synthesis, cellular proliferation and angiogenesis. Moreover, MSC-treated wounds showed decreased expression of pro-inflammatory cytokines (interleukin-2 and interferon-γ) and wound healing-related factors (basic fibroblast growth factor and matrix metalloproteinase-2). Conclusion and clinical importance Topical transplantation of MSCs results in paracrine effects on cellular proliferation and angiogenesis, as well as modulation of local mRNA expression of several factors related to cutaneous wound healing. Resume Contexte Les cellules souches adultes ont ete largement etudiees dans les approches de bio-ingenierie pour la therapie de reparation tissulaire. Nous evaluons l'efficacite clinique et la securite de l'application de cellules souches mesenchymateuses allogeniques en culture derivees de moelle osseuse (MSCs) pour le traitement de plaies cutanees dans un modele canin. Hypothese La transplantation de MSC allogenique topique peut accelerer la fermeture en toute epaisseur de plaies cutanees experimentales et attenuer l'inflammation locale. Sujets Des chiens beagles adultes sains (n = 10; 3–6 ans; 7.2–13.1 kg) ont ete etudies. Methodes Des plaies cutanees en pleine epaisseur ont ete crees sur la face dorsale des beagles sains et des MSCs allogenes ont ete injectees par voie intradermique. Le taux de cicatrisation et le degre de production de collagene ont ete analyses sur le plan histologique par colorations a l'hematoxyline et eosine et par trichrome. Le degre de proliferation cellulaire et d'angiogenese ont ete evalues par immunohistochimie a l'aide d'anticorps specifiques d'antigene nucleaire de proliferation cellulaire, de vimentine et d'actine de muscle lisse α. Les taux d'expression local d'ARNm d'interleukine-2, d'interferon-γ, du facteur de croissance basique de fibroblaste et de metalloproteinase-2 de matrice, ont ete evalues par RT-PCR. Resultats Compare avec les plaies traitees par excipient, les plaies traitees par les MSCs ont montre une plus rapide cicatrisation et une augmentation de synthese de collagene, de proliferation cellulaire er d'angiogenese. En outre, Les plaies traitees au MSC ont montre une expression diminuee de cytokines pro-inflammatoires (interleukine-2 et interferon-γ) et des facteurs lies a la cicatrisation (facteur de croissance basique de fibroblaste et metalloproteinase-2 de matrice). Conclusion et importance clinique La transplantation topique de MSCs resulte en des effets paracrines de proliferation cellulaire et d'angiogenese ainsi qu'en une modulation de l'expression locale d'ARNm de plusieurs facteurs lies a la cicatrisation cutanee. Resumen Introduccion Las celulas madre de adultos se han estudiado extensivamente en estrategias de bioingenieria para la reparacion de tejidos. Hemos evaluado el valor clinico y la seguridad de la aplicacion de celulas madre mesenquimales (MSCs) alogeneicas derivadas de la medula osea para tratar las heridas de la piel en un modelo canino. Hipotesis El transplante topico alogeneico de MSCs puede acelerar la cicatrizacion de heridas cutaneas experimentales de todo el grosor de la piel y disminuir la inflamacion local. Animales Se estudiaron perros de raza Beagle sanos adultos (n=10; de 3-6 anos de edad; 7,2-13,1 kg de peso). Metodos Se crearon heridas de todo el grosor de la piel en el dorso de perros Beagle sanos, y se inyectaron MSCs alogeneicas intradermicamente. El ritmo de reparacion de la herida y el grado de produccion de colageno se analizaron histologicamente utilizando tinciones de hematoxilina-eosina y tricromico. El grado de proliferacion celular y la angiogenesis se evaluaron mediante inmunohistoquimica utilizando anticuerpos especificos para el antigeno de proliferacion celular nuclear (PCNA), vimentina y α-actina de musculo liso. La expresion local de mRNA para interleuquina-2 (IL-2), interferon- γ (IFN- γ), factor basico de crecimiento de fibroblastos (BFGF) y metaloproteinasa de matriz-2 se evaluaron mediante