Predictive performance of the sequential organ failure assessment score for in-hospital mortality in patients with end-stage kidney disease in intensive care units: A multicenter registry in Japan

INTRODUCTION

There is limited evidence regarding whether the performance of the Sequential Organ Failure Assessment (SOFA) score differs between patients with and without end-stage kidney disease (ESKD) in intensive care units (ICUs).

METHODS

We used a multicenter registry (Japanese Intensive care Patient Database) to enroll adult ICU patients between April 2018 and March 2021. We recalibrated the SOFA score using a logistic regression model and evaluated its predictive ability in both ESKD and non-ESKD groups. The primary outcome was in-hospital mortality.

RESULTS

128 134 patients were enrolled. The AUROC of the SOFA score was lower in the ESKD group than in the non-ESKD group [0.789 (95% CI, 0.774-0.804) vs. 0.846 (95% CI, 0.841-0.850)]. The calibration plot revealed good performance in both groups. However, it overestimated in-hospital mortality in ESKD groups.

CONCLUSION

The SOFA score demonstrated good predictive ability in patients with and without ESKD, but it overestimated the in-hospital mortality in ESKD patients.

Reliability of the respiratory rate and oxygenation index for successful high-flow nasal cannula support in coronavirus disease pneumonia: a retrospective cohort study

BACKGROUND

High-flow nasal cannula (HFNC) therapy is an important non-invasive respiratory support in acute respiratory failure, including coronavirus disease (COVID-19) pneumonia. Although the respiratory rate and oxygenation (ROX) index is a simple and useful predictor for HFNC failure and mortality, there is limited evidence for its use in patients with COVID-19 pneumonia. We aimed to evaluate the ROX index as a predictor for HFNC failure in patients with COVID-19 pneumonia. We also evaluated the ROX index as a predictor for 28-day mortality.

METHODS

In this single-center, retrospective, cohort study, 248 patients older than 18 years of age with COVID-19 pneumonia received HFNC therapy for acute respiratory failure. The ROX index was evaluated within 4 h from the start of HFNC therapy. Past medical history, laboratory data, and the ROX index were evaluated as predictors for HFNC failure and 28-day mortality.

RESULTS

The ROX index < 4.88 showed a significantly high risk ratio for HFNC failure (2.13 [95% confidence interval [CI]: 1.47 - 3.08], p < 0.001). The ROX index < 4.88 was significantly associated with 28-day mortality (p = 0.049) in patients with COVID-19 pneumonia receiving HFNC therapy. Age, chronic hypertension, high lactate dehydrogenase level, and low ROX index showed significantly high risk ratio for HFNC failure. C-reactive protein level and low ROX index were predictors of 28-day morality.

CONCLUSION

The ROX index is a useful predictor for HFNC success and 28-day mortality in patients with COVID-19 pneumonia receiving HFNC therapy.

TRIAL REGISTRATION

An independent ethics committee approved the study (Research Ethics Review Committee of Kobe City Medical Center General Hospital [number: zn220303; date: February 21, 2022]), which was performed in accordance with the Declaration of Helsinki, Guidelines for Good Clinical Practice.

Predictive factors and clinical impact of ICU-acquired weakness on functional disability in mechanically ventilated patients with COVID-19

BACKGROUND

Patients with critical COVID-19 often require invasive mechanical ventilation (IMV) and admission to the intensive care unit (ICU), resulting in a higher incidence of ICU-acquired weakness (ICU-AW) and functional decline.

OBJECTIVE

This study aimed to examine the causes of ICU-AW and functional outcomes in critically ill patients with COVID-19 who required IMV.

METHODS

This prospective, single-center, observational study included COVID-19 patients who required IMV for ≥48 h in the ICU between July 2020 and July 2021. ICU-AW was defined as a Medical Research Council sum score <48 points. The primary outcome was functional independence during hospitalization, defined as an ICU mobility score ≥9 points.

RESULTS

A total of 157 patients (age: 68 [59-73] years, men: 72.6%) were divided into two groups (ICU-AW group; n = 80 versus non-ICU-AW; n = 77). Older age (adjusted odds ratio [95% confidence interval]: 1.05 [1.01-1.11], p = 0.036), administration of neuromuscular blocking agents (7.79 [2.87-23.3], p < 0.001), pulse steroid therapy (3.78 [1.49-10.1], p = 0.006), and sepsis (7.79 [2.87-24.0], p < 0.001) were significantly associated with ICU-AW development. In addition, patients with ICU-AW had significantly longer time to functional independence than those without ICU-AW (41 [30-54] vs 19 [17-23] days, p < 0.001). The development of ICU-AW was associated with delayed time to functional independence (adjusted hazard ratio: 6.08; 95% CI: 3.05-12.1; p < 0.001).

CONCLUSIONS

Approximately half of the patients with COVID-19 requiring IMV developed ICU-AW, which was associated with delayed functional independence during hospitalization.

Association between ICU admission during off-hours and in-hospital mortality: a multicenter registry in Japan

BACKGROUND

The effect of ICU admission time on patient outcomes has been shown to be controversial in several studies from a number of countries. The imbalance between ICU staffing and medical resources during off-hours possibly influences the outcome for critically ill or injured patients. Here, we aimed to evaluate the association between ICU admission during off-hours and in-hospital mortality in Japan.

METHODS

This study was an observational study using a multicenter registry (Japanese Intensive care PAtient Database). From the registry, we enrolled adult patients admitted to ICUs from April 2015 to March 2019. Patients with elective surgery, readmission to ICUs, or ICU admissions only for medical procedures were excluded. We compared in-hospital mortalities between ICU patients admitted during off-hours and office-hours, using a multilevel logistic regression model which allows for the random effect of each hospital.

RESULTS

A total of 28,200 patients were enrolled with a median age of 71 years (interquartile range [IQR], 59 to 80). The median APACHE II score was 18 (IQR, 13 to 24) with no significant difference between patients admitted during off-hours and those admitted during office-hours. The in-hospital mortality was 3399/20,403 (16.7%) when admitted during off-hours and 1604/7797 (20.6%) when admitted during office-hours. Thus, off-hours ICU admission was associated with lower in-hospital mortality (adjusted odds ratio 0.91, [95% confidence interval, 0.84-0.99]).

CONCLUSIONS

ICU admissions during off-hours were associated with lower in-hospital mortality in Japan. These results were against our expectations and raised some concerns for a possible imbalance between ICU staffing and workload during office-hours. Further studies with a sufficient dataset required for comparing with other countries are warranted in the future.

Impact of serum lactate dehydrogenase on the short-term prognosis of COVID-19 with pre-existing cardiovascular diseases

Background

Patients with coronavirus disease 2019 (COVID-19) and underlying cardiovascular comorbidities have poor prognoses. Our aim was to identify the impact of serum lactate dehydrogenase (LDH), which is associated with mortality in acute respiratory distress syndrome, on the prognoses of patients with COVID-19 and underlying cardiovascular comorbidities.

