Young Jin Lim

Morphine preconditions Purkinje cells against cell death under in vitro simulated ischemia-reperfusion conditions

BackgroundMorphine pretreatment via activation of &dgr;1-opioid receptors induces cardioprotection. In this study, the authors determined whether morphine preconditioning induces ischemic tolerance in neurons. MethodsCerebellar brain slices from adult Sprague-Dawley rats were incubated with morphine at 0.1–10 &mgr;m in the presence or absence of various antagonists for 30 min. They were then kept in morphine- and antagonist-free buffer for 30 min before they were subjected to simulated ischemia (oxygen–glucose deprivation) for 20 min. After being recovered in oxygenated artificial cerebrospinal fluid for 5 h, they were fixed for morphologic examination to determine the percentage of undamaged Purkinje cells. ResultsThe survival rate of Purkinje cells was significantly higher in slices preconditioned with morphine (≥ 0.3 &mgr;m) before the oxygen–glucose deprivation (57 ± 4% at 0.3 &mgr;m morphine) than that of the oxygen–glucose deprivation alone (39 ± 3%, P < 0.05). This morphine preconditioning–induced neuroprotection was abolished by naloxone, a non–type-selective opioid receptor antagonist, by naltrindole, a selective &dgr;-opioid receptor antagonist, or by 7-benzylidenenaltrexone, a selective &dgr;1-opioid receptor antagonist. However, the effects were not blocked by the &mgr;-, &kgr;-, or &dgr;2-opioid receptor antagonists, &bgr;-funaltrexamine, nor-binaltorphimine, or naltriben, respectively. Morphine preconditioning–induced neuroprotection was partially blocked by the selective mitochondrial adenosine triphosphate–sensitive potassium channel antagonist, 5-hydroxydecanoate, or the mitochondrial electron transport inhibitor, myxothiazol. None of the inhibitors used in this study alone affected the simulated ischemia–induced neuronal death. ConclusionsThese data suggest that morphine preconditioning is neuroprotective. This neuroprotection may be &dgr;1-opioid receptor dependent and may involve mitochondrial adenosine triphosphate–sensitive potassium channel activation and free radical production. Because morphine is a commonly used analgesic, morphine preconditioning may be explored further for potential clinical use to reduce ischemic brain injury.

The carina as a useful radiographic landmark for positioning the intraaortic balloon pump.

BACKGROUND:The aortic knob is thought to be the most useful radiographic landmark for the proper positioning of the intraaortic balloon pump (IABP) tip. However, this has not been studied formally. In this study we assessed whether the aortic knob is a reliable landmark for positioning the IABP and compared it with another potential landmark, the carina. METHODS:We measured the distance from the top of the distal aortic arch (aortic knob) to the left subclavian artery (LSCA) on three-dimensional computed tomography angiography in 100 patients. The distance from the level of the LSCA origin to the level of the carina was also measured using three-dimensional computed tomography in 150 additional patients. RESULTS:In 16% of the aortic knob study population, the LSCA to aortic knob distance was <0 cm or 0 cm. The median distance from the LSCA to the carina was 42 mm (range: 30–63 mm). In the carina study population, the origin of the LSCA was 35–55 mm above the carina in 95.3% of patients. CONCLUSION:In 16% of patients, the IABP was too close to the LSCA origin when it was placed at the aortic knob, whereas positioning the IABP at 2 cm above the carina provided an adequate position for the IABP tip (1.5–3.5 cm distal to the origin of the LSCA) in 95.3% of patients. The carina may be a more reliable landmark for positioning the IABP than the aortic knob.

Sugammadex versus neostigmine reversal of moderate rocuronium-induced neuromuscular blockade in Korean patients

Background Rapid and complete reversal of neuromuscular blockade (NMB) is desirable at the end of surgery. Sugammadex reverses rocuronium-induced NMB by encapsulation. It is well tolerated in Caucasian patients, providing rapid reversal of moderate (reappearance of T2) rocuronium-induced NMB. We investigated the efficacy and safety of sugammadex versus neostigmine in Korean patients. Methods This randomized, safety assessor-blinded trial (NCT01050543) included Korean patients undergoing general anesthesia. Rocuronium 0.6 mg/kg was given prior to intubation with maintenance doses of 0.1-0.2 mg/kg as required. Patients received sugammadex 2.0 mg/kg or neostigmine 50 µg/kg with glycopyrrolate 10 µg/kg to reverse the NMB at the reappearance of T2, after the last rocuronium dose. The primary efficacy endpoint was the time from sugammadex or neostigmine administration to recovery of the train-of-four (TOF) ratio to 0.9. The safety of these medications was also assessed. Results Of 128 randomized patients, 118 had evaluable data (n = 59 in each group). The geometric mean (95% confidence interval) time to recovery of the TOF ratio to 0.9 was 1.8 (1.6, 2.0) minutes in the sugammadex group and 14.8 (12.4, 17.6) minutes in the neostigmine group (P < 0.0001). Sugammadex was generally well tolerated, with no evidence of residual or recurrence of NMB; four patients in the neostigmine group reported adverse events possibly indicative of inadequate NMB reversal. Conclusions Sugammadex was well tolerated and provided rapid reversal of moderate rocuronium-induced NMB in Korean patients, with a recovery time 8.1 times faster than neostigmine. These results are consistent with those reported for Caucasian patients.

