Jun-ichi Koyama

Description and first clinical application of AirWay Scope for tracheal intubation.

We have developed a novel airway apparatus, AirWay Scope, which we have used in the orotracheal intubation of 10 consecutive patients requiring general anesthesia before neurosurgical procedures. The characteristic shape of the introducer (INTLOCK), the tube guiding function and the sighting device of the AirWay Scope has possibility to facilitate tracheal intubation. Here, we report the first clinical application of this system and describe potential advantages of the apparatus.

NeuRobot: Telecontrolled Micromanipulator System for Minimally Invasive Microneurosurgery—Preliminary Results

OBJECTIVE Microneurosurgery can be performed less invasively with the recent advances in neuronavigation and neuroendoscopy. For even less invasive microneurosurgery, we have developed a telecontrolled micromanipulator system. METHODS The NeuRobot telecontrolled micromanipulator system was developed. With the use of this system, surgical simulations were performed with a human cadaveric head. RESULTS The system consists of four main parts, i.e., a micromanipulator (slave manipulator), a manipulator-supporting device, an operation-input device (master manipulator), and a three-dimensional display monitor. Three 1-mm forceps and a three-dimensional endoscope, which could be remotely controlled with three degrees of freedom (rotation, neck swinging, and forward/backward motion), were installed in the slave manipulator. All surgical procedures were accurately performed with this system. CONCLUSION The use of telecontrolled manipulator systems in neurosurgery is very promising, and we are convinced that this system will facilitate more accurate, less invasive microneurosurgery. The details of the NeuRobot system and preliminary results are presented.

The role of proteases in stratum corneum: involvement in stratum corneum desquamation

The effects of protease inhibitors on cell dissociation were studied in vitro in order to examine the involvement of proteases in stratum corneum desquamation. Stratum corneum sheet (peeled from human backs after sunburn) was incubated in a detergent mixture containing 8 mMN,N-dimethyldodecylamine oxide, 2 mM sodium lauryl sulphate and 60 Μg/ml kanamycin with or without protease inhibitors, and the number of released cells was counted after incubation for 48 h. Cell dissociation was inhibited strongly by antipain or aprotinin, but not at all by N-[N-(l-3-transcarboxyoxiran-2-carbonyl)-l-leucyl]-agmatin, N-ethylmaleimide or pepstatin, which suggests that only serine proteases are associated with desquamation. Furthermore, leupeptin and chymostatin each reduced cell dissociation about half as effectively as aprotinin or antipain, while a mixture of leupeptin and chymostatin prevented stratum corneum dissociation as potently as antipain or aprotinin. In addition, the activity of chymotrypsin-like protease in scaly skin was higher than that in normal skin, as we have previously found for trypsin-like protease. These results suggest that both trypsin-like and chymotrypsin-like serine proteases are involved in stratum corneum desquamation.

Modulatory effect of L-NAME, a specific nitric oxide synthase (NOS) inhibitor, on stress-induced changes in plasma adrenocorticotropic hormone (ACTH) and corticosterone levels in rats: physiological significance of stress-induced NOS activation in hypothalamic-pituitary-adrenal axis.

We investigated whether NG-nitro-L-arginine methyl ester (L-NAME), a specific inhibitor of nitric oxide synthase (NOS), can modify the stress-induced adrenocorticotropic hormone (ACTH) and corticosterone responses, because we found that immobilization-induced stress increases NOS mRNA and protein levels and enzyme activity in the adrenal cortex. The physiological significance of these phenomena, however, remains unknown. Plasma ACTH and corticosterone levels were determined by radioimmunoassay (RIA) of systemic blood samples and NOS enzyme activity was measured as the rate of [3H]arginine conversion to [3H]citrulline in the presence of tissue homogenate of adrenal cortex separated from the adrenal gland. The NOS enzyme activity in the adrenal cortex of rats pre-injected with saline at 2 h after the 2-h immobilization was significantly higher (P < 0.01) than that in the non-stressed controls. Pre-injection of L-NAME (100 mg/kg, s.c.) almost completely abolished the activity. This dose of L-NAME maintained a significantly elevated plasma corticosterone level (P < 0.05, compared with basal level) even 2 h after the 2-h stress, whereas the plasma corticosterone level in rats pre-injected with saline returned to the basal level at the same time point. Plasma ACTH level in L-NAME-pre-treated rats was higher than that in those pre-treated with saline 2 h after the stress, but the difference was not significant. This dose of L-NAME did not influence plasma ACTH or corticosterone levels under resting conditions without stress. These findings suggest that the stress-induced increase in NO synthesis in the adrenal cortex can modify the stress-induced corticosterone response to facilitate the recovery from the elevated corticosterone secretion by stress in the adrenal cortex to the resting basal level.

Dry condition affects desquamation of stratum corneum in vivo

We examined whether a dry condition actually induces scaly skin in vivo. Hairless mice were kept in a high humidity condition or a low humidity condition and skin changes were examined. Scales appeared on the backs of mice kept for 3 days under the dry condition. The weight of stratum corneum (SC) was increased at this point, and these alterations were not accompanied with hyperproliferation of the nucleated cell layer of the epidermis. A decrease of desmosomal degradation was observed, though, desquamation-related enzyme activity was not altered. The regulation mechanism of desquamation is not yet clear, however, in vitro experiments suggest that the water content in SC is an important factor. The water content of SC was decreased in the dry condition. These results indicate that a dry environment perturbs desmosome degradation in intact SC by decreasing the water content of SC, and the consequent impairment of desquamation in normal skin in vivo may lead to the induction of a scaly skin surface.

