Independent Predictors of Delay in Emergence From General Anesthesia

Some patients with intellectual disabilities spend longer than others in emergence from ambulatory general anesthesia for dental treatment. Although antiepileptic drugs and anesthetics might be involved, an independent predictor for delay of the emergence remains unclear. Thus, a purpose of this study is to identify independent factors affecting the delay of emergence from general anesthesia. This was a retrospective cohort study in dental patients with intellectual disabilities. Patients in need of sedative premedication were removed from participants. The outcome was time until emergence from general anesthesia. Stepwise multivariate regression analysis was used to extract independent factors affecting the outcome. Antiepileptic drugs and anesthetic parameters were included as predictor variables. The study included 102 cases. Clobazam, clonazepam, and phenobarbital were shown to be independent determinants of emergence time. Parameters relating to anesthetics, patients'' backgrounds, and dental treatment were not independent factors. Delay in emergence time in ambulatory general anesthesia is likely to be related to the antiepileptic drugs of benzodiazepine or barbiturates in patients with intellectual disability.Key Words: Day case, Propofol, Remifentanil, Anticonvulsants, Benzodiazepines, Barbituric acidAmbulatory general anesthesia is useful for dental treatment of patients with severe intellectual disabilities because it is hard for them to cooperate with dental treatment and to stay in the hospital.^1–3 Because controlling the recovery state is important in managing ambulatory general anesthesia, we perform total intravenous anesthesia consisting mainly of propofol and remifentanil, which allows a quick and comfortable recovery.^4–7 Midazolam, a short-acting benzodiazepine injection, was shown to be a clear determinant of delayed recovery from general anesthesia in our previous study,⁸ so we ceased using midazolam injection in ambulatory general anesthesia in our facility. Nevertheless, some patients still spent longer than others in emergence and/or recovery from general anesthesia. Therefore, other independent factors were suspected to affect the recovery state in patients with intellectual disabilities.Patients with intellectual disabilities use antiepileptic drugs (AEDs) at a higher rate; these are known to interact with other drugs, mainly by affecting drug metabolism, such as CYP and/or uridine diphosphate-glucuronosyl-transferase (UGT).^9–13 Because AEDs have a sedative effect, they are considered to enhance the clinical effects of anesthetics. In addition, patients with epilepsy are often controlled with multidrug therapy, and several anesthetics can be used for general anesthesia. It is therefore difficult to identify independent factors affecting recovery from general anesthesia when a patient with epilepsy has a delayed emergence from general anesthesia. We therefore sought to identify factors affecting emergence from general anesthesia. We used multivariate analysis in a retrospective cohort study, in which each AED was included as a predictor variable, in addition to anesthetic parameters.     

Blue-emitting acridine-tagged silver(i)-bis-N-heterocyclic carbene

Herein, the photophysical properties of an acridine derivative of a bis-N-heterocyclic carbene silver complex were investigated. The HOMO and LUMO energy differences between 9-[(N-methyl imidazol-2-ylidene)]acridine and 4,5-bis[(N-methyl-imidazol-2-ylidene)methyl]acridine were theoretically compared. Based on the calculation, the 4,5-bis N-heterocyclic carbene-tethered acridine type of ligand was found to be a potential source for tuning the fluorescent nature of the resultant metal derivatives. Thus, a 4,5-bis N-heterocyclic carbene (NHC)-tethered acridine silver(i) salt was synthesized, and its photophysical properties were investigated. The 4,5-bis[(N-isopropylimidazol-2-ylidene)methyl]acridine silver(i) hexafluorophosphate complex was obtained from the reaction between [4,5-bis{(N-isopropylimidazolium)methyl}acridine] hexafluorophosphate and Ag₂O in very good yield; this molecule was characterized by elemental analysis and FTIR, multinuclear (¹H and ¹³C) NMR, UV-Vis, and fluorescence spectroscopic techniques. The molecular structure has been confirmed by single-crystal X-ray diffraction analysis, which has revealed that the complex is a homoleptic mononuclear silver(i) cationic solid. The charge of the Ag(i)–NHC cation is balanced by the hexafluorophosphate anion. The cationic moieties are closely packed in the chair and inverted chair forms where silver(i) possesses a quasi-linear geometry. Moreover, the silver complex provided blue emission from all the three excitations with good fluorescence quantum yield. The fluorescence lifetime of the silver(i) complex has been determined using the time-correlated single photon counting technique. Interestingly, the fluorescence decay pattern and the fluorescence lifetimes of the silver complex are largely different from those of the parent ligand acridine imidazolium salt. Moreover, the theoretical predictions have been found to be in good agreement with the experimental results.