Association Between Tumor Necrosis Factor α 308G/A Polymorphism and Increased Proinflammatory Cytokine Release After Cardiac Surgery With Cardiopulmonary Bypass in the Korean Population

OBJECTIVES The G-308A polymorphism of the tumor necrosis factor alpha (TNF-alpha) gene has been suggested to be linked to high TNF promoter activity in in vitro studies. However, there have been some controversies in in vivo studies. This study investigated whether A allele at TNF-308 site is associated with (1) the changes in plasma cytokine levels during and after cardiopulmonary bypass (CPB) and (2) an increased incidence of pulmonary morbidity after CPB. DESIGN Prospective and observational investigation. SETTING A university hospital, single institution. PARTICIPANTS Patients scheduled for cardiac surgery with CPB. INTERVENTION TNF genotype was determined by the real-time polymerase chain reaction method. IL-6 and TNF-alpha levels were measured by enzyme-linked immunosorbent assay at the following time points: T1, before initiation of CPB; T2, 30 minutes of CPB; T3, 30 minutes after CPB; T4, 2 hours after CPB; and T5, 24 hours after CPB. The oxygen index, serum creatinine level, 24-hour blood loss, intubation time, and length of intensive care unit (ICU) stay were examined. MEASUREMENTS AND MAIN RESULTS The levels of TNF-alpha in group A (TNF-308GA/AA, n = 25) were higher at T3, T4, and T5 than group G (TNF-308GG, n = 225). The levels of IL-6 showed no statistical difference. The oxygenation index, serum creatinine level, 24-hour blood loss, intubation time, and length of ICU stay showed no statistical difference. CONCLUSIONS TNF G-308A polymorphism may be associated with excess TNF-alpha secretion in this study and may not be associated with excess IL-6 secretion and postoperative morbidity after CPB.

The positive and negative affect schedule: psychometric properties of the korean version.

Objective The Positive and Negative Affect Schedule (PANAS) was developed as a measure of positive affect (PA) and negative affect (NA). The aim here is to examine the factor structure and concurrent validity of the Korean version of the Positive and Negative Affect Schedule (K-PANAS) in a clinical sample in Korea. Methods K-PANAS was administered to a clinical sample in Korea. Internal consistency, test-retest reliability, and confirmatory factor analysis (CFA) were undertaken to examine the factorial structure and reliability of the K-PANAS. Results The reliability of K-PANAS is satisfactory. CFA showed that several of the models commonly used in Western populations provided an insufficient fit. The modified model provided a more adequate fit to the data. Conclusion The authors demonstrate that the K-PANAS has adequate psychometric properties, and that findings obtained in the West using PANAS were partially replicated.

Comparison of Thoracic Epidural Pressure in the Sitting and Lateral Decubitus Positions

Background:The hanging drop technique identifies the epidural space using the negative pressure of this space. Although the hanging drop technique is popular at the thoracic level, there is still controversy on the negative epidural pressure at this level. The authors hypothesized that the epidural pressure is more consistently negative in the sitting position than in the lateral decubitus position at the thoracic level. Methods:This study compared the epidural pressures of 28 awake patients in the sitting (sitting group, n = 14) or lateral decubitus (lateral group, n = 14) position. The T5–T6 epidural pressure was measured using a closed pressure measurement system connected to a Tuohy needle. Results:All of the thoracic epidural pressures in the sitting group were negative (median, −5 mmHg; range, −18 to −1; mean, −7.2; SD, 6.3), in contrast to the lateral group (median, 5 mmHg; range, −4 to 13; mean, 5.1; SD, 4.4). The thoracic epidural pressure in the sitting group was significantly lower than in the lateral group (P < 0.001). Conclusions:The thoracic epidural pressure is more negative in the sitting position than in the lateral decubitus position. These results suggest that the patient should be sitting when the hanging drop technique is used to identify the epidural space.

The influence of neck flexion and extension on the distribution of contrast medium in the high thoracic epidural space.

BACKGROUND:For safe and effective thoracic epidural analgesia (TEA), it is important to control the level of TEA and to identify factors that influence its spread. In this study, we observed the distribution of contrast injected into the high thoracic epidural space during neck flexion and extension. METHODS:An epidural catheter was inserted into the epidural space until its tip was located at the T1–2 intervertebral level. Patients were randomly allocated to three groups (extension, flexion, and neutral groups), and were injected with 5 mL of contrast when the neck was extended, flexed, or in the neutral position. Extent of contrast spread was determined by counting the number of vertebral body units (VBUs) through lateral epidurography. RESULTS:Forty-two patients were equally allocated to the three groups. Radiographic spreads in the cephalad direction (median) was 1.0, 5.5, and 1.5 VBUs in the extension, flexion, and neutral groups, and spread was greater in the flexion than in the other two groups (P < 0.001). Median radiographic caudal spread was 10.0, 10.0, and 7.0 VBUs in the extension, flexion, and neutral groups, respectively, which was not significantly different among groups (P = 0.145). CONCLUSIONS:Cranial spread of contrast in the high thoracic epidural space is limited. However, neck flexion increases cranial spread. These results suggest that when TEA is high, the tip of the epidural catheter should be located at the upper part of the level to be blocked and that neck flexion may cause an unwanted cervical block.

