Trust, Multidimensional Health Literacy, and Medication Adherence among Patients Undergoing Long-Term Hemodialysis

BACKGROUND

Basic health literacy and trust in physicians can influence medication adherence in patients receiving dialysis. However, how high-order health literacy is associated with medication adherence and how trust in physicians mediates this association remain unclear. We assessed the inter-relationships between health literacy, trust in physicians, and medication adherence. We investigated the mediating role of trust in physicians in the relationship between health literacy and medication adherence.

METHODS

This multicenter cross-sectional study included Japanese adults receiving outpatient hemodialysis at six dialysis centers. Multidimensional health literacy was measured using the 14-item Functional, Communicative, and Critical Health Literacy scale. Trust in physicians was measured using the five-item Wake Forest Physician Trust scale. Medication adherence was measured using the 12-item Adherence Starts with Knowledge scale. A series of general linear models were created to analyze the associations between health literacy and Adherence Starts Knowledge scores with and without trust in physicians. Mediation analysis was performed to determine whether trust in physicians mediated this association.

RESULTS

In total, 455 patients were analyzed. Higher functional and communicative health literacies were associated with less adherence difficulties (per 1-point higher: -1.79 [95% confidence interval (CI): -2.59 to -0.99] and -2.21 [95% CI: -3.45 to -0.96], respectively), whereas higher critical health literacy was associated with greater adherence difficulties (per 1-point higher: 1.69 [95% CI: 0.44 to 2.94]). After controlling for trust in physicians, the magnitude of the association between health literacies and medication adherence decreased. Trust in physicians partially mediated the association between functional or communicative health literacy and medication adherence (especially beliefs) and completely mediated the association between critical health literacy and medication adherence (especially behaviors).

CONCLUSIONS

Functional and communicative health literacies were positively associated with medication adherence, whereas critical health literacy was negatively associated with it. Each association was mediated by trust in physicians.

Association between person-centred care quality and advance care planning participation in haemodialysis

OBJECTIVE

Person-centred care (PCC), which incorporates patients' preferences and values for medical care and their life, has been proposed in decision-making for promoting advance care planning (ACP) among patients with kidney failure. Therefore, we aimed to examine variations in PCC across facilities and the association between PCC and ACP participation.

METHODS

This multicentre cross-sectional study included Japanese adults undergoing outpatient haemodialysis at six dialysis centres. The main exposure was PCC, measured using the 13-item Japanese version of the Primary Care Assessment Tool-short form. The main outcome was ACP participation as defined by discussion with the attending physician or written documentation or notes regarding treatment preferences. A general linear model was used to examine the covariates of the quality of PCC. Modified Poisson regression models were used to examine the associations of ACP participation.

RESULTS

A total of 453 individuals were analysed; 26.3% of them participated in ACP. Higher PCC was associated with greater ACP participation in a dose-response manner (adjusted prevalence ratios for the first to fourth quartiles: 1.36, 2.31, 2.64 and 3.10, respectively) in respondents with usual source of care (USC) than in those without USC. Among the PCC subdomains, first contact, longitudinality, comprehensiveness (services provided) and community orientation were particularly associated with ACP participation. A maximum of 12.0 points of facility variation was noted in the quality of PCC.

CONCLUSIONS

High quality of PCC was associated with ACP participation. The substantial disparity in PCC between facilities provides an opportunity to revisit the quality improvement in PCC.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A five-wheel wheelchair with an active-caster drive system