RT-PCR. Resultados comparado con las heridas tratadas solo con el vehiculo, las heridas tratadas con MSCs mostraron una reparacion mas rapida y un aumento en la produccion de colageno, proliferacion celular y angiogenesis. Ademas, las heridas tratadas con MSCs mostraron una expresion aumentada de citoquinas proinflamatorias (IL-2 e IFN- γ) y factores relacionados con la reparacion de la herida (BFGF y metaloproteinasa de matriz-2). Conclusion e importancia clinica El transplante topico de MSCs resulta en efectos paracrinos en la proliferacion celular y angiogenesis, asi como en la modulacion de la expresion de mRNA de diversos factores relacionados con la cicatrizacion de heridas. Zusammenfassung Hintergrund Adulte Stammzellen sind fur ihre biotechnologische Verwendung bei der Wiederherstellung von Geweben bereits weit reichend erforscht. Wir haben die klinische Bedeutung und Sicherheit der Applikation von kultivierten allogenen mesenchymalen Stammzellen (MSCs) aus dem Knochenmark zur Behandlung von Hautwunden in einem caninen Modell evaluiert. Hypothese Die topische allogene MSC Transplantation kann den Wundverschluss experimenteller Hautwunden (Brandwunden Grad III) beschleunigen und die lokale Entzundung mildern. Tiere Erwachsene gesunde Beagles (n=10; 3-6 Jahre alt; 7,2-13,1kg) wurden in der Studie verwendet. Methoden Es wurden Hautwunden 3. Grades am Rucken der gesunden Beagles verursacht und allogene MSCs intradermal injiziert. Die Schnelligkeit des Wundverschlusses und das Ausmas der Kollagenproduktion wurden histologisch mittels Hamatoxylin und Eosin Farbung und Trichromfarbung untersucht. Das Ausmas der zellularen Proliferation und der Angiogenese wurde mittels Immunzytochemie unter Verwendung von Proliferating-Cell-Nuclear-Antigen, Vimentin und Alpha Smooth Muscle Actin-spezifischen Antikorpern evaluiert. Die lokale Exprimierung von mRNA von Interleukin-2, Interferon-γ, Basic Fibroblasten Wachstumsfaktor und Matrix Metalloproteinase-2 wurde mittels RT PCR evaluiert. Ergebnisse Im Vergleich zu den Wunden, die nur mit dem Tragermedium behandelt worden waren, zeigten die mit MSC-behandelten Wunden einen rascheren Verschluss und eine erhohte Kollagensynthese, zellulare Proliferation und Angiogenese. Daruber hinaus zeigten MSC-behandelte Wunden eine verminderte Exprimierung pro-entzundlicher Zytokine (Interleukin-2 und Interferon-γ) und Wundheilungsfaktoren (Basic Fibroblasten Wachstumsfaktor und Matrix Metalloproteinase-2). Schlussfolgerung und klinische Bedeutung Die topische Transplantation von MSCs resultiert in parakrinen Effekten auf die zellulare Proliferation und Angiogenese sowie die Modulierung lokaler mRNA Exprimierung verschiedener Faktoren, die mit der Wundheilung der Haut im Zusammenhang stehen. 摘要 背景 以成体干细胞的生物工程法用于组织修复治疗已被广泛研究。将骨髓培养得到的外源性间充质干细胞(MSCs)用于犬模型上治疗皮肤创伤,我们来评估其临床价值和安全性。 假设 局部外源性MSC移植能使试验的皮肤创口全层愈合加快,并使局部炎症减轻。 动物 研究成年健康比格犬(n = 10;3–6 岁;7.2–13.1 kg)。 方法 在健康的比格犬背部创造全层皮肤创口,皮内注射外源性MSCs。使用苏木精和伊红染色法和三色染色法,从组织结构上分析伤口愈合率和胶原产生的程度。通过免疫细胞化学使用增殖细胞核抗原、维生素和α-平滑肌肌动蛋白-特定抗体,评估细胞增殖和血管生成程度。通过RT PCR评估白介素-2、γ-干扰素、基纤维母细胞生长因子和基质金属蛋白酶-2局部mRNA表达等级。 结果 与媒介物治疗创口相比,MSC治疗创口显示出更快的创口愈合,以及胶原合成、细胞增殖和血管生成增加。 此外,MSC治疗创口显示出炎性细胞因子(白介素-2和γ-干扰素)和与创口愈合相关因子(碱性成纤维细胞生长因子和基质金属蛋白酶-2)表达减少。 结论和临床价值 局部移植MSCs造成了对细胞增殖和血管生成的旁分泌作用,也同样引起几个与皮肤创伤愈合相关因子局部mRNA表达的调节。 要約 背景 成熟した幹細胞は組織修復療法に対して生物工学的なアプローチで広く研究されている。著者らは培養した骨髄由来の同種異系の間葉系肝細胞(MSCs)を犬の皮膚創傷の治療に応用し、臨床的な価値と安全性を評価した。 仮説 同種異系MSCの局所への移植は実験的な皮膚全層創傷の閉鎖と炎症の軽減を加速する可能性がある。 供与動物 成熟した健常ビーグル犬(n = 10; 3–6 歳齢; 7.2–13.1 kg)を用いた。 方法 健常ビーグルの背部に皮膚全層潰瘍を作成し、同種異系MSCを皮内に注射した。創傷閉鎖率とコラーゲン産生度をヘマトキシリン染色トリクローム染色を用いて組織学的に解析した。細胞増殖度と血管新生は核内増殖抗原−、ビメンチン−、α−平滑筋アクチン−特異的抗体を用いて免疫組織化学染色で評価した。局所のインターロイキン−2、インターフェロンγ、塩基性線維芽細胞増殖因子とマトリックスメタロプロテアーゼ2のmRNA発現レベルをRT-PCRで評価した。 結果 賦形剤のみで治療した創傷と比較し、MSCで治療した創傷はより早期に閉鎖し、コラーゲン合成の増加、細胞増殖や血管新生を示した。さらに、MSCで治療した創傷は炎症後サイトカイン(インターロイキン−2とインターフェロン−γ)と創傷治癒関連因子(塩基性線維芽細胞増殖因子とマトリックスメタロプロテアーゼ−2)の発現が減少していた。 結論と臨床的な重要性 MSCの局所への移植により細胞増殖と血管新生に対してはパラクライン効果を示すのと同時に,皮膚創傷治癒に関連する様々な因子の局所mRNA発現を調節した。