Subcutaneous granuloma annulare following herpes zoster.

A 57‐year‐old Korean man developed a papulovesicular eruption on the right chest with unilateral T2 dermatomal distribution; acute herpes zoster (HZ) was diagnosed. The past medical history revealed diabetes mellitus, but was otherwise noncontributory. His pain gradually subsided with treatment in the Pain Clinic of the Anesthesiology Department. Five months later, however, new skin lesions composed of several papules were detected at the site of the HZ scar. There were several discrete, nontender, firm, erythematous papules of about 0.8 cm in diameter on the right chest ( Fig. 1 ). Histologic examination revealed foci of necrobiotic collagen surrounded by a vague palisade of histiocytes in the deep dermis and subcutis ( Fig. 2 ). Mucin deposits were seen within the center of the palisaded granuloma and there were scattered multinucleated giant cells. Gram, Gomeri‐methenamine silver, and acid‐fast stains were negative. Polarizing microscopy did not reveal any material. Subcutaneous granuloma annulare at the HZ scar was diagnosed, and intralesional injections of triamcinolone caused flattening of the papules after 4 weeks of follow‐up.

Sevoflurane Postconditioning Reduces Apoptosis by Activating the JAK-STAT Pathway After Transient Global Cerebral Ischemia in Rats.

Background: The antiapoptotic effects of sevoflurane postconditioning are responsible for neuroprotection against cerebral ischemia-reperfusion injury. Phosphorylation of the Janus family tyrosine kinases (JAK) 2-signal transducers and activators of transcription (STAT) 3 pathway is linked to antiapoptosis. Here, we determined whether the antiapoptotic effects of sevoflurane postconditioning are associated with activation of the JAK2-STAT3 pathway after global transient cerebral ischemia in rats. Materials and Methods: Forty-five rats were randomly assigned to 5 groups: sham (n=5), control (10 min of ischemia, n=10), sevoflurane postconditioning (2 periods of sevoflurane inhalation after ischemia for 10 min, n=10), AG490 (a JAK2 selective inhibitor, intraperitoneal administration of 40 mg/kg before ischemia, n=10), and sevoflurane postconditioning plus AG490 group (n=10). The number of apoptotic cells as well as the expression of JAK2, phosphorylated JAK2 (P-JAK2), STAT3, phosphorylated STAT3 (P-STAT3), Bcl-2 (antiapoptotic protein), and Bax (proapoptotic protein) were evaluated 3 days after ischemia. Results: The apoptotic cell count was significantly lower in the sevoflurane postconditioning group than in the control, AG490, and sevoflurane postconditioning plus AG490 groups. JAK2 and STAT3 levels were comparable among all 5 groups. P-JAK2, P-STAT3, and Bcl-2 levels were higher and Bax levels were lower in the sevoflurane postconditioning group relative to the control, AG490, and sevoflurane postconditioning plus AG490 groups. Conclusions: Sevoflurane postconditioning reduced apoptosis by increasing P-JAK and P-STAT expression after transient global ischemia in rats, and AG490 reversed the beneficial antiapoptotic effects of sevoflurane postconditioning, suggesting that the JAK-STAT pathway may be involved in the antiapoptotic mechanism of sevoflurane postconditioning.

Effect of head position on postoperative chemosis after prone spinal surgery.

Conjunctival swelling is a common finding in patients positioned prone. The purpose of this study was to evaluate the effect of head position on postoperative chemosis after prone spinal surgery. On the basis of the head position, 108 patients scheduled for prone lumbar surgery were randomly allocated to 1 of 2 groups: head neutral group (n=54) versus head down (HD) group (n=54). Head position was defined as neutral when the imaginary line from the occipital protuberance to the top of C7 spine process is parallel to the operating table. HD position was maintained by adjusting the height of the prone headrest 5 cm lower than neutral position. Chemosis was evaluated after surgery. The severity of chemosis, which was graded as none, mild, moderate, and severe, showed statistically significant difference between the head neutral group [24 (44%), 25 (46%), 3 (6%), 2 (4%), respectively] and HD group [10 (19%), 23 (43%), 17 (31%), 4 (7%), respectively, P<0.01]. Positive fluid balance and duration of surgery were risk factors for the development of postoperative chemosis. This result suggested that neutral head position, smaller fluid administration, and shorter duration of surgery were useful in decreasing the development of postoperative chemosis after prone spinal surgery.