A novel wheelchair system with an active-caster drive mechanism is presented in this paper. A manual (hand propelled) wheelchair with an external single-wheel drive system forms a five-wheel configuration. The active-caster mechanism is applied to a drive system to motorize a manual wheelchair. Two electric motors which drive a wheel axis and a steering axis of a drive wheel independently are equipped on the active-caster. A coordinated control of the two motors enables the velocity vector on the steering shaft to direct in an arbitrary direction with an arbitrary magnitude. The generated velocity vector allows a wheelchair to go straight and/or rotate completely in a same way as a standard electric wheelchair. Namely 2DOF of the wheelchair can be controlled independently by a single drive wheel without any constraint, such as the orientation of the drive wheel which is well known as a non-holonomic constraint. In addition to the 2DOF mobility, the proposed system enables wheelchair users to change drive modes, a rear drive and a front drive. The drive wheel on the back side of the wheelchair is vertically actuated by a linear motor to change the height of the drive wheel that can vary load distribution and the number of wheels contacting to the ground. The five-wheel-contact makes the wheelchair to move as the normal mode in which the center of rotation is located at the midpoint of the main wheels. Depressing the drive wheel results in lost contacts of the main wheels from the ground in which the center of rotation is jumped at the midpoint of the front wheels, namely it performs as a front drive wheelchair. In this paper, kinematic models of the wheelchair and that with an active-caster drive system are analyzed and a control method by using a 2DOF joystick is derived. Based on the kinematic model, a prototype mechanism of the active-caster is designed and mounted on a manual wheelchair to realize the five-wheel wheelchair. In the experiments, the independent 2DOF motion can be achieved by the control of the active-caster in which the wheelchair shows successful translation, rotation and compound motions which include flip motions of the active-caster mechanism. Additionally, the two drive modes (front and rear) are tested by the prototype with a linear actuator.

Rapid inhibitory effect of tacrolimus on T cell migration by suppressing CD29-related functions

OBJECTIVE

To clarify the direct effect of Tacrolimus (FK506) on T cell function in relation to CD29.

METHODS

Human T cell line H9 and phytohemagglutinin (PHA)-activated T cells were incubated with or without Tacrolimus. The cells underwent cell migration assay by using fibronectin-coated trans-wells, and at the same time the degree of adherence by cultured cells to fibronectin-coated plastic wells was measured. For H9 cells, intracellular filamentous actin formation and the cell surface expression of CD3, CD11a, CD25, CD26, CD44, CD29 were measured by using flow cytometry. Intracellular tyrosin-phosphorylation induced by fibronectin by CD29 stimulation in H9 cells was analyzed by immunoblotting.

RESULTS

The ability of H9 cells and PHA-activated T cells incubated with Tacrolimus for 2 hours (hrs) to migrate and to adhere to fibronectin was significantly suppressed. However, the inhibiton was transient, because the ability of cells incubated with Tacrolimus for 24 hrs to migrate was not affected despite the suppression of cell replication. Tacrolimus showed slight but significant reduction of cell surface expression of CD29 within 4 hrs, but CD3, CD11a, CD25, CD26 and CD44 were not affected. Tacrolimus rapidly inhibited intracellular filamentous actin formation; the maximum inhibition was within 2 hrs and the effect was not observed at 6 hrs. Intracellular tyrosin-phosphorylation induced by CD29 stimulation was also inhibited by, Tacrolimus in H9 cells.

CONCLUSION

Tacrolimus appeared to have transient early phase inhibitory effects on CD29-related function that may be associated with T cell migration.

Ebastine inhibits T cell migration, production of Th2-type cytokines and proinflammatory cytokines

BACKGROUND

Cytokine imbalance and cellular migration to inflammatory sites are critical components of allergic diseases. Redirecting cytokine imbalance and inhibiting cell migration therefore represent important therapeutic strategies for the treatment of these disorders.

OBJECTIVES

To study the in vitro effect of ebastine, a novel non-sedating H1 receptor antagonist, on cytokine secretion and migration of activated T cells, as well as production of pro-inflammatory cytokines by macrophages.

METHODS

Peripheral T cells obtained from healthy volunteers were cultured in wells coated with the combination of anti-CD3 monoclonal antibody (mAb) and anti-CD26 mAb, anti-CD3 mAb and anti-CD28 mAb, or anti-CD3 mAb with PMA, in the presence or absence of ebastine. T cell proliferation and the production of cytokines were measured by [3H]thymidine incorporation assay and ELISA, respectively. In addition, transendothelial migration of T cells and production of pro-inflammatory cytokines by macrophages were examined.

RESULTS

Ebastine inhibited T cell proliferation and the production of IL-4, IL-5, IL-6, and TNF-alpha by T cells under each co-stimulatory condition tested, whereas it exhibited no effect on the production of IL-2 or IFN-gamma. In addition, T cell migration and the production of such pro-inflammatory cytokines as TNF-alpha and IL-6 by macrophages were inhibited by ebastine.