Background: Etomidate has a stable hemodynamic profile after induction, but hypertension and tachycardia are frequent after intubation as well as myoclonus. We compared the effects of fentanyl and remifentanil on the hemodynamic response to intubation and myoclonus during etomidate induction in elderly patients. Methods: Ninety ASA I or II patients aged over 65 were randomly assigned to 3 groups. Group C received normal saline 10 ml (n = 30), group F and R were pretreated with fentanyl 1.0 μg/kg (n = 30) or remifentanil 1.0 μg/kg with continuous infusion of 0.1 μg/kg/min (n = 30) 1 min before induction with etomidate 0.2 mg/kg. Endotracheal intubation was performed after administration of rocuronium 0.8 mg/kg. Systolic blood pressure (SBP), mean arterial pressure, diastolic blood pressure (DBP), heart rate (HR), and the incidence and intensity of myoclonus were recorded. Results: After intubation, group R showed significant decreases compared with groups C and F for all of the hemodynamic variables measured. The incidences of increases in SBP and HR of more than 30% of the baseline levels, SBP of > 200 mmHg, and HR of > 120 beats/min were significantly lower in group R (0%, 10%, 0%, and 0%, respectively) compared with groups C (83%, 83%, 30%, and 13%, respectively) and F (63%, 77%, 13%, and 7%, respectively). The frequency and intensity of myoclonus were significantly decreased in both groups F and R compared with group C. Conclusions: Pretreatment with remifentanil suppressed cardiovascular reactions to endotracheal intubation more effectively than that of fentanyl during etomidate induction. Both opioids reduced the incidence of myoclonus. (Korean J Anesthesiol 2013; 64: 12-18)