Methods

Among 1518 patients hospitalized with COVID-19 enrolled in the CLAVIS-COVID (Clinical Outcomes of COVID-19 Infection in Hospitalized Patients with Cardiovascular Diseases and/or Risk Factors study), 515 patients with cardiovascular comorbidities were analyzed. Patients were divided into tertiles based on LDH levels at admission [tertile 1 (T1), <235 U/L; tertile 2 (T2), 235–355 U/L; and tertile 3 (T3); ≥356 U/L]. We investigated the impact of LDH levels on the in-hospital mortality.

Results

The mean age was 70.4 ± 30.0 years, and 65.3% were male. There were significantly more in-hospital deaths in T3 than in T1 and T2 [n = 50 (29.2%) vs. n = 15 (8.7%), and n = 24 (14.0%), respectively; p < 0.001]. Multivariable analysis adjusted for age, comorbidities, vital signs, and laboratory data including D-dimer and high-sensitivity troponin showed T3 was associated with an increased risk of in-hospital mortality (adjusted hazard ratio, 3.04; 95% confidence interval, 1.50–6.13; p = 0.002).

Conclusions

High serum LDH levels at the time of admission are associated with an increased risk of in-hospital death in patients with COVID-19 and known cardiovascular disease and may aid in triage of these patients.

Rapid Response System for In-Hospital Large Vessel Occlusion: A Case-Control Study

Objective

Acute ischemic stroke due to large vessel occlusion (LVO) in hospitalized patients is relatively rare but important condition. However, unlike community-onset cases, there are only few time-saving protocols for in-hospital LVO. This study aimed to evaluate the time-saving effects of rapid response system (RRS) for the management of in-hospital LVO.

Methods

We retrospectively evaluated consecutive in-hospital LVO patients who underwent mechanical thrombectomy (MT) between April 2015 and January 2020. In November 2017, we added "acute hemiparesis, eye deviation, and convulsive seizures" to the activation criteria for RRS. In this protocol, the patient is immediately transported from the ward to the emergency room (ER) by Medical Emergency Team (MET). The stroke team can then start assessment in the same manner as for community-onset cases. The time metrics between those with and without RRS intervention were compared. The primary outcome was time from detection to the first assessment by stroke team and to initial CT. To investigate the validity of the revised criteria, we also analyzed all RRS-activated cases.

Results

In total, 26 patients (RRS group, 11 patients; non-RRS group, 15 patients) were included. The median time from detection to stroke team assessment (10.0 [interquartile range: IQR, 8-15] minutes vs 65.5 [18-89] minutes) and to CT (22.0 [16-31] minutes vs. 46.5 [35-93] minutes) were significantly shorter in the RRS group. RRS was activated in 34 patients (mean, 1.3/month) according to the added criteria, of whom 20 (58.8%) had cerebral infarction and 9 underwent MT. About two-thirds of the other patients developed neurological emergencies (e.g., epileptic seizure, syncope, or hypoglycemia) that required acute care.

Conclusion

RRS has the potential to shorten response time efficiently in the management of in-hospital LVO. Prompt transportation of the patient to the ER by MET enables faster intervention by the stroke team.

Longer term hemodialysis-dependent chronic renal failure increases the risk of post-cardiac surgery vasoplegic syndrome

PURPOSE

We evaluated whether longer term hemodialysis (HD) is associated with a higher incidence of vasoplegic syndrome (VS) after cardiac surgery.

METHODS

This retrospective, single-center cohort study included 562 consecutive patients who underwent cardiac surgery in a tertiary hospital from January 2015 to December 2016. We assessed VS occurrence and its relationship with HD duration and other risk factors. To assess the effect of the HD duration on VS occurrence, we constructed ordinal variables: HD = 0 (non-HD), 0 < HD ≤ 5 (HD ≤ 5 years), 5 < HD ≤ 10, and 10 < HD.

RESULTS

The overall mean (± standard deviation) age of patients was (73 ± 11) years, and there were 60.9% men. Forty-one patients (7.3%) were HD dependent. Cardiac surgeries included all coronary artery bypass graft procedures, all valvular procedures, and aortic surgery involving cardiopulmonary bypass (CPB). Sixty-six patients (10%) developed VS. Most preoperative patient characteristics were comparable between the VS and no-VS groups; a chronic HD status and a total CPB time of > 180 min were significantly more common in the VS group (P < 0.0001 and P = 0.02, respectively). Longer term HD significantly correlated with VS incidence (P < 0.0001). Ordinal variables for the HD duration and age and known risk factors for VS (preoperative use of angiotensin-converting enzyme inhibitors and beta-blockers, low left-ventricular ejection fraction, and CPB time > 180 min) were subjected to multivariate regression analysis. Long-term HD was identified as an independent predictor of VS (odds ratio, 2.29, 95% confidence interval, 1.66-3.18).

CONCLUSIONS

Longer term HD may be associated with a higher VS incidence after cardiac surgery. VS should be given attention after cardiac surgery in chronic HD-dependent patients.

Energy intake in the first week in an emergency intensive care unit may not influence clinical outcomes in critically ill, overweight Japanese patients

BACKGROUND AND OBJECTIVES

The American Society for Parenteral and Enteral Nutrition recommends hypocaloric feeding for critically ill patients with a BMI of >=30.0 kg/m2. However, the cut-off value of obesity in Japan is BMI >25.0 kg/m2, due to the higher prevalence of type 2 diabetes mellitus, and cardiovascular risk factors, even at a lower BMI than in Western populations. Thus, the optimal energy intake for critically ill, overweight Asian patients is unknown.

METHODS AND STUDY DESIGN

A retrospective chart review was conducted in patients with BMI of >=25.0 kg/m2 in an emergency intensive care unit (EICU). Patients were categorized into two groups by average daily energy intake during the first week in the EICU, with Group A at <50% of requirement and Group B at >=50%.

RESULTS

A total of 72 patients with a median BMI of 27.5 kg/m2 were included in the study. No significant differences between the groups were observed for all-cause mortality, ICU-free days, or length of hospital stay. The number of ventilator-free days (VFDs) was significantly higher in Group A than Group B (20.0 [15.5-24.5] vs 17.0 [2.0-21.0] days; p=0.042). On multiple adjusted analysis, however, we found that %energy intake/requirement was not independently associated with VFDs (regression coefficient=0.019; 95% confidence interval, -0.115-0.076).

CONCLUSIONS

Energy intake in the first week in the EICU did not influence clinical outcomes in critically ill, overweight Japanese patients. Confirmation of these results in larger, randomized trials is required.