The synthesis and photophysical properties of blue-emitting acridine-tagged silver(i)-bis-N-heterocyclic carbene are reported.     

Motion analysis of wheelchair propulsion movements in hemiplegic patients: effect of a wheelchair cushion on suppressing posterior pelvic tilt

[Purpose] This study sought to ascertain whether, in hemiplegic patients, the effect of a wheelchair cushion to suppress pelvic posterior tilt when initiating wheelchair propulsion would continue in subsequent propulsions. [Subjects] Eighteen hemiplegic patients who were able to propel a wheelchair in a seated position participated in this study. [Methods] An adjustable wheelchair was fitted with a cushion that had an anchoring function, and a thigh pad on the propulsion side was removed. Propulsion movements from the seated position without moving through three propulsion cycles were measured using a three-dimensional motion analysis system, and electromyography was used to determine the angle of pelvic posterior tilt, muscle activity of the biceps femoris long head, and propulsion speed. [Results] Pelvic posterior tilt could be suppressed through the three propulsion cycles, which served to increase propulsion speed. Muscle activity of the biceps femoris long head was highest when initiating propulsion and decreased thereafter. [Conclusion] The effect of the wheelchair cushion on suppressing pelvic posterior tilt continued through three propulsion cycles.Key words: Hemiplegia, Wheelchair cushion, Continuity of effect     

Abnormalities of pulmonary function in patients with non-insulin-dependent diabetes mellitus.

To examine the possible association between the vascular complications of diabetes and changes in pulmonary function, we performed pulmonary function tests including assessment of the diffusing capacity (%DLco) in 80 patients with non-insulin-dependent diabetes mellitus (45 males and 35 females) without overt lung or heart disease. The mean age of the subjects was 57.9 years and the mean duration of diabetes was 10.8 years. The %DLco decreased significantly as the duration of diabetes increased (r = -0.38, p less than 0.01), and the same relationship was also observed in non-smoking subjects (N = 37). The reduction in %DLco was greater in patients with diabetic microangiopathy (especially nephropathy) and in those treated with insulin. Other pulmonary function tests (%VC, FEV1.0, PaO2 and PaCO2) showed no relationship to the duration of diabetes, the degree of microangiopathy or the type of treatment. These results suggest that diabetic microangiopathy may play an important role in the decrease of %DLco.     

Effect of filamentation and mode of growth on antifungal susceptibility of Candida albicans

Biofilm formation involving profuse hyphal growth is a major characteristic of Candida spp. and confers higher antifungal resistance than its planktonic mode of growth. We investigated the antifungal susceptibility of Candida albicans and its hyphal mutants (Δefg1/efg1, Δcph1/cph1 and ΔΔcph1/cph1 efg1/efg1) to commonly used antifungals during planktonic, adhesion and biofilm modes of growth. The minimum inhibitory concentration (MIC) of each antifungal agent was determined for a lower inoculum (1 × 10³ cells/mL) and higher inoculum (1 × 10⁷ cells/mL) of planktonic Candida. Furthermore, MICs of C. albicans biofilms and adhesion modes of growth were determined with a standard XTT assay. Candida albicans in adhesion and biofilm modes of growth, but not in planktonic mode, were resistant to all five antifungal agents tested. Although Δefg1/efg1 and ΔΔcph1/cph1 efg1/efg1 mutants formed less biofilm than wild-type C. albicans SC5314, they were similarly resistant to caspofungin. However, these mutants were more sensitive to amphotericin B and nystatin than the wild-type. Adhesion per se confers increased resistance to antifungal agents, which is further pronounced in the biofilm mode of Candida. Filamentation does not appear to be a major determinant of the antifungal resistance in Candida biofilms.