Blood cysts of the heart are rare benign tumors, usually involving the cardiac valves. They are found mainly in the first month of life and in children; and are rarely seen in adults. Here, we report a case of a blood cyst on the subvalvular apparatus of the mitral valve, which was incidentally discovered during chest computed tomography in a 47-year-old man. To the best of our knowledge, this is the first reported case of blood cyst of the heart in an adult in Korea.

A 48-year-old male visited the emergency room of the authors’ hospital due to nausea, vomiting, and myalgia for four days. Acute hepatitis A was identified from the serologic marker of the hepatitis A virus. Mild elevation of the serum creatinine and creatinine phosphokinase (CPK) suggested rhabomyolysis, which was confirmed with the serum aldolase, myoglobin, and urine myoglobin. With supportive care, both the liver and renal functions were recovered gradually and fully. This case shows that rhabdomyolysis can be one of the mechanisms of renal complication in cases of acute symptomatic hepatitis A.

Cryptococcosis is an invasive fungal infection, which is more common in immunocompromised patients. However, pulmonary cryptococcosis can occur in immunocompetent patients and should be considered on a differential diagnosis for nodular or mass-like lesions in chest radiograph. Recently, we experienced a patient with pulmonary cryptococcosis, successfully treated with oral fluconazole therapy. A 74-year-old female patient was referred for an evaluation of abnormal images, a large consolidative mass with multiple nodular consolidations and small nodules that mimics primary lung cancer with multiple lung to lung metastases. Computed tomography-guided lung biopsy confirmed the diagnosis of pulmonary cryptococcosis. The follow-up image taken after 4 months with oral fluconazole treatment showed marked improvement.

We present a study of HII regions in M51 using the Hubble Space Telescope ACS images taken as part of the Hubble Heritage Program. We have catalogued about 19,600 HII regions in M51 with Ha luminosity in the range of L = 10^{35.5} erg/s to 10^{39.0} erg/s. The Ha luminosity function of HII regions (HII LF) in M51 is well represented by a double power law with its index alpha=-2.25\pm0.02 for the bright part and alpha=-1.42\pm0.01 for the faint part, separated at a break point L= 10^{37.1} erg/s. This break was not found in previous studies of M51 HII regions. Comparison with simulated HII LFs suggests that this break is caused by the transition of HII region ionizing sources, from low mass clusters (with ~ 10^3 M_sun, including several OB stars) to more massive clusters (including several tens of OB stars). The HII LFs with L < 10^{37.1} erg/s are found to have different slopes for different parts in M51: the HII LF for the interarm region is steeper than those for the arm and the nuclear regions. This observed difference in HII LFs can be explained by evolutionary effects that HII regions in the interarm region are relatively older than those in the other parts of M51., 36 pages, 12 figures, 2 tables, accepted to ApJ

Background The purpose of this study was to evaluate the gender-related changes in the function and distribution of α(1)-adrenoceptors in the distal mesenteric artery of streptozotocin (STZ)-induced diabetic rats at the level of α(1)-adrenoceptor subtypes. Methods Diabetes was induced by intravenous injection of STZ in a dose of 60 mg/kg through the tail vein in 8 week-old male or female Sprague-Dawley rats (n = 13/group). Age-matched normal rats (n = 15) were used as a control group. Four weeks after STZ injection, the change in mean arterial pressure caused by a 45° tilting was recorded. The α(1)-adrenoceptor subtypes mediating contractions of the distal mesenteric artery were investigated using the agonist, phenylephrine as well as subtype-selective antagonists including prazocin, 5-methylurapidil, and BMY 7378. The expression of α(1)-adrenoceptor subtypes of each artery was examined by immunofluorescence staining and western blotting using subtype selective antibodies. Results Compared with normal male rats, the contractile response to phenylephrine was decreased in the distal mesenteric artery in normal female rats. Moreover, a decrease in contractile force was observed in STZ-induced diabetic rats compared with age-matched controls. Western blotting revealed that there was the difference between normal male and female rats in manifestation of the α(1D)-adrenoceptor. In STZ-induced male and female diabetic rats, all α(1)-adrenoceptor subtypes were decreased in distal mesenteric arteries, compared with normal rats. Conclusions There was the gender-related functional difference of α(1)-adrenoceptors in normal rats. In both male and female rats, diabetes decreased the contractile response in mesenteric arteries, which might be caused by the overall change in α(1)-adrenoceptor.