Relationship between Ventilator-Associated Events and Timing of Rehabilitation in Subjects with Emergency Tracheal Intubation at Early Mobilization Facility

The present study aimed to investigate the relationship between the occurrence of ventilator-associated events (VAE) in the intensive care unit and the timing of rehabilitation intervention. We included subjects who underwent emergency tracheal intubation and received rehabilitation. We performed rehabilitation according to our hospital’s protocol. We assessed the mechanical ventilation parameters of inspired oxygen fraction and positive-end expiratory pressure, and a VAE was identified if these parameters stabilized or decreased for ≥2 days and then had to be increased for ≥2 days. We defined time in hours from tracheal intubation to the first rehabilitation intervention as Timing 1 and that to first sitting on the edge of the bed as Timing 2. Data were analyzed by the t-test and χ² tests. We finally analyzed 294 subjects. VAE occurred in 9.9% and high mortality at 48.3%. Median values of Timing 1 and Timing 2 in the non-VAE and VAE groups were 30.3 ± 24.0 and 30.0 ± 20.7 h, and 125.7 ± 136.6 and 127.9 ± 111.4 h, respectively, and the differences were not significant (p = 0.95 and p = 0.93, respectively). We found no significant relationship between the occurrence of VAE leading to high mortality and timing of rehabilitation intervention.

Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: a multicenter randomized controlled study

BACKGROUND

To compare the efficacy of three antiseptic solutions [0.5%, and 1.0% alcohol/chlorhexidine gluconate (CHG), and 10% aqueous povidone-iodine (PVI)] for the prevention of intravascular catheter colonization, we conducted a randomized controlled trial in patients from 16 intensive care units in Japan.

METHODS

Adult patients undergoing central venous or arterial catheter insertions were randomized to have one of three antiseptic solutions applied during catheter insertion and dressing changes. The primary endpoint was the incidence of catheter colonization, and the secondary endpoint was the incidence of catheter-related bloodstream infections (CRBSI).

RESULTS

Of 1132 catheters randomized, 796 (70%) were included in the full analysis set. Catheter-tip colonization incidence was 3.7, 3.9, and 10.5 events per 1000 catheter-days in 0.5% CHG, 1% CHG, and PVI groups, respectively (p = 0.03). Pairwise comparisons of catheter colonization between groups showed a significantly higher catheter colonization risk in the PVI group (0.5% CHG vs. PVI: hazard ratio, HR 0.33 [95% confidence interval, CI 0.12-0.95], p = 0.04; 1.0% CHG vs. PVI: HR 0.35 [95% CI 0.13-0.93], p = 0.04). Sensitivity analyses including all patients by multiple imputations showed consistent quantitative conclusions (0.5% CHG vs. PVI: HR 0.34, p = 0.03; 1.0% CHG vs. PVI: HR 0.35, p = 0.04). No significant differences were observed in the incidence of CRBSI between groups.

CONCLUSIONS

Both 0.5% and 1.0% alcohol CHG are superior to 10% aqueous PVI for the prevention of intravascular catheter colonization.

TRIAL REGISTRATION

Japanese Primary Registries Network; No.: UMIN000008725 Registered on 1 September 2012.

The clinical practice guideline for the management of ARDS in Japan

Background

The Japanese Society of Respiratory Care Medicine and the Japanese Society of Intensive Care Medicine provide here a clinical practice guideline for the management of adult patients with ARDS in the ICU.

Method

The guideline was developed applying the GRADE system for performing robust systematic reviews with plausible recommendations. The guideline consists of 13 clinical questions mainly regarding ventilator settings and drug therapies (the last question includes 11 medications that are not approved for clinical use in Japan).

Results

The recommendations for adult patients with ARDS include: we suggest against early tracheostomy (GRADE 2C), we suggest using NPPV for early respiratory management (GRADE 2C), we recommend the use of low tidal volumes at 6-8 mL/kg (GRADE 1B), we suggest setting the plateau pressure at 30cmH₂0 or less (GRADE2B), we suggest using PEEP within the range of plateau pressures less than or equal to 30cmH₂O, without compromising hemodynamics (Grade 2B), and using higher PEEP levels in patients with moderate to severe ARDS (Grade 2B), we suggest using protocolized methods for liberation from mechanical ventilation (Grade 2D), we suggest prone positioning especially in patients with moderate to severe respiratory dysfunction (GRADE 2C), we suggest against the use of high frequency oscillation (GRADE 2C), we suggest the use of neuromuscular blocking agents in patients requiring mechanical ventilation under certain circumstances (GRADE 2B), we suggest fluid restriction in the management of ARDS (GRADE 2A), we do not suggest the use of neutrophil elastase inhibitors (GRADE 2D), we suggest the administration of steroids, equivalent to methylprednisolone 1-2mg/kg/ day (GRADE 2A), and we do not recommend other medications for the treatment of adult patients with ARDS (GRADE1B; inhaled/intravenous β2 stimulants, prostaglandin E₁, activated protein C, ketoconazole, and lisofylline, GRADE 1C; inhaled nitric oxide, GRADE 1D; surfactant, GRADE 2B; granulocyte macrophage colony-stimulating factor, N-acetylcysteine, GRADE 2C; Statin.)

Conclusions

This article was translated from the Japanese version originally published as the ARDS clinical practice guidelines 2016 by the committee of ARDS clinical practice guideline (Tokyo, 2016, 293p, available from http://www.jsicm.org/ARDSGL/ARDSGL2016.pdf). The original article, written for Japanese healthcare providers, provides points of view that are different from those in other countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s40560-017-0222-3) contains supplementary material, which is available to authorized users.

Effects of non-invasive ventilation in patients with acute respiratory failure excluding post-extubation respiratory failure, cardiogenic pulmonary edema and exacerbation of COPD: a systematic review and meta-analysis

BACKGROUND

This meta-analysis compared the effects of non-invasive ventilation (NIV) with invasive mechanical ventilation (InMV) and standard oxygen (O₂) therapy on mortality and rate of tracheal intubation in patients presenting acute respiratory failure (ARF).

METHODS

We searched the MEDLINE, EMBASE and Cochrane Central Register of clinical trials databases between 1949 and May 2015 to identify randomized trials of NIV for ARF. We excluded the ARF caused by extubation, cardiogenic pulmonary edema, and COPD.

RESULTS

The meta-analysis included 21 studies and 1691 patients, of whom 846 were assigned to NIV and 845 to control (InMV or standard O₂ therapy). One hundred ninety-one patients (22.6%) in the NIV group and 261 patients (30.9%) in the control group died before discharge from hospital. The pooled odds ratio (OR) for short-term mortality (in-hospital mortality) was 0.56 (95% CI 0.40-0.78). When comparing NIV with standard O₂ therapy, the short-term mortality was 155 (27.4%) versus 204 (36.0%), respectively. For this comparison, the pooled OR of short-term mortality was 0.56 (95% CI 0.36-0.85). When comparing NIV with InMV, the short-term mortality was 36 (12.9%) versus 57 (20.5%) patients, respectively. For this comparison, the pooled OR of short-term mortality was 0.56 (95% CI 0.34-0.90). Tracheal intubation was performed in 106 patients (22.7%) in the NIV and in 183 patients (39.4%) in the standard O₂ group, representing a pooled OR of 0.37 (95% CI 0.25-0.55). There were publication biases and the quality of the evidence was graded as low.

