Author: SSAdmin

One HSPer’s experience

Chairman of the UK HSP Support Group, Adam Lawrence, has very helpfully written about his personal experience in managing bowel issues related to HSP.

Adam writes …

Here’s a summary of my bowel story – not so much of an update, but more of a recap.

For a few months prior to my first visit to the National hospital in London (2014) I’d been experiencing some bowel urgency issues – basically not being able to get to the toilet quickly enough. This had been happening about once a month, and had been a symptom that I had been getting more often. I’d been devising various coping mechanisms – basically carrying extra pants around with me (generally, as well as the “plus one” rule on packing for trips away). Unlike my bladder problems I’d not been experiencing bowel frequency issues. I mentioned this to my GP, and then again at the National.

Another notable feature of my bowel habits is the “two part poo” – where I have a poo as normal, but after this has come out I know that there is more to come out, but I also know that the sphincter has closed and it will be some time before “part two” is going to make an appearance. So, rather than sitting on the toilet and waiting/forcing the rest out I get on with life, knowing I’ll be back in a little while. Back at that time the “little while” might be half an hour or so.

I’ve mentioned various bits of this previously:

First Nov 2013: http://hspjourney.blogspot.co.uk/2013/11/symptoms-update-illness-tiredness.html

Second Jan 2014: http://hspjourney.blogspot.co.uk/2014/01/a-trip-to-doctor.html

Following the trip to the National I had a referral to the “colorectal” team. http://hspjourney.blogspot.co.uk/2014/11/a-trip-to-doctor.html.

I have noticed that since taking my bladder medication the bowel issues are pretty much entirely under control, as noted here: http://hspjourney.blogspot.co.uk/2015/02/bladder-medication-update.html

At one of the clinics I went to they did an anorectal physiology test. The test measures how well your anal sphincter is functioning. The advice I was given was to bring my knees up whilst having a poo. I had a follow-up appointment after this, but as the problem had more-or-less gone away we didn’t take things any further. Essentially, if things do start to get worse I have a direct route back.

On reflection I think that I have noticed both of the effects mentioned in the tests – Sometimes I know I need a poo, but I can sit down and nothing will come out. The delay in sensing that a poo is there would appear to me to be the urgency issue explained – i.e. the pressure continues to build up, and I only get ‘action’ when the pressure is so high that I don’t have enough time to get to the toilet and the sphincter is going to operate itself.

In the intervening five years (since I’ve been taking the bladder medication) the issue has generally gone away. There is still the odd time that I can’t get to the toilet quickly enough, but this might be one or twice a year rather than roughly every month. The two part poo is still a regular feature – I think that the gap between the two parts is getting longer, and the half an hour I noted back at that time might now be a delay through to the next day sometimes.

They also recommended that I try to regularise my toilet trips so that I can get into a regular routine. This does happen some of the time, but it is more by luck than design. Perhaps another task to put into my daily routine.

SOURCE: http://hspjourney.blogspot.com/2018/10/the-bowel-story.html

Symptoms update: The bowel story

Adam Lawrence, Saturday, 25 July 2020

Regular sunshine or supplements needed

Vitamin D is important to maintaining a strong immune system, especially with ageing. SP Foundation member in the USA, Dr Malin Dollinger recently wrote about the topic:

 

This is about vitamin D deficiency. As you likely know, vitamin D production is stimulated by exposure to sunlight, so people who are indoors a lot, like us, may become deficient. One of us, me, has in addition been “outside” only briefly for the past several months, related to my decision to isolate myself from coronavirus exposure. So my recent comprehensive physical exam showed a very low vitamin D level, and I am now taking a large dose of vitamin D (4000u daily) to replace what is missing.

Now I will discover if some of my symptoms are related to this vitamin D deficiency. I offer here the standard list of what symptoms vitamin D deficiency can produce: tiredness, frequent infections, bone loss, back pain, loss of bone structure, depression, slow wound healing, hair loss, muscle pain, and weight gain. Especially important now with the coronavirus, vitamin D is involved with activation of T lymphocytes, a vital part of our immune response.

So why don’t you ask your doctor to check your blood level of vitamin D, next time you are there. Normal is 30 to 100; mine is 17, and I was already taking 1000u a day, obviously not enough. It seems that the HSP and PLS introductory “rule books” should mention checking vitamin D levels. My doctor told me that vitamin D deficiency is a risk factor for the coronavirus.