A hidden primary tumor presenting as an isolated Lung mass is a diagnostic challenge to physicians because the diagnosis of Lung cancer is Likely to be made if the histologic findings are not inconsistent with Lung cancer. A Large Lung mass was found incidentally in a 59-year-old man. Although adenocarcinoma was diagnosed by percutaneous needle biopsy, thyroid transcription factor-1(TTF-1) immunostaining was negative, raising suspicion that there was another primary site. There was no abnormal finding except for the Lung mass on a 18FDG-PET/CT scan and the patient did not complain of any discomfort. Finally, prostatic cancer was confirmed through the study of tumor markers and prostate-specific antigen(PSA) immunostaining. Because of the rare presentation of a single Lung mass in malignancies that have another primary site, physicians should carefully review all data before making a final diagnosis of Lung cancer.

Despite reductions in surgical mortality, neurologic sequelae remain a devastating complication after cardiac surgery with car- diopulmonary bypass. Neurologic complications may be induced by a massive air embolism during cardiopulmonary bypass, even with extensive monitoring. This report describes a patient who had a fatal cerebral infarct during aortic valve and ascending aorta replacement surgery. We monitored jugular venous O2 saturation (SjvO2) and cerebral oximetry using near-infrared spectro- scopy in the perioperative period. The operation and anesthesia were uneventful until the deep hypothermic total arrest for the replacement of the ascending aorta. However, restarting the cardiopulmonary bypass after deep hypothermic total arrest produced a brief (less than 10 seconds) but large amount of air in the root cannula. At this time, although cerebral oximetry did not show any changes, the SjvO2 decreased to 21% for about 3 minutes and then normalized. At 8 hours after surgery, the patient showed seizures and severe edema in both cerebral hemispheres on the MRI. The patient died 21 days after surgery. (Korean J Anesthesiol 2009; 56: 102~5)

Background: Patients may be unwilling to accept blood products for religious reasons – Jehovah’s Witnesses (JW). Because of its minority, as well as JW patients, physicians have a lot of difficulty and anxiety to treatment. Furthermore, sometimes cancer patients are needed transfusion during operation or chemotherapy. So, we analyze the clinical outcomes of JW cancer patients who had treated for identifying the risk of treatment and transfusion need. Methods: We analyzed 77 cases of histological confirmed cancer patients (JW) from Jan. 2001 to Apr. 2008. Results: Male to female ratio was 1:1.48. Median age of patients was 59 years (range, 8 –83 years). The most common primary site was stomach (20.8%) followed by breast (14.3%), colorectal (11.7%), liver (7.8%), lung (6.5%), and hematologic malignancy (5.2%). At diagnosis, 53 patients (68.8%) were operable early cancer patients. Operation was done in 47 patients (89%). three patients refused operation itself. Change of CBC profile after operation was observed in hemoglobin (Mean ± SD; 12.7 ± 2.1 g/dL to 10.6 ± 2.3 g/dL, P Conclusion: Bloodless cancer treatment was not accompanied with serious complication. A few cases of palliative chemotherapy were needed transfusion, but adequate physician’s assist - dose modification and use of G-CSF and erythropoietin - could make keep the patient’s hope and quality of life.