CONCLUSION

Compared with standard O₂ therapy or InMV, NIV lowered both the short-term mortality and the rate of tracheal intubation in patients presenting with ARF.

Critical Care Management Focused on Optimizing Brain Function After Cardiac Arrest

The discussion of neurocritical care management in post-cardiac arrest syndrome (PCAS) has generally focused on target values used for targeted temperature management (TTM). There has been less attention paid to target values for systemic and cerebral parameters to minimize secondary brain damage in PCAS. And the neurologic indications for TTM to produce a favorable neurologic outcome remain to be determined. Critical care management of PCAS patients is fundamental and essential for both cardiologists and general intensivists to improve neurologic outcome, because definitive therapy of PCAS includes both special management of the cause of cardiac arrest, such as coronary intervention to ischemic heart disease, and intensive management of the results of cardiac arrest, such as ventilation strategies to avoid brain ischemia. We reviewed the literature and the latest research about the following issues and propose practical care recommendations. Issues are (1) prediction of TTM candidate on admission, (2) cerebral blood flow and metabolism and target value of them, (3) seizure management using continuous electroencephalography, (4) target value of hemodynamic stabilization and its method, (5) management and analysis of respiration, (6) sedation and its monitoring, (7) shivering control and its monitoring, and (8) glucose management. We hope to establish standards of neurocritical care to optimize brain function and produce a favorable neurologic outcome.

Reduction in gastrointestinal bleeding by development and implementation of a protocol for stress ulcer prophylaxis: a before-after study

Background

The implementation of a protocol has been associated with improvements in the processes of care in clinical settings. Although stress ulcer prophylaxis is recommended for critically ill patients at high risk, there is currently no consensus on its use. Therefore, we herein developed a protocol for stress ulcer prophylaxis, and evaluated therapeutic outcomes in a before-after study.

Methods

The protocol was developed by considering the effectiveness, disadvantages (including adverse events) and cost of each agent based on previous findings. Patients who were admitted to the 8-bed emergency intensive care unit (ICU) of our hospital for more than 24 h during the year before and after implementation of the study were eligible. Each investigation item was evaluated retrospectively.

Results

There were 211 and 238 study patients before and after implementation of the protocol, respectively. The baseline characteristics of patients on/during ICU admission were similar in the two groups. The proportion of medicated patients was 79.6 % before and 84.5 % after protocol implementation. Before implementation of the protocol, 4.3 % of patients developed clinically important gastrointestinal bleeding, and this incidence decreased significantly to 0.8 % after its implementation (P = 0.019). The frequency at which medication was discontinued due to adverse events was slightly lower after implementation of the protocol. No significant differences were observed in the costs of stress ulcer prophylactic agents or mortality in the ICU.

Conclusions

The results of the present study indicated that the development and implementation of a protocol for stress ulcer prophylaxis, for which there are currently no criteria, improved a main outcome, clinically important gastrointestinal bleeding.

Efficacy of High-Flow Nasal Cannula Therapy in Acute Hypoxemic Respiratory Failure: Decreased Use of Mechanical Ventilation

BACKGROUND

We evaluated the efficacy of high-flow nasal cannula (HFNC) therapy, a promising respiratory support method for acute hypoxemic respiratory failure (AHRF).

METHODS

We conducted a retrospective single-center cohort study comparing the periods before (June 2010 to May 2012) and after (June 2012 to May 2014) HFNC introduction (pre- and post-HFNC periods). During these periods, we retrieved cases of AHRF treated with any respiratory support (invasive ventilation, noninvasive ventilation [NIV], and HFNC) and compared in-hospital mortality, ICU/intermediate care unit/hospital stay, and need for mechanical ventilation.

RESULTS

Eighty-three subjects (65 treated with NIV, and 18 treated with invasive ventilation) and 89 subjects (33 treated with HFNC, 43 treated with NIV, and 13 treated with invasive ventilation) identified from 782 pre-HFNC and 930 post-HFNC records of acute respiratory failure who required emergent admissions to the respiratory care department were analyzed. Overall, the in-hospital mortality rate was similar, although there was a non-significant and slight decrease from 35 to 27% (P = .26). There was no significant difference among ICU, intermediate care unit (P = .80), and hospital (P = .33) stay. In the post-HFNC period, significantly fewer subjects required mechanical ventilation (NIV or invasive ventilation) (100% vs 63%, P < .01). Additionally, there were significantly fewer ventilator days (median [interquartile range] of 5 [2-11] vs 2 [1-5] d, P < .05) and more ventilator-free days (median [interquartile range] of 18 [0-25] vs 26 [20-27] d, P < .01).

CONCLUSIONS

HFNC might be an alternative for AHRF subjects with NIV intolerance.

Pneumatosis cystoides intestinalis associated with toxic epidermal necrolysis: A case report

Toxic epidermal necrolysis (TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis (PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography (CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.

Fulminant hepatitis following crizotinib administration for ALK-positive non-small-cell lung carcinoma

We herein report a case of fatal fulminant hepatitis secondary to crizotinib administration. The patient was 54-year-old female with a history of Hepatitis C infection (not current), dermatomyositis and steroid-induced diabetes mellitus. She was diagnosed with advanced lung adenocarcinoma with anaplastic lymphoma kinase rearrangement. We began 400 mg of crizotinib as first-line therapy. No adverse effects were seen until Day 16. On Day 29, she was admitted to hospital with elevated liver enzymes (aspartate aminotransferase 3236 IU/l, alanine aminotransferase 5201 IU/l) and coagulopathy (prothrombin time <10%), and was diagnosed with crizotinib-induced fulminant hepatitis. We started intensive care, using plasma exchange, continuous hemodiafiltration and high-dose steroid therapy. Unfortunately, she did not respond to therapies, and died on Day 36. The mechanism and risk factors of crizotinib-induced hepatotoxicity are uncertain. Physicians should be aware of possible adverse effects of crizotinib. A systemic survey is imperative to identify possible risk factors of crizotinib-related hepatotoxicity.

Detection of herpes viruses by multiplex and real-time polymerase chain reaction in bronchoalveolar lavage fluid of patients with acute lung injury or acute respiratory distress syndrome

BACKGROUND

Human herpes viruses (HHVs) are important pathogens in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Rapid and efficient diagnostic tools are needed to detect HHVs in the lung in ALI/ARDS patients.

OBJECTIVES

This study aimed to evaluate the usefulness of multiplex and real-time polymerase chain reaction (PCR) analysis of bronchoalveolar lavage fluid (BALF) for detecting HHV reactivation in ALI/ARDS patients.