What to do
If you might be at risk, ask your doctor and get your Vitamin D level checked.

How much sun do I need?
Just a few minutes in the sun a few times a week with skin exposed on legs and arms is all that is needed.

And this from the Cancer Council
The sun’s ultraviolet (UV) radiation is both the major cause of skin cancer and the best source of vitamin D. Sensible sun protection does not put people at risk of vitamin D deficiency. Read more …

Helping recently diagnosed marathon runner

Radial extracorporeal shockwave treatment (R-SWT) is helping a recently HSP diagnosed 59 year old marathon runner with toe dragging, spasticity, pain and cramping.

It is also helping his athletic performance, recording significantly faster times following treatment. It is thought that more frequent treatment sessions may be required to maintain the benefits achieved.

R-SWT is a relatively new form of SWT that is more affordable and easier to administer. Read more …

Abstract

A 59 year-old male marathon runner presented with recent diagnosis of hereditary spastic paraplegia in a setting of gait deviation and spasticity. He noted asymmetric wear pattern of his right shoe and toe drag, with recent development of left lower extremity pain and cramping attributed to spasticity.

He elected to proceed with radial extracorporeal shockwave treatment (R-SWT) targeting affected muscles. The night following initial treatment, he was able to run 2 minutes per mile faster over a 4 mile run with resolution of toe drag. He completed 6 sessions of R-SWT along with maintaining regular cardiovascular exercise and strength training. He was seen 6 weeks after series of treatment with recent worsening and toe drag that recurred. He completed further sessions with return to improved function seen following his initial series of shockwave and ability to return to running up to 13 miles.

His neurological symptoms remained controlled without noted progression. This case illustrates the potential use of R-SWT in spasticity management of hereditary spastic paraplegia and that more frequent sessions may be required to maintain benefits of treatment.

SOURCE: Am J Phys Med Rehabil. 2020 Jul 22.  doi: 10.1097/PHM.0000000000001547. Online ahead of print. PMID: 32732747

Improved function in a runner with hereditary spastic paraparesis with use of extracorporeal shockwave therapy: personal clinical experience

Craig Rovito ¹, Sabrina Paganoni ¹, Suma Babu ², Adam S Tenforde ¹

1. Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital/Harvard Medical School.
2. Department of Neurology, Massachusetts General Hospital/Harvard Medical School.

Treated with drug therapy

A drug therapy, Topiramate, has been used to treat tremor, which rarely occurs in HSP, but is reported in this case of a girl with SPG15 HSP.

 

Abstract

Hereditary spastic paraplegia (HSP) is group of a rare neurodegenerative disorder with both genetically and clinically diverse neurologic features. Indeed, disease progression varies greatly within the different forms and current treatment modalities are exclusively for symptoms of HSP.

Tremor in HSP patients is only mentioned with rare case reports, so treatment options lack clinical grounding. We report a case of a HSP-15 girl with a previously reported novel mutation of SPG15 complaining of a life disturbing tremor and topiramate as a drug therapy for tremor in our HSP patient.

SOURCE: Clin Neuropharmacol. Jul/Aug 2020;43(4):121-122. doi: 10.1097/WNF.0000000000000392. PMID: 32501858

Topiramate-Responsive Tremor in a Novel Pathogenic Variant of SPG15 Patient

Atilla Ersen 1, Pınar Gençpınar 2, Pınar Arıcan 3, Sema Bozkaya Yılmaz 1, Nargiz Aliyeva 1, Taha Reşid Özdemir 4, Özgür Öztekin 5, Nihal Olgaç Dündar 2

1 Department of Pediatric Neurology, Health Sciences University, Izmir Tepecik Training and Research Hospital.

2 Department of Pediatric Neurology, Izmir Katip Celebi University, Izmir.

3 Department of Pediatric Neurology, Necip Fazıl State Hospital, Kahramanmaras.

4 Genetic Diagnostic Center.

5 Department of Radiology, Health Sciences University, Izmir Tepecik Training and Research Hospital, Izmir, Turkey.

Cognitive and social/emotional impairment found

 

A pattern has been established in MRI scans in people with SPG7 type HSP that has been linked with impairment in cognition and social functioning.