Rupture of the left ventricle is a dreadful complication after mitral valve replacement. It is infrequent but potentially lethal. We have experienced a case of sudden hemorrhagic shock immediately after arriving at intensive care unit postoperatively and revealed left ventricle rupture on resternotomy. The possible mechanism and surgical maneuver are reviewed and the preventive measures in aspect of anesthetic management are discussed. (Korean J Anesthesiol 2008; 54: 363～5)

Background: Etomidate is frequently used as an induction agent in the elderly patients. This study was done to determine whether etomidate-based induction can provide hemodynamic stability and fentanyl decreases the incidence of myoclonus. Methods: Eighty ASA II or III patients older than 65 years were randomly allocated to four groups. Group 1 (n = 20) received etomidate 0.2 mg/kg after normal saline 3 ml, Group 2 (n = 20) received etomidate 0.25 mg/kg after normal saline 3 ml, Group 3 (n = 20) received fentanyl 2 ug/kg before the administration of etomidate 0.2 mg/kg, Group 4 (n = 20) received fentanyl 2 ug/kg before the administration of etomidate 0.25 mg/kg. The time interval from etomidate infusion to loss of eyelash reflex, to decrease bispectral index (BIS) 50, to intubation were recorded. We measured hemodynamic change, the BIS index, the incidence, duration and grade of myoclonus. Results: There were no significant differences in time interval, mean arterial pressure (MAP), BIS index between groups. MAP and HR were increased after intubation in all groups. The incidence of myoclonus were 25%, 30%, 0%, 15% respectively. There were no significant differences in incidence and duration of myoclonus between 4 groups, but group 3 had reduced incidence compared with group 1. Conclusions: Loss of consciousness and hemodynamic changes during induction with 0.2 mg/kg and 0.25 mg/kg of etomidate were appropriate. Pretreatment with fentanyl and small dose of etomidate decrease the incidence of myoclonus.

Background: Propranolol potentiates the effect of neuromuscular blocking agents and induces myasthenic syndromes through curare-like and local anesthetic activities. The purpose of this study was to determine if propranolol potentiated the neuromuscular block caused by rocuronium during both single (0.1 Hz) and tetanic stimulation (50 Hz for 1.9 seconds). Methods: Left phrenic nerve-hemidiaphragms (Male Sprague-Dawley rats, 150−250 g) were mounted in Krebs solution, and three consecutive single twitches and one tetanic tension were obtained prior to each treatment. Each preparation was exposed to one of 4 propranolol concentrations (0, 1.0, 2.5, 5μM), 5μM propranolol with 2μM norepinephrine or 2μM norepinephrine alone and the concentration of rocuronium was then increased cumulatively until a 80% reduction of single twitch occurred. The effects of the drugs used were allowed to reach a steady state by waiting for 20 minutes at each concentration before measuring the tension. Effective concentrations of rocuronium at each treatment were calculated using a probit model. Differences between treatments were tested with student’s t-test and Bonferroni’s c orrection with a P ＜ 0.05 being regarded as significant. Results: The neuromuscular block caused by rocuronium was augmented by propranolol, however the augmentation caused by propranolol was not reversed by norepinephrine. Conclusions: The results of this study indicate that the potentiation by propranolol of the neuromuscular block caused by rocuronium is independent of its adrenoceptor blocking action. (Korean J Anesthesiol 2008; 54: 315∼9)

A 51-year-old man with dermatomyositis and severe interstitial pulmonary disease was planed for bilateral sequential lung transplantation under general anesthesia. He was supported by extracorporeal membrane oxygenation (ECMO) because of respiratory failure in the preoperative period. ECMO was used during induction and maintenance of anesthesia. After the reperfusion, ECMO was successfully weaned. Postoperatively, the patient was transferred to intensive care unit and discharged without serious complications.

Systolic anterior motion of the mitral valve (SAM) is well known in the concentric left ventricular hypertrophy or post mitral valvuloplasty. However, SAM has not been reported in Off-pump coronary artery bypass surgery (OPCAB). Preoperatively, SAM in combination with a left ventricular outflow tract obstruction leads to severe cardiovascular destabilization. Moreover, a diagnosis of SAM is very important because the administration of conventional therapy to hypotension can aggravate SAM. We report a patient with un-identified left ventricular wall hypertrophy or mitral valve regurgitation, who was diagnosed with SAM by TEE during OPCAB. This report describes the diagnostic and therapeutic strategies for the perioperative management of SAM.