METHODS

Between August 2008 and July 2012, eighty-seven BALF samples were obtained from ALI/ARDS patients with unknown etiology and analyzed for HHVs. The types of HHVs in the BALF samples were determined using qualitative multiplex PCR followed by quantitative real-time PCR.

RESULTS

Multiplex PCR identified herpes simplex virus type 1 (HSV-1) (n = 11), Epstein-Barr virus (EBV) (n = 16), cytomegalovirus (CMV) (n = 21), HHV type 6 (HHV-6) (n = 2), and HHV-7 (n = 1) genomic DNA in 35 (40%) of the BALF samples, including 14 (16%) samples containing 2 or 3 HHV types. CMV and EBV reactivation was rare in immunocompetent patients, whereas reactivation of HSV-1 was predominantly observed in intubated patients regardless of their immune status. Overall, HHVs were almost exclusively found in patients with immunosuppression or endotracheal intubation. Real-time PCR detected 0.95-1.59 × 10(6) copies of viral DNA/μg human genome DNA, and HSV-1 (n = 4), CMV (n = 9), and HHV-6 (n = 1) were identified as potentially pathogenic agents.

CONCLUSIONS

The implementation of multiplex and real-time PCR of BALF was feasible in ALI/ARDS patients, which allowed efficient detection and quantification of HHV DNA.

[Investigation of the outcomes and complications in right thoracotomy approach for mitral valve reoperation]

BACKGROUND

Right thoracotomy is an alternative surgical technique for mitral valve reoperation. The purpose of this study is to determine whether right thoracotomy for mitral valve reoperation affects its perioperative outcomes and complications.

METHODS

We investigated the perioperative events in consecutive mitral valve reoperations between January 2006 and November 2009. Demographic, intraoperative and postoperative data were collected and analyzed retrospectively.

RESULTS

Five right thoracotomy cases and 22 repeated sternotomy cases were included. Thoracotomy group needed more platelet transfusion (median, 20 units in thoracotomy; 10 units in sternotomy; P=0.047). We had a higher frequency of adrenaline administration (60% in thoracotomy; 4.6% in sternotomy; P=0.005) and needed more doses of dobutamine in thoracotomy group (median, 16.0 microg x kg(-1) x min(-1) in thoracotomy ; 7.5 microg x kg(-1) x min(-1) in sternotomy; P=0.037) to wean them from cardiopulmonary bypass. Right thoracotomy did not reduce cardiopulmonary bypass time (median, 265 min in thoracotomy ; 199 min in sternotomy; P=0.126). We experienced two serious complications requiring reoperation in thoracotomy group, but diagnosed them with intraoperative transesophageal echocardiography.

CONCLUSIONS

When we choose right thoracotomy for mitral valve reoperation, we should prepare more blood products and inotropic agents and should evaluate cardiac function by using intraoperative transesophageal echocardiography.

[Remifentanil prevents hyperglycemia and reduces insulin use during cardiopulmonary bypass in adult cardiac surgery]

BACKGROUND

Remifentanil may be beneficial in patients undergoing cardiac surgery, by attenuating the neurohumoral stress response to surgical stimulation and inflammation evoked by cardiopulmonary bypass (CPB).

METHODS

We retrospectively examined blood glucose monitored every 30 minutes during CPB and insulin dose in patients during CPB under remifentanil anesthesia (remifentanil group) and those under low dose fentanyl anesthesia (fentanyl group) in adult cardiac surgery. Furthermore we also investigated incidence of atrial fibrillation within 72 hours after surgery in both groups.

RESULTS

There were 35 patients in remifentanil group and 22 patients in fentanyl group. Although blood glucose at the beginning and the end of CPB in both groups were not different, remifentanil group showed lower maximum blood glucose (median 172 mg x dl(-1), interquatile range 156-205 mg x dl(-1)) during CPB than in fentanyl group (197 mg x dl(-1), 176-219 mg x dl(-1); P = 0.009). Significantly less insulin was administered during CPB in remifentanil group than in fentanyl group. Incidence of postoperative atrial fibrillation was similar between the groups.

CONCLUSIONS

Maximum blood glucose was lower and less insulin was administered during CPB in remifentanil group. These data may suggest that remifentanil reduce stress response to surgical stimulation in cardiac surgery.

[A case of lung cancer combined with pregnancy; dramatically deteriorating condition after caesarian section]

A 34-year-old pregnant woman was diagnosed with pneumonia at another hospital in her 26th week of pregnancy. Antibiotics were administered, but they were not effective. She was then introduced and admitted to our hospital. Lung cancer was suspected from her chest-CT scan on admission. Caesarian section was performed on the day after admission at 33 weeks of gestation. Adenocarcinoma of the lung was diagnosed based on the results of a right-axillary lymph node biopsy performed simultaneously with the caesarian section. On the 8th day after admission, we began to administer gefitinib. We expected positive results from gefitinib, because the patient fitted the optimal profile: female, never smoker, adenocarcinoma histology. Her respiratory condition had worsened dramatically after her caesarian section, so she was given noninvasive positive pressure ventilation from the 13th day after admission. Disseminated intravascular coagulation progressed, and her chest X-ray showed bilateral extensive infiltration. Moreover, tests showed that her tumor was negative for epidermal growth factor recepter mutation, so we judged that gefitinib was not effective for her. Although her performance status was very poor, she and her family strongly desired further chemotherapy. We thus began to administer gemcitabine, but her respiratory condition deteriorated further, and she died on the 17th day after admission. Lung cancer combined with pregnancy is a very rare situation, so we report this case with some references.

[An autopsy case of racemose hemangioma of bronchial arteries associated with neovascularization from the chest wall after ligation and frequent embolizations]

We report an autopsied 33 year old pregnant woman with racemose hemangioma of the bronchial arteries. She was first given a diagnosis of racemose hemangioma of the bronchial arteries at age 19 and underwent surgical ligation. Nevertheless, she had to be admitted to the hospital for bronchial artery embolizations every time hemoptysis recurred. In her 21st gestational week, she was admitted to our hospital because of her 9th recurrent massive hemoptysis and dyspnea. Bronchial artery embolizations were repeatedly performed under intubation to ventilate the healthy left lung separately. We succeeded in temporarily stopping the hemoptysis, but her case was complicated by bacterial pneumonia and septic shock. Her baby was born dead on day 11 and she died on day 12. The autopsy revealed abnormal convoluted and dilated arteries branching from the right intercostal and subclavian arteries and intruding into the lung parenchyma through adhesion caused by her previous thoracostomy. The connections of these abnormal arteries with pulmonary arteries and veins, which had been shown by angiography, were confirmed by autopsy. The autopsy findings suggest that temporal surgical procedures with thoracostomy in this condition can induce abnormal neovascularization via pleural adhesion.