CONCLUSIONS

These results indicate that ebastine has a specific inhibitory effect on Th2-type cytokine production. Moreover, ebastine inhibited T cell migration and pro-inflammatory cytokine production by T cells and macrophages, suggesting that ebastine might be useful for the treatment of T cell-mediated allergic inflammatory disorders, including asthma, atopic dermatitis, and Th2-type autoimmune diseases.

Soluble CD26/dipeptidyl peptidase IV induces T cell proliferation through CD86 up-regulation on APCs

CD26 is a T cell costimulatory molecule with dipeptidyl peptidase IV enzyme activity in its extracellular region. We have previously reported that the addition of soluble CD26 (sCD26) resulted in enhanced proliferation of peripheral blood T lymphocytes induced by the recall Ag, tetanus toxoid (TT). However, the mechanism involved in this immune enhancement has not yet been elucidated. In this paper, we demonstrate that the enhancing effect of sCD26 on TT-induced T cell proliferation occurred in the early stages of immune response. The cells directly affected by exogenously added sCD26 are the CD14-positive monocytes in the peripheral blood. Mannose-6 phosphate interfered with the uptake of sCD26 into monocytes, suggesting that mannose-6 phosphate/insulin-like growth factor II receptor plays a role in the transportation of sCD26 into monocytes. When sCD26 was added after Ag presentation had taken place, enhancement in TT-induced T cell proliferation was not observed. In addition, enhancement of TT-mediated T cell proliferation by sCD26 does not result from trimming of the MHC-bound peptide on the surface of monocytes. Importantly, we also showed that exogenously added sCD26 up-regulated the expression of the costimulatory molecule CD86 on monocytes through its dipeptidyl peptidase IV activity, and that this increased expression of CD86 was observed at both protein and mRNA level. Therefore, our findings suggest that sCD26 enhances T cell immune response to recall Ag via its direct effect on APCs.

Intraosseous ganglion in the first metacarpal bone

Intraosseous ganglia occur most frequently in the long bones of the lower limbs, particularly in the medial malleolus of the tibia. They usually appear as radiographically well circumscribed juxta-articular cystic lesions, containing myxoid fibrous tissue histologically. Intraosseous ganglia in the hand are very rare. Most reported cases have involved the carpal bones, in particular the lunate and scaphoid. To our knowledge, the present case is the third report of an intraosseous ganglion appearing in the first metacarpal bone; it arose in a patient who had been on dialysis for 25 years, mimicking amyloidosis of bone.

All together now: when dissociations between knowledge and action disappear

Why do people sometimes seem to know things but fail to act appropriately on the basis of this knowledge? Such dissociations between knowledge and action often occur in infants and children, and in adults following brain damage. These dissociations have supported inferences about the organization of cognitive processes (e.g., separable knowledge and action systems) and their development (e.g., knowledge systems develop before action systems). The current study tested the basis for knowledge-action dissociations in a card-sorting task in which children typically correctly answer questions about sorting rules while sorting cards incorrectly. When questions and sorting measures were more closely equated for the amount of conflict that needed to be resolved for a correct response, children showed no systematic dissociation between knowledge and action. The results challenge standard interpretations of knowledge-action dissociations and support an alternative account based on graded knowledge representations.

Graded representations in behavioral dissociations

Why do people sometimes seem to know things when they are tested in one way, while seeming unaware of this information when tested in a different way? Such task-dependent behaviors, or dissociations, often occur in infants and children, and in adults following brain damage. To explain these dissociations, researchers have posited separable knowledge systems that are differentially tapped by various tasks, develop at different rates and can be selectively impaired. There is an alternative account in which knowledge is viewed as graded in nature. Certain tasks tap weaker representations, while other tasks require stronger representations, leading to dissociations in behavior. The graded representations approach addresses dissociations observed in perception, attention, memory, executive functioning and language, and has implications for the organization, development and impairment of our cognitive systems.

Visual representation in the wild: how rhesus monkeys parse objects

Visual object representation was studied in free-ranging rhesus monkeys. To facilitate comparison with humans, and to provide a new tool for neurophysiologists, we used a looking time procedure originally developed for studies of human infants. Monkeys' looking times were measured to displays with one or two distinct objects, separated or together, stationary or moving. Results indicate that rhesus monkeys used featural information to parse the displays into distinct objects, and they found events in which distinct objects moved together more novel or unnatural than events in which distinct objects moved separately. These findings show both commonalities and contrasts with those obtained from human infants. We discuss their implications for the development and neural mechanisms of higher-level vision.