The aim of the present study was to assess the clinical and histopathological findings in a canine model of ischemic stroke. Cerebral ischemic stroke was induced by middle cerebral artery occlusion in four healthy beagle dogs using silicone plugs. They showed neurological signs of forebrain dysfunction such as reduced responsiveness, head turning, circling, postural reaction deficits, perceptual deficits, and hemianopsia. These signs gradually regressed within 4 weeks without therapy. On magnetic resonance imaging, T2 hyperintensity and T1 hypointensity were found in the cerebral cortex and basal ganglia. These lesions were well-defined and sharply demarcated from adjacent brain parenchyma with a homogenous appearance. No abnormalities of the cerebrospinal fluid were observed. At necropsy, atrophic and necrotic lesions were observed in the cerebral cortex. The cerebral cortex, basal ganglia, and thalamus were partially unstained with triphenyl- tetrazolium chloride. Histopathologically, typical features of infarction were identified in cortical and thalamic lesions. This study demonstrates that our canine model resembles the conditions of real stroke patients.

Background: Hexamethonium (HM) and Rocuronium (R) are nAChR antagonists. However, there is some controversy as to whether R has a selective presynaptic effect. (-)Vesamicol (V) inhibits the transport of acetylcholine into the vesicles. This study compared the neuromuscular blockade of HM, R and V. Methods: Hemidiaphragm-phrenic nerve preparations (male Sprague-Dawley rats [150-250 g]) were bathed in a Krebs solution maintained at 32℃ and aerated with a mixture of 95% O2 and 5% CO2. Isometric forces were generated in response to 0.1 Hz, and 1.9-second 50 Hz with supramaximal stimulation (0.2 ms, rectangular) of the phrenic nerve. HM, R and V were added sequentially to achieve an 80-90% decrease in the ST. The ECs for ST, PTT and TF were calculated using a probit model. The antagonism indices of calcium (5 mM) and neostigmine (N) (250 nM) were assessed at the 85 ± 5% level. Results: The potency of ST, PTT and TF were respectively, 5.92, 3.56 and 1.99 mM for HM, 10.81, 5.27 and 4.4 1μM for R, and 19.4, 15.2 and 13.3μM for V. The neuromuscular blockades of R were reversed by N but not by calcium. Those of V were not reversed by either of them. Calcium and N inhibited the decrease in ST and TF by HM, respectively. Conclusions: The mechanism for how HM and R affect the neuromuscular blockade are different. V might not affect the release of acetylcholine. (Korean J Anesthesiol 2007; 52: 681~6)

Fibrinolysis, which commonly occurs following cardiopulmonary bypass (CPB), may be related to the excessive bleeding (EB) and morbidity after CPB. It is known that tissue factor (TF), which is triggered by CPB, plays an important role in the initiation of fibrinolysis during and after CPB, however, EB and fibrinolysis after CPB show inter-individual variance. Therefore, in this study, TF -603A/G polymorphism was evaluated to determine if it is associated with fibrinolysis and/or EB and morbidity following CPB. Methods: RT-PCR was used to determine the TF genotype of each patient. In addition, the amount of blood loss that occurred during the first 24 hours following surgery was documented, and EB was diagnosed when more than 1 L of blood was lost during the first 24 hours following surgery. The D-dimer levels were measured at; a) Time 1; prior to initiation of CPB, b) Time 2; 2 hours after CPB, and c) Time 3; 24 hours after CPB. The oxygen index (OI) was calculated at; 1) OI1; upon admission to the ICU, b) OI2; 24 hrs after admission to the ICU, and c) OI3; 48 hrs after admission to the ICU. The intubation time and the length of the ICU stay were also documented. Results: The serum D-Dimer level of the TF -603AA group (n = 72) measured at time 3 was higher than that of the TF -603GG/GA group (n = 25) measured at the same time. In addition, the incidence of EB and the intubation time of the TF -603AA group were higher than those of the TF -603GG/GA group. Finally, the OI3 of the TF -603AA group was lower than that of the TF -603GG/GA group. Conclusions: The G allele that is associated with TF -603A/G polymorphism may be protective against fibrinolysis following CPB, therefore, it may also be protective against EB and morbidity following CPB.