 

Alterations in language, verbal memory and executive function were documented along with impairment of social task and emotional functions.

 

Abstract

Spastic paraplegia type 7 (SPG7), which represents one of the most common forms of autosomal recessive spastic paraplegia (MIM#607259), often manifests with a complicated phenotype, characterized by progressive spastic ataxia with evidence of cerebellar atrophy on brain MRI. Recent studies have documented the presence of peculiar dentate nucleus hyperintensities on T2-weighted images and frontal executive dysfunction in neuropsychological tests in SPG7 patients.

Therefore, we decided to assess whether any particular MRI pattern might be specifically associated with SPG7 mutations and possibly correlated with patients’ cognitive profiles. For this purpose, we evaluated six SPG7 patients, studying the cerebello-cortical network by MRI voxel-based morphometry and functional connectivity techniques, compared to 30 healthy control subjects. In parallel, we investigated the cognitive and social functioning of the SPG7 patients.

Our results document specific cognitive alterations in language, verbal memory, and executive function in addition to an impairment of social task and emotional functions. The MRI scans showed a diffuse symmetric reduction in the cerebellar gray matter of the right lobule V, right Crus I, and bilateral lobule VI, together with a cerebral gray matter reduction in the lingual gyrus, precuneus, thalamus, and superior frontal gyrus.

The evidence of an over-connectivity pattern between both the right and left cerebellar dentate nuclei and specific cerebral regions (the lateral occipital cortex, precuneus, left supramarginal gyrus, and left superior parietal lobule) confirms the presence of cerebello-cortical dysregulation in different networks involved in cognition and social functioning in SPG7 patients.

 

SOURCE: Front Neurol. 2020 Feb 25;11:82. doi: 10.3389/fneur.2020.00082. eCollection 2020. Copyright © 2020 Lupo, Olivito, Clausi, Siciliano, Riso, Bozzali, Santorelli, Silvestri and Leggio. PMID: 32161564

 

Cerebello-Cortical Alterations Linked to Cognitive and Social Problems in Patients With Spastic Paraplegia Type 7: A Preliminary Study

 

Michela Lupo 1, Giusy Olivito 2 3, Silvia Clausi 1 2, Libera Siciliano 2, Vittorio Riso 4, Marco Bozzali 3 5, Filippo M Santorelli 6, Gabriella Silvestri 4, Maria Leggio 1 2

1 Ataxia Laboratory, IRCCS Fondazione Santa Lucia, Rome, Italy.

2 Department of Psychology, Sapienza University of Rome, Rome, Italy.

3 IRCCS Fondazione Santa Lucia, Rome, Italy.

4 Department of Neurology, IRCCS Fondazione Policlinico Agostino Gemelli, Rome, Italy.

5 Clinical Imaging Science Center, Brighton and Sussex Medical School, Brighton, United Kingdom.

6 Molecular Medicine, IRCCS Fondazione Stella Maris, Pisa, Italy.

Data on wellbeing, mobility, medication

Indicators for improved quality of life from the 2019 survey results include:

• Decreasing loneliness and/or isolation

• Taking part in activities which are found enjoyable

• Being able to travel outside the home regularly

• Getting help/support/counselling for abuse

• Getting Treatment, advice and exercise.

 

Adam Lawrence, HSPer, blogger and Chairman of the UK HSP support group has been surveying the global HSP community for 7 years now. The results of the 2019 multi-language survey from 367 respondents are now in, including a large block of responses from Europe in French, Dutch, Spanish and Italian. 7% of respondents (25 people) were from Australia. There were questions on wellbeing, mobility, medication, spasticity and spasms, life with HSP and more.

 

Wellbeing

The average score on the Warwick-Edinburgh Mental Well-being scale (WEMWBS) for people with HSP is lower than for the general population, however it is still within the “average” range and similar to those who don’t have HSP but who see their health status as “poor”.