Stratum corneum lipid morphology and transepidermal water loss in normal skin and surfactant-induced scaly skin

Stratum corneum lipid morphology was evaluated using attenuated total reflectance infrared spectroscopy (ATR-IR) in normal skin and surfactant-induced scaly skin to evaluate skin barrier function. To evaluate the degree of order of the intercellular lipid alkyl chain conformation, we measured the wavenumbers (frequency shifts) of the symmetrical and asymmetrical C-H stretching vibrations observed at approximately 2850 cm−1 and 2920 cm−1, respectively. There was a correlation between the wave-number and transepidermal water loss in normal skin. However, no difference was observed in surfactant-induced scaly skin from the baseline value in the wavenumbers of the C-H vibrations. These results suggest that in normal skin, lipid morphology plays an important role in the barrier function of the stratum corneum. However, the decline in barrier function in scaly skin is not due to conformational disorder of the lipid alkyl chain.

Keratinocytes synthesize enteropeptidase and multiple forms of trypsinogen during terminal differentiation.

Members of the trypsin-like and chymotrypsin-like kallikrein family are important in the desquamation process. In this study, we isolated cDNA clones encoding trypsinogen 4 (brain trypsinogen) and a previously unreported isoform of trypsinogen from a human keratinocyte cDNA library. The nucleotide sequence of the new isoform only differs from those of trypsinogen 3 (mesotrypsinogen) and trypsinogen 4 in an exon encoding the N-terminal region, indicating that this isoform is an alternative splicing variant of the mesotrypsinogen gene PRSS3. Both isoforms contained the sequence DDDDK-I, a putative cleavage site for activation by enteropeptidase. Thus, after activation, mesotrypsin would be produced. Immunohistochemical and in situ hybridization studies revealed that trypsinogens were expressed and localized in the upper epidermis, especially in the granular layer. In cultured keratinocytes, enteropeptidase mRNA was expressed at the confluent stage, and its expression was strongly upregulated after air exposure. Interestingly, it was synthesized and localized only at the granular layer, suggesting that the generation of active mesotrypsin is restricted to this layer. The enteropeptidase-cleavage product was also found at the same layer. When a skin equivalent model was cultured in the medium without air exposure, the cornified layer was not formed, and many cells expressed trypsinogens and enteropeptidase. Those cells were found to be TUNEL positive. Because mesotrypsin is resistant to naturally occurring trypsin inhibitors, confined expression of the isoforms of mesotrypsinogens and enteropeptidase may indicate that mesotrypsin is involved in keratinocyte terminal differentiation.

Comparison of three types of laryngoscope for tracheal intubation during rhythmic chest compressions: A manikin study

BACKGROUND If tracheal intubation can be performed during uninterrupted chest compressions, this will sustain circulation during the procedure of intubation and may lead to successful resuscitation. We compared three types of laryngoscope on a manikin as to whether they enabled tracheal intubation while the manikins chest was rhythmically compressed. METHODS A total of 35 persons who had little or no experience in intubation served as examinees. The laryngoscopes employed were a conventional Macintosh laryngoscope (MAC), a new video laryngoscope, Pentax-AWS (AWS) and an optic laryngoscope Airtraq (ATQ). During chest compression on the manikin by an assistant, the examinee attempted to perform intubation. The success rate and the time for successful intubation were measured. RESULTS During rhythmic chest compressions, nine examinees failed in tracheal intubation with the MAC, seven failed with the ATQ, and no one failed with the AWS. The success rates with the AWS were significantly higher than those with the MAC (P<0.01) or ATQ (P<0.05). The time needed for intubation was significantly shorter with the Pentax-AWS than with the others. CONCLUSIONS These results suggest that the use of the Pentax-AWS enables tracheal intubation while the patients chest is rhythmically compressed, and would more often lead to successful intubation, which in turn may lead to more successful resuscitation.

Functionally essential neuronal population of the facial motor nucleus

Cranial nerve impairment is one of the more serious complications in neurosurgery. Nevertheless, the important question of how many neurons are required for cranial nerve functions remains unanswered. The VIIth cranial nerve (facial nerve) in mice was subjected to graded crush injuries. After assessment of the facial function, the number of uninjured, healthy facial motor neurons was quantified with a retrograde neuronal tracer. We report that normal facial function is preserved if intact neurons account for more than 56% of the control value, while complete facial paralysis occurs if intact neurons are reduced to less than 32% of the control value.

Dumbbell C2 schwannomas involving both sensory and motor rootlets: report of two cases.

OBJECTIVE AND IMPORTANCEIntradural-extradural dumbbell C2 schwannomas are rare. This report concerns two such cases with the intradural compartment located ventral to the spinal cord and involving both sensory and motor rootlets. CLINICAL PRESENTATIONOne patient was a 57-year-old woman with sensory disturbances in the right extremities and hyperreflexia in the left extremities. The other patient was a 73-year-old man who presented with tetraparesis, walking disability, atrophy of the nuchal and bilateral shoulder muscles, and pain in the right C2 dermatome. INTERVENTIONThe extradural component of the tumor was removed first; next, the intradural component was removed successfully via the posterior approach combined with a C1–C2 laminectomy. The patients experienced symptomatic improvement without further deficits except for sensory impairment of the C2 dermatome in one of the patients. CONCLUSIONIntradural-extradural dumbbell C2 schwannomas can be satisfactorily managed with a posterior approach. Removal of the extradural component and opening of the dural ring of the C2 nerve root are necessary for safe extraction of the intradural ventrally located component after debulking. These tumors may arise extradurally within the nerve sheath, extend intradurally and ventrally toward the spinal cord, and involve both sensory and motor rootlets.