Chemically modified ribozyme to V gene inhibits anti-DNA production and the formation of immune deposits caused by lupus lymphocytes

A variety of autoantibodies is responsible for the tissue injury in autoimmune diseases. We have demonstrated that the human anti-DNA Ab O-81, of which Ids are commonly detected in renal glomeruli of active lupus nephritis, uses the V3-7 gene. We tried to develop a new therapy for lupus nephritis by using chemically modified ribozymes to specifically inhibit the expression of the mRNA of Ig V gene. The transfection of hammerhead ribozyme or the addition of chemically modified ribozyme against the flanking region of V3-7 caused a potent and selective inhibition of anti-DNA production in V3-7-using B cell clones, but not in irrelevant V gene-using clones in vitro. Chemically modified ribozyme was long-acting and resistant to RNase, and nonspecific cytotoxicity of the ribozyme was negligible. To know the efficacy of the ribozyme in vivo, we used a model of immune complex nephritis in SCID mice in which 5 x 10(6) PBLs from patients with active lupus nephritis (lupus PBL) were transferred twice. The injection of lupus PBL in combination with chemically modified ribozyme to increase resistance to RNase significantly reduced anti-DNA Ab levels in blood and decreased levels of urinary protein in the immune deposit models. Immunofluorescence study also revealed a marked decrease in IgG deposits at renal glomeruli in the ribozyme-treated group. These results indicate an efficacy of chemically modified ribozyme therapy for autoantibody-mediated immune diseases.

Internalization of CD26 by mannose 6-phosphate/insulin-like growth factor II receptor contributes to T cell activation

CD26 is a T cell activation antigen known to bind adenosine deaminase and have dipeptidyl peptidase IV activity. Cross-linking of CD26 and CD3 with immobilized mAbs can deliver a costimulatory signal that contributes to T cell activation. Our earlier studies revealed that cross-linking of CD26 induces its internalization, the phosphorylation of a number of proteins involved in the signaling pathway, and subsequent T cell proliferation. Although these findings suggest the importance of internalization in the function of CD26, CD26 has only 6 aa residues in its cytoplasmic region with no known motif for endocytosis. In the present study, we have identified the mannose 6-phosphate/insulin-like growth factor II receptor (M6P/IGFIIR) as a binding protein for CD26 and that mannose 6-phosphate (M6P) residues in the carbohydrate moiety of CD26 are critical for this binding. Activation of peripheral blood T cells results in the mannose 6 phosphorylation of CD26. In addition, the cross-linking of CD26 with an anti-CD26 antibody induces not only capping and internalization of CD26 but also colocalization of CD26 with M6P/IGFIIR. Finally, both internalization of CD26 and the T cell proliferative response induced by CD26-mediated costimulation were inhibited by the addition of M6P, but not by glucose 6-phosphate or mannose 1-phosphate. These results indicate that internalization of CD26 after cross-linking is mediated in part by M6P/IGFIIR and that the interaction between mannose 6-phosphorylated CD26 and M6P/IGFIIR may play an important role in CD26-mediated T cell costimulatory signaling.

Novel in vitro effects of bucillamine: inhibitory effects on proinflammatory cytokine production and transendothelial migration of T cells

OBJECTIVE

To investigate the novel antiinflammatory mechanism of a disease-modifying antirheumatic drug, bucillamine, on activated T cells, specifically its effect on T cell proliferation, cytokine production, and migration of T cells.

METHODS

T cells were cultured in wells coated with anti-CD3 monoclonal antibodies (mAb) plus anti-CD26 mAb or anti-CD3 plus anti-CD28 mAb, with or without bucillamine. Proliferative responses and the production of interleukin-2 (IL-2), interferon-gamma (IFNgamma), tumor necrosis factor alpha (TNFalpha), IL-6, IL-4, and IL-5 were measured under these costimulatory conditions. Phytohemagglutinin (PHA)-activated T cells were cultured on human umbilical vein endothelial cell-coated transwells in the presence or absence of bucillamine, and T cells migrating through the endothelial cell layer were counted. Immunofluorescence analysis was also performed to analyze the effect of bucillamine on the surface expression of adhesion molecules on T cells.