[Legionella longbeachae pneumonia infection from home garden soil]

A 72-year-old critically ill and intubated man was transferred to our hospital, because of worsening pneumonia unresponsive to Cefazolin and Meropenem, from the hospital where he had been admitted 8 days before to start maintenance hemodialysis for chronic renal failure but had fever from admission. In a few days his critical condition rapidly subsided with the initiation of Ciprofloxacin and his sputum culture on GVPC medium indicated Legionellosis, which was afterwards identified as L. longbeachae by PCR and DNA-DNA hybridization. After recovery he said that he had been fond of gardening and had been gardening immediately before the initial admission. Moreover, several reports from Australia suggested inhalation of aerosolized potting soil as the route of L. longbeacachae infection; therefore, we examined the soil of his home garden and identified it. Thus, we present this case as the first of L. longbeachae pneumonia in Japan, proved to be infected via inhalation of aerosolized home garden soil.

High-dose ifosfamide, carboplatin and etoposide (HD-ICE) with peripheral blood stem cell transfusion (PBSCT) for limited stage small-cell lung cancer (LD-SCLC)

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Background: Efficacy of high dose chemotherapy with autologous PBSCT has been demonstrated in the treatment of lymphoma. The purpose of this trial is to determine progression-free survival and long-term survival for LD-SCLC patients (pts) who responded to first-line concurrent chemo-radiotherapy followed by HD-ICE with PBSCT. Methods: Patients (pts) with pathologically proven SCLC without malignant pleural and pericardial effusion, stage II-IIIB, ECOG-PS 0–1 were eligible. All pts were treated with cisplatin (P) 60 mg/m2 day1 and etoposide (E) 100 mg/m2, days 1–3, with concurrent hyperfractionted radiotherapy initially (1.5Gy X 2/day X 15 days, total 45Gy) and then two or three cycles of chemotherapy consisted of P 60 mg/m2, day 1, and E 120 mg/m2, days 1–3, or APE (adriamycin 30 mg/m2, day 1, P 60 mg/m2, day1 and E 100 mg/m2, days 1–3) were repeated. Pts with tumor shrinkage more than 90% after initial therapy received HD-ICE (ifosfamide 3 g/m2, days 1–3, carboplatin 400 mg/m2, days 1–3, etoposide 400 mg/m2, days 1–3) followed by PBSCT. All pts received prophylactic cranial irradiation (1.5 Gy × 2/day × 9 days, total 27 Gy). Results: Between 1996 and 2001, 15 pts were eligible and all 15 pts received HD-ICE with PBSCT. Patient characteristics included M/F:14/1, median age: 55 (47–62), PS 0/1: 7/8 stage IIIA/IIIB: 7/8. Grade IV neutropenia and thorombocytopenia were observed in all pts and 93% of pts experienced neutropenic fever after HD-ICE. There was no toxic death. Median follow up time was 83.2 months. Median progression free survival time was 10. 7 months and overall median survival time (MST) was 30.9 months. Two, 3 and 5-year survival rates after initial chemoradiotherapy were 67%, 33%, 25%, respectively. Conclusion: HD-ICE with PBSCT for LD-SCLC revealed promising MST and a 5-year survival rate with manageable treatment-related toxicity. A randomized phase III study comparing chemo-radiotherapy followed by HD-ICE with PBSCT to standard chemo-radiotherapy for LD-SCLC is ongoing.

No significant financial relationships to disclose.

Characterization of single actomyosin rigor bonds: load dependence of lifetime and mechanical properties

Load dependence of the lifetime of the rigor bonds formed between a single myosin molecule (either heavy meromyosin, HMM, or myosin subfragment-1, S1) and actin filament was examined in the absence of nucleotide by pulling the barbed end of the actin filament with optical tweezers. For S1, the relationship between the lifetime (tau) and the externally imposed load (F) at absolute temperature T could be expressed as tau(F) = tau(0).exp(-F.d/k(B)T) with tau(0) of 67 s and an apparent interaction distance d of 2.4 nm (k(B) is the Boltzmann constant). The relationship for HMM was expressed by the sum of two exponentials, with two sets of tau(0) and d being, respectively, 62 s and 2.7 nm, and 950 s and 1.4 nm. The fast component of HMM coincides with tau(F) for S1, suggesting that the fast component corresponds to single-headed binding and the slow component to double-headed binding. These large interaction distances, which may be a common characteristic of motor proteins, are attributed to the geometry for applying an external load. The pulling experiment has also allowed direct estimation of the number of myosin molecules interacting with an actin filament. Actin filaments tethered to a single HMM molecule underwent extensive rotational Brownian motion, indicating a low torsional stiffness for HMM. From these results, we discuss the characteristics of interaction between actin and myosin, with the focus on the manner of binding of myosin.

In vitro fertilization outcomes after intracytoplasmic sperm injection with fresh or frozen-thawed testicular spermatozoa

OBJECTIVE

To compare the outcomes of intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF) with fresh and cryopreserved testicular spermatozoa in patients with obstructive and nonobstructive azoospermia.

DESIGN

Retrospective analysis of consecutive ICSI cycles.

SETTING

Large urban reproductive medicine program.

PATIENT(S)

Twenty-nine patients with obstructive and nonobstructive azoospermia undergoing testicular sperm extraction for a total of 46 IVF-ICSI cycles (12 fresh, 34 frozen).

INTERVENTION(S)

Testicular sperm extraction, cryopreservation, and IVF-ICSI with fresh or frozen-thawed spermatozoa.

MAIN OUTCOME MEASURE(S)

Fertilization rates, embryo cleavage rates, embryo implantation rates, clinical pregnancy rates per cycle and per embryo transfer, and delivery and spontaneous abortion rates.

RESULT(S)

No statistically significant differences were noted in any of the parameters examined between IVF-ICSI cycles from fresh or frozen-thawed testicular spermatozoa. Fertilization rates were 56% with fresh vs. 61% with frozen-thawed testicular sperm, cleavage rates 92% vs. 95%, implantation rates 26% vs. 17%, clinical pregnancy rates per cycle 33% vs. 41%, and pregnancy rates per embryo transfer 33% vs. 45%, respectively. Delivery rates were 75% with fresh vs. 69.2% with frozen-thawed testicular sperm, and spontaneous abortion rates 25% and 30.8%, respectively.

CONCLUSION(S)

No differences were found in IVF-ICSI outcomes between cryopreserved and fresh testicular sperm. In addition, cryopreservation provides several advantages for the patients and reproductive team.

A pitch glide activates an intermediate response between auditory N1 and mismatch negativity

Pitch glides of a continuous tone elicit auditory N1-like responses. However, their characteristics have not well been investigated, and it remained unclear whether the response is an auditory true N1 or the mismatch negativity (MMN). We found here that a rapid pitch glide activates almost the same response as a true N1. On the contrary, as the rate of the pitch glide decreases, the response continuously varies the characteristics from true N1 to MMN. This suggests that there would exist intermediate responses between auditory N1 and MMN.