Life with HSP

• 67% consider themselves disabled, while 33% do not
• 32% consider themselves lonely, with those whose mobility is more restricted tending to consider themselves lonely more often than those with less restricted mobility
• 30% consider themselves isolated, again more often in those whose mobility is more restricted
• Wellbeing scores for those who consider themselves either or both lonely and isolated are significantly lower than for those who do not
• Around half consider themselves as vulnerable with HSP. Those who do point to the physical changes reducing their ability to defend themselves or resist attack; or they point to balance problems, incontinence and difficulty of movement as the reasons they consider themselves vulnerable
• 14% report having been abused, with a general trend of those with restricted mobility reporting abuse more than those who are more mobile. Three-quarters of those who have been abused indicate that this was as a result of their HSP
• Those who report being abused tend to have lower wellbeing scores.

Positive wellbeing factors (in order of frequency of mention):

• not feeling isolated (255)
• not feeling lonely (245)
• not feeling vulnerable (166)
• travel to town daily (69)
• no medication (46)
• travel further than town daily (35)
• occasional music (34)
• weekly music (28)
• daily use of cardiovascular gym machines (21)

Negative wellbeing factors (in order of frequency of mention):

• feeling lonely (116)
• feeling isolated (107)
• experiencing abuse (52)
• having SPG7 (35)
• taking 4 medicines for HSP (17)
• uncertain diagnosis (7)
• taking 6 medicines for HSP (5)

Mobility

Use of mobility aids:

• 19% don’t use mobility aids
• 24% use them some of the time
• 28% use sticks most/all the time
• 11% use frames most/all of the time
• 19% used chairs most/all of the time

Types of mobility aids used:

• 51% use sticks, poles, crutches or canes
• 38% use wheelchairs for mobility scooters
• 27% use orthotics, ankle-foot orthotics or insoles
• 21% use a walking frame or Rollator

Medication

The survey explores the medication people take for HSP, the reasons that people take medicines for, and how effective they perceive those medicines to be:

• Around 85% of people say they are prescribed at least one form of medication for their HSP, a slightly higher proportion than in the 2014 survey.
• Around 15% say that they did not take any medication at all.
• Almost 60% of the medication being taken is used to treat spasticity and spasms, with the biggest proportion of people taking Baclofen.
• Medications are also taken for pain, nerve pain, bladder control, depression, anxiety, bowel control, sleep problems or fatigue.

Stretches

• Stretches are the most common form of exercise with over 90% of respondents doing them
• Over 75% do stretches regularly.
• Over 33% regularly do activities including walking/running, physiotherapy, music and cycling/manual wheelchair
• Over 20% regularly do activities including weights, swimming, cardiovascular gym machines and yoga/pilates/tai chi.

Respondents identified stretching, walking and aerobic activities as the ones they felt were most important for exercise, relaxing and flexibility. Music and stretches were identified as most important for relaxing. Stretches and physiotherapy were identified as most important for flexibility.

 

You can find Adam’s blog with survey results here: http://hspjourney.blogspot.com/2020/02/

For the full analysis, access this PDF: https://drive.google.com/open?id=1Vrh5bd8ss0XDU_DR39kEpneo-3YZuaGm

 

HSPers share their experiences

 

People with HSP are reporting that their gait has become noticeably worse recently due to the stress of COVID-19.  Below are some comments from people with HSP in an online forum.

 

“I wouldn’t class myself as vulnerable as such… Where I would say I’m vulnerable though is due to the stress all of this is causing me through the behaviour of others …  my walking has gone much worse …. I think it may depend which type of HSP you have and what your personal symptoms are. They say a vulnerable group includes neurological disorders”

 

“My walking has deteriorated in lockstep (pardon the pun) with the spread of the virus — and for the exact same reasons you described — panic and hype. For the first time in my life I think I need counselling, actually. It just all seems so selfish when you look at the big picture. I never considered myself much of a worry wart, but this pandemic has me freaked”

 

“My employer graciously advised me to stay home. That was last week, actually. This week, he gave that same message to all my healthy able-bodied co-workers. Crazy, scary times right now for everyone. The stress alone has agitated my symptoms three-fold. (I can’t even fathom how all this is affecting people with pre-existing mood/psychological issues.)”

 

What can you do?

On the physical side, get creative about physical activities that can compensate for the loss of access to the gym, pool or community centre that you used to regularly attend. There are plenty of good ideas on the Internet for using gravity, bodyweight, everyday household items – walls, beds, sofas and chairs, to get a good full body stretch and workout.