Protective effect of FK409, a spontaneous nitric oxide releaser, on ischemic acute renal failure in rats

The contribution of nitric oxide (NO) to ischemic acute renal failure (ARF) is controversial. In the present study, we investigated the effect of FK409 ((+/-)-(E)-4-ethyl-2-[(E)-hydroxyimino]-5-nitro-3-hexanamide ), a spontaneous NO donor, on ischemic ARF in rats. Ischemic ARF was induced by occlusion of the left renal artery and vein for 45 min followed by reperfusion, 2 weeks after contralateral nephrectomy. Renal functional parameters such as blood urea nitrogen, plasma creatinine, creatinine clearance, urine flow, urinary osmolality and fractional excretion of sodium were measured to test the effectiveness of the drug. Renal function in untreated ARF rats markedly decreased at 24 hr after reperfusion and thereafter tended to recover gradually. Intravenous bolus injection of FK409 at a dose of 1 mg/kg before the occlusion markedly attenuated the ischemic ARF-induced decreases in renal function, to the same extent as verapamil (1 mg/kg i.v.). The protective effect of FK409, at a dose of 3 mg/kg, was much more potent than that of the lower dose. Histopathological examination of the kidney of untreated ARF rats revealed severe renal damages, such as tubular necrosis, proteinaceous casts in tubuli and medullary congestion. These renal damages were significantly attenuated by treatment with FK409, at each dose given and this attenuation exceeded that seen with verapamil treatment. FK 409 administration led to a dose-dependent increase in NO metabolites concentration in renal venous blood immediately after the reperfusion. These findings suggest that NO has a crucial role in the pathogenesis of ischemic ARF. Spontaneous NO donors may be clinically effective in cases of ischemic ARF.

Ipsilateral dominance of human olfactory activated centers estimated from event-related magnetic fields measured by 122-channel whole-head neuromagnetometer using odorant stimuli synchronized with respirations

The aim of this study was to measure and analyze olfactory event-related magnetic fields using a whole-cortex biomagnetometer (122-channel SQUID gradiometer). Amyl-acetate gas (approx. 1%) was administered for 300 msec into either the right or left nostril in synchronization with respiration using a mask and an optical fiber sensor. Clear olfactory event-related magnetic fields were asymmetrically obtained on both sides of the forehead in all six subjects. The generators of olfactory magnetic fields were estimated at two regions located fairly asymmetrivally near the bilateral frontal deep areas. The goodness-of-fit was better for the two-dipole model than the one-dipole model in all experiments. In almost all subjects the latency and intensity of ipsilateral olfactory magnetoencephalography (MEG) responses were shorter and larger than those of the contralateral responses, respectively. These results suggest that the olfactory MEG responses on the ipsilateral side are generally larger and more dominant than those on the contralateral side in the human olfactory system.

Auditory evoked off-response: its source distribution is different from that of on-response

Offset auditory responses were investigated by electroencephalography mainly in the 1970s, but since then no particular attention has been paid to them. Among the studies using magnetoencephalography (MEG) devices there are, to our knowledge, only three studies of the auditory off-response, and no significant variance has ever been observed between the source locations of on- and off-responses elicited from pure tones. We measured auditory evoked magnetic fields (AEFs) to various frequency pure tone stimulation in 5 healthy subjects with a 122-channel helmet-shaped magnetometer, and compared the distributions of the source locations of auditory N100m-Off (magnetic off-response around 100 ms) with those of N100m-On. Their spatial distributions were quite close to each other, and yet they were significantly different.

Blastomycosis of the epididymis and prostate

We report a case of blastomycosis presenting as epididymitis and prostatitis. The diagnosis was suggested by pathologic findings in the prostate and epididymis and was further supported by serology. The diagnosis was confirmed by culture and special staining. Long-term cure was accomplished after a 12-month course of oral ketoconazole (400 mg/day). Therapy was monitored by culture and serology. Blastomycosis is an unusual but significant pathogen which occasionally presents with genitourinary tract involvement. Effective diagnostic and oral treatment regimens are now available but are dependent on a high degree of suspicion in cases of chronic prostatitis or epididymitis.

Inhibition of prostate ductal morphogenesis by retinoic acid

PURPOSE

To examine the effect of retinoic acid on prostate ductal morphogenesis.

MATERIALS AND METHODS

Newborn male Balb/C mice were injected with 25 mg./kg. all-trans retinoic acid or vehicle alone. Animals were sacrificed at 60 days of age and prostate ductal morphology was quantitatively assessed by microdissection. Total prostate DNA was quantitated by DPA assay.

RESULTS

The greatest effect was seen in the ventral prostate. Retinoic acid treated animals showed a 20% decrease in mean number of branch-points (p = 0.0006) with a corresponding 13% decrease in duct tips (p = 0.026). The combined ventral and dorsal prostate showed an effect with a 12% decrease in ductal branchpoints (p = 0.048). There was no effect on animal or organ weight and no effect on DNA content within the prostate. There was no difference in the prostate histology of treated and control animals.

CONCLUSION

Retinoic acid administration in the newborn period inhibits mouse prostate ductal morphogenesis. This effect appears independent of an inhibition of overall growth.

Micro-magnetic resonance imaging of the inner ear in the guinea pig

We applied a magnetic resonance microscopy at 7.05 T with a gradient coil unit to image the fine structure of the guinea pig cochlea. First, a three-dimensional MR image of the surface of the cochlea was obtained to select the location of cross-sectional images. Then, cross-sectional images of the basal turn, the second turn and the apical turn of the cochlea were obtained. Based upon the different protein concentrations of the endolymph vs the perilymph, the scala vestibuli, scala tympani and the cochlear duct could be clearly distinguished. This allowed a determination of the location of both the basilar membrane and Reissner's membrane. We raise the possibility that MRM may become useful in the diagnosis of endolymphatic hydrops (Meniere's disease).

High-resolution MRI of the human cochlea

The majority of magnetic resonance imaging (MRI) studies in neurotology concern the evaluation of retrocochlear pathologies or temporal bone lesions. Recently, quite a number of investigators have attempted to use imaging diagnosis to obtain a diagnosis and manifest the pathological findings of Meniere's disease. However, there is no evidence that endolymphatic hydrops in patients with Meniere's disease can be identified by imaging techniques. In this study we could depict Reissner's membrane clearer than before with the use of image processing. At the present time, we cannot apply the 2.11T MRI machine to patients under FDA regulation. We believe that MRI diagnoses of endolymphatic hydrops and small lesions of the internal structures of the inner ear will be possible in the near future.

Functional imaging of the human olfactory cortex by magnetic resonance imaging

Our understanding of the neural mechanism of human olfaction is still equivocal. Several recent reports document that functional magnetic resonance imaging (MRI) has a potential to visualize dynamic brain function in humans without invasion. In the present study, we applied functional MRI with odor stimulation for the purpose of clarifying the localization of olfactory cortices in the human. We obtained a significant increase in cerebral blood flow in the piriform cortex, orbitofrontal cortex, and inferior medial frontal lobe, corresponding to olfactory cortices. These results suggest that, in the near future, precise diagnosis of the patients with olfactory disorders will be possible using functional MRI with odor stimulation.