 

On the mental side, it is probably a good idea to revisit the comprehensive five-part series on achieving and maintaining good mental health that is archived on this website. Have a look through these ideas and tools and put as much effort into mental health as into physical health. However if anxiety or depression have got the upper hand at present, don’t be slow to reach out and ask others for help.

 

Achieving & maintaining good mental health

Achieving and maintaining good mental health

Achieving and maintaining good mental health

Achieving and maintaining good mental health

Achieving and maintaining good mental health

 

 

Improvement in spasticity and quality of life

 

18 adults with various types of HSP (50/50 male:female) but all requiring mobility aids showed improvement in:

• muscle tone/reduced spasticity

• walking speed and endurance

• pain and quality-of-life.

Scores on the Spastic Paraplegia Rating Scale were significantly reduced after treatment and maintained when measured at both one and three months after treatment.

 

Participants in this Italian study received pinpoint accurate Botox injections, mainly in the hamstrings, the large mid-thigh muscle (rectus femoris) and the calf muscles followed by intensive physiotherapy.

 

Abstract

Introduction: The Hereditary Spastic Paraplegia (HSP) is a heterogeneous group of neurodegenerative disorders characterized by progressive spasticity and lower limbs (LL) weakness. There is no treatment to cure or halt the disease, except for symptomatic therapy. The use of botulinum toxin type A (BoNT-A) is one of the primary treatment for focal spasticity. Physiotherapy (PT) can help in maintaining residual functioning. We performed a retrospective study to evaluate the effect of the combined BoNT-A and intensive PT in patients with HSP.

Methods: Eighteen adult patients (50% females) with clinical diagnosis of HSP were recruited. Eleven patients had a genetic diagnosis of SPG4, 5, 7, 8, 11, 72. Patients were all autonomously deambulant or needed support. BoNT-A was injected in 36 LL in different spastic muscles under electromyographic guidance and followed by intensive PT sessions. Outcome measures included disease severity, motor functional measures, perceived pain self-report and quality of life. Assessments occurred at baseline, 1 and 3 months after BoNT-A injection.

Results: Most inoculated muscles were hamstrings, rectus femoris and gastrocnemius. We observed an improvement in muscle tone, in the gait velocity and distance length. Spastic Paraplegia Rating Scale was significantly reduced after treatment, in addition to improving pain and quality of life. These results were re-confirmed in 3 months time.

Conclusion: Our study indicates that combined treatment of BoNT-A and PT can lead to improvement of spasticity and quality of life in patients with HSP.

 

SOURCE: Front Neurosci. 2020 Feb 21;14:111. doi: 10.3389/fnins.2020.00111. eCollection 2020. Copyright © 2020 Paparella, Vavla, Bernardi, Girardi, Stefan and Martinuzzi. PMID: 32153352

 

Efficacy of a Combined Treatment of Botulinum Toxin and Intensive Physiotherapy in Hereditary Spastic Paraplegia

 

Gabriella Paparella 1, Marinela Vavla 1 2, Lisa Bernardi 1, Giulia Girardi 1, Cristina Stefan 1, Andrea Martinuzzi 1 2

1 Acquired Neuropsychological Disease Rehabilitation Unit, Scientific Institute, IRCCS Eugenio Medea, Pieve di Soligo, Italy.

2 Severe Developmental Disabilities Unit, Scientific Institute, IRCCS Eugenio Medea, Conegliano, Italy.

Large survey conducted in the Netherlands

 

The greatest burden identified by people with pure HSP is from muscle stiffness, standing and walking, and leg and/or back pain.

More than half reported falling at least twice a year and half reported being injured from falling. 75% reported fear of falling.

109 people with pure HSP in the Netherlands responded to an HSP-specific survey aimed at quantifying the burden of HSP to individuals and to better understand their needs.

 

Abstract

Background: Hereditary spastic paraplegia (HSP) is a group of inherited disorders characterized by progressive spastic paresis of the lower limbs. Treatment is often focused on reducing spasticity and its physical consequences.

To better address individual patients’ needs, we investigated a broad range of experienced complaints, activity limitations, and loss of motor capacities in pure HSP. In addition, we aimed to identify patient characteristics that are associated with increased fall risk and/or reduced walking capacity.

Methods: We developed and distributed an HSP-specific online questionnaire in the Netherlands. A total of 109 out of 166 questionnaires returned by participants with pure HSP were analyzed.