ONO-4057, a novel, orally active leukotriene B4 antagonist: effects on LTB4-induced neutrophil functions

ONO-4057(5-[2-(2-Carboxyethyl)-3-[6-(4-methoxyphenyl)-5E- hexenyl]oxyphenoxy]valeric acid), an orally active leukotriene B4(LTB4) antagonist, displaced the binding of [3H] LTB4 to the LTB4 receptor in human neutrophil (Ki = 3.7 +/- 0.9 nM). ONO-4057 inhibited the LTB4-induced rise in cytosolic free calcium (the concentration causing 50% inhibition (IC50) = 0.7 +/- 0.3 microM) and inhibited human neutrophil aggregation, chemotaxis or degranulation induced by LTB4 (IC50 = 3.0 +/- 0.1, 0.9 +/- 0.1 and 1.6 +/- 0.1 microM) without showing any agonist activity at concentration up to 30 microM. ONO-4057 did not inhibit fMLP or C5a-induced neutrophil activation at concentrations up to 30 microM. In the in vivo study, ONO-4057 given orally, prevented LTB4-induced transient neutropenia or intradermal neutrophil migration in guinea pig (the dose causing 50% efficacy (ED50) = 25.6mg/kg or 5.3mg/kg). Furthermore, ONO-4057 given topically, suppressed phorbol-12-myristate-13-acetate (PMA)-induced neutrophil infiltration in guinea pig ear (the effective dose = 1 mg/ear). These results indicate that ONO-4057 is a selective and orally active LTB4 antagonist and may be a potential candidate for the treatment of various inflammatory diseases.

High-resolution magnetic resonance imaging of the human temporal bone

A magnetic resonance imaging (MRI) system (Hitachi, Naka, Japan) with a superconductive magnet running at 2.11 T was used to obtain 2-mm-thick slices of fixed, decalcified and celloidin-embedded human temporal bone. The temporal bone was then sectioned and stained for routine histological evaluation. Both the MR images and the histological sections were in the mid-modiolar slice plane, and comparable images and sections were analyzed to confirm the identity of the inner-ear structures visualized on the MR images. The cochlear duct, scala tympani, scala vestibuli and basement membrane of all three cochlear turns were clearly imaged on MRI. In addition, the vestibule and three semicircular ducts were also clearly seen. This study raises the possibility of some day using MRI for the diagnosis of inner-ear diseases.

Effects of ONO-3708, an antagonist of the thromboxane A2/prostaglandin endoperoxide receptor, on blood vessels

The pharmacological properties of a novel thromboxane A2/prostaglandin endoperoxide receptor antagonist, ONO-3708, on blood vessels were examined in vitro and in vivo. ONO-3708, 10 microM, inhibited the rabbit aorta contractions induced by thromboxane A2, prostaglandin H2, 11,9-epoxymethano-prostaglandin H2 (U-46619) or prostaglandin F2 alpha without affecting the contractions induced by angiotensin II, serotonin or norepinephrine. ONO-3708, at a concentration of 1 to 100 nM, appeared to be a competitive inhibitor of the contractile responses of the canine basilar artery to 9,11-epithio-11,12-methano-thromboxane A2 (STA2), U-46619 and PGF2 alpha, and a non-competitive inhibitor of the contractile responses to 15-hydroperoxy-eicosatetraenoic acid (15-HPETE). In in vivo studies, ONO-3708 (10 and 100 micrograms/kg per min i.v.) ameliorated the decrease in diameter of the basilar artery induced by the i.v. infusion of STA2 (0.1 microgram/kg per min) in cats. Furthermore, infusion of ONO-3708 (10 and 30 micrograms/kg per min i.v.) prevented the cerebral vasospasm in an experimental subarachnoid hemorrhage model in dogs. These results indicate that ONO-3708 is a potent antagonist of the thromboxane A2/prostaglandin endoperoxide receptor in vitro and in vivo and may be of therapeutic use in preventing cerebral vasospasm.

Effects of ONO-3708, an antagonist of the thromboxane A2/prostaglandin endoperoxide receptor, on platelet aggregation and thrombosis

The beneficial effects of an antagonist of the thromboxane A2/prostaglandin endoperoxide receptor, 7-[2 alpha,4 alpha-(dimethylmethano)-6 beta-(2-cyclopentyl-2 beta- hydroxyacetamido)-1 alpha-cyclohexyl]-5(Z)-heptenoic acid (ONO-3708) on thrombosis were examined. ONO-3708 at 0.1-3 microM inhibited the human platelet aggregation induced by thromboxane A2, prostaglandin H2, collagen, ADP (secondary phase) and epinephrine (secondary phase) without affecting prostanoid synthesis and the content of cyclic AMP in platelets. The in vivo effects, on coronary thrombosis in this case, were examined in two canine models. ONO-3708, 3 to 300 micrograms/kg i.v., prevented dose dependently the coronary thrombosis induced by partial obstruction of the coronary artery. ONO-3708, 3 micrograms/kg per min i.v., significantly prevented electrically stimulated coronary thrombosis without affecting systemic blood pressure and heart rate. These results indicate that the thromboxane A2/prostaglandin endoperoxide receptor could play an important role in the pathogenesis of thrombosis and that ONO-3708 may have therapeutic advantages in preventing thrombosis.

Two-step purification of cytochrome P-450 from rat liver microsomes using high-performance liquid chromatography

Cytochrome P-450 from rat liver microsomes treated with phenobarbital (PB) was separated into six fractions, as was cytochrome P-450 treated with 3-methylcholanthrene (MC), by high-performance liquid chromatography (HPLC) with an anion-exchange column. PB and MC induced three forms and one form of cytochrome P-450, respectively. The major forms induced by PB and by MC were further purified to apparent homogeneity based on sodium dodecyl(lauryl)sulphate--polyacrylamide gel electrophoresis by HPLC using a hydroxyapatite column. These new HPLC techniques are simple, rapid and useful for the purification of major forms of cytochrome P-450 from solubilized microsomes.

Multiple forms of cytochrome P-450 from microsomes of rat liver, kidney, and lung resolved by high-performance liquid chromatography

The amount of cytochrome P-450 in microsomes of rat kidney and lungs was 23 and 7%, respectively, of the amount in microsomes of the liver. HPLC profiles of solubilized microsomes showed that there were five or more forms of cytochrome P-450 in microsomes of kidneys and also of lungs of untreated rats. While 3-methylcholanthrene induced a new form of cytochrome P-450 in kidney and lung microsomes, phenobarbital caused no major change in the HPLC profiles of these microsomes.