Results: Participants experienced the greatest burden from muscle stiffness and limited standing and walking activities, while 72% reported leg and/or back pain. Thirty-five and 46% reported to use walking aids (e.g. crutches) indoors and outdoors, respectively; 57% reported a fall incidence of at least twice a year (‘fallers’); in 51% a fall had led to an injury at least once; and 73% reported fear of falling. Duration of spasticity and incapacity to rise from the floor were positively associated with being a ‘faller’, whereas non-neurological comorbidity and wheelchair use were negatively associated. Higher age, experienced gait problems, not being able to stand for 10 min, and incapacity to open a heavy door showed a negative association with being a ‘walker without aids’ (> 500 m).

Conclusions: Our results emphasize the large impact of spastic paraparesis on the lives of people with pure HSP and contribute to a better understanding of possible targets for rehabilitation.

 

SOURCE: Orphanet J Rare Dis. 2020 Mar 4;15(1):64. doi: 10.1186/s13023-020-1338-4. PMID: 32131864

 

Experienced Complaints, Activity Limitations and Loss of Motor Capacities in Patients With Pure Hereditary Spastic Paraplegia: A Web-Based Survey in the Netherlands

 

Bas J H van Lith 1, Hans C J W Kerstens 2 3, Laura A C van den Bemd 4, Maria W G Nijhuis-van der Sanden 3, Vivian Weerdesteyn 5, Rob J E M Smeets 6, Klemens Fheodoroff 7, Bart P C van de Warrenburg 8, Alexander C H Geurts 5

1 Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands. bas.vanLith@Radboudumc.nl.

2 HAN University of Applied Sciences, PO Box 6960, 6503, GL, Nijmegen, The Netherlands.

3 Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud university medical center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.

4 Department of Rehabilitation, Sint Maartenskliniek, PO Box 9011, 6500, GM, Nijmegen, The Netherlands.

5 Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.

6 Department of Rehabilitation Medicine, Maastricht University, Research School CAPHRI, PO Box 616, 6200, MD, Maastricht, the Netherlands.

7 Gailtal-Klinik, Radnigerstrasse 12, 9620, Hermagor, Austria.

8 Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.

Successful formula reported in a recent study

 

Great care and skilful planning are needed for people with HSP who require a general anaesthetic. This case study details a successful anaesthesia process.

 

BACKGROUND: Hereditary spastic paraplegia (HSP) is a rare, genetic neurodegenerative condition. Thus far, ideal anesthetic management is not established for patients with HSP; therefore, careful selection and dosage of anesthetic agents is required.

 

CASE PRESENTATION: A 54-year-old woman with HSP, who was diagnosed with severe lumbar spinal canal stenosis, underwent decompressive laminectomy to relieve her back pain. Preoperatively, she experienced slight difficulty in walking independently; however, she exhibited no other dysfunction. Anesthesia was maintained with desflurane after tracheal intubation. Rocuronium and sugammadex were used for neuromuscular blockade and reversal, respectively, with neuromuscular monitoring equipment. The patient showed uneventful postoperative recovery without signs of neurological deterioration after extubation.

 

CONCLUSIONS: Our successful experience in this case implies that, for patients with neuromuscular diseases, including HSP, desflurane may be an option for anesthetic management; moreover, careful assessment (e.g., medical condition, bispectral index, and train-of-four) should be performed prior to administration of anesthesia.

 

SOURCE: JA Clin Rep. 2019 Apr 30;5(1):30. doi: 10.1186/s40981-019-0250-1. PMID: 32025921

Desflurane for management of decompressive laminectomy in a patient with hereditary spastic paraplegia: a case report.

Tada M1,2, Tateoka K3, Yamamoto K3, Inagaki Y4, Kunisawa T5.

1 Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan. a070026@al.asahikawa-med.ac.jp.

2 Department of Anesthesiology, National Hospital Organization Obihiro Hospital, Obihiro, Hokkaido, Japan. a070026@al.asahikawa-med.ac.jp.

3 Department of Anesthesia, Nayoro City General Hospital, Nayoro, Hokkaido, Japan.

4 Department of Emergency Medicine, Nayoro City General Hospital, Nayoro, Hokkaido, Japan.

5 Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.