RESULTS

Bucillamine (64 microM) significantly inhibited T cell proliferation and the production of IL-2, IFNgamma, TNFalpha, and IL-6, whereas it had no inhibitory effects on the production of IL-4 and IL-5 in the cultures with anti-CD3 plus anti-CD26 mAb. In contrast, bucillamine had no effects on T cell proliferation or any cytokine production in the cultures with anti-CD3 plus anti-CD28 mAb. Furthermore, the same concentration of bucillamine inhibited transendothelial migration of PHA-activated T cells, and reduced the expression level of CD44 on T cells.

CONCLUSION

This study demonstrated the novel effects of bucillamine in vitro, showing inhibition of type 1 T helper-type cytokine production and proinflammatory cytokine production induced by certain costimulatory conditions, and inhibition of transendothelial migration of T cells. The inhibition of T cell migration appeared to be mediated partly through the reduced expression of CD44, an adhesion molecule on the T cell surface.

[A case of far advanced breast cancer with distant metastases which had mostly disappeared after chemoendocrine therapy]

We report a case of far advanced breast cancer showing an excellent response to chemo-endocrine therapy. A 40-year-old female with a huge ulcerated tumor on her left anterior chest visited our hospital. Distant metastases were found in the lymph nodes, liver and bone. Therefore, endocrine therapy (toremifene and medroxyprogesterone acetate) and chemotherapy (cyclophosphamide, Therarubicin and 5-fluorouracil) were started as a combination treatment. As a result, the main tumor and metastatic lesion were remarkably reduced, and extended mastectomy with resection of right axillary lymph nodes was performed. Histologically, cancer cells in the primary lesion mostly disappeared, and only one lymph node in the left axillary lesion showed metastasis. No recurrence was found for 16 months after the surgical treatment. The combined therapy in the present case was extremely effective.

Detection of complement-fixing antiphospholipid antibodies in association with thrombosis

Antiphospholipid antibody (aPL) is a hallmark of antiphospholipid syndrome (APS), characterized by thrombosis and recurrent fetal loss. We developed a novel ELISA system to detect complement-fixing ability of anticardiolipin antibody (aCL), and evaluated its clinical usefulness through studying the prevalence of the antibodies in rheumatic diseases, especially in association with thrombosis and recurrent abortion. Among 189 patients with rheumatic diseases, the complement-fixing aCL was positive in 26 (83.9%) of 31 patients with APS and 2 (1.3%) of 158 with other disease categories, whereas it was not positive among 52 normal subjects. Twenty-seven of 28 patients (96.4%), who were positive for complement-fixing aCL, had the episodes or history of thrombosis and/or recurrent abortion, at the time we studied. The remaining one in this group developed APS manifesting pulmonary infarction and occlusion of mesenteric artery 6 months after the evaluation. The sensitivity and specificity of this assay system were 75.0% and 99.3%, respectively, in relation with thrombotic episodes. On the other hand, the IgG aCL were positive in 28 (77.8%) of 36 cases with recent thrombotic episodes and 24 (15.7%) of 153 cases with no recent thrombotic episodes. The sensitivity and specificity of IgG aCL assay system were 77.8% and 84.3%, respectively, in relation with thrombotic episodes. These results indicate that complement-fixing aCL may specifically occur in association with the episodes of thrombosis and/or recurrent abortion in patients with APS compared to IgG-aCL. The method for detecting the complement-fixing aCL is simple, and it provides the useful diagnostic marker for thrombotic manifestations associated with APS.

Role of GABAA and GABAC receptors in the biphasic GABA responses in neurons of the rat major pelvic ganglia

The role of gamma-aminobutyric acid-A (GABAA) and GABAC receptors in the GABA-induced biphasic response in neurons of the rat major pelvic ganglia (MPG) were examined in vitro. Application of GABA (100 microM) to MPG neurons produced a biphasic response, an initial depolarization (GABAd) followed by a hyperpolarization (GABAh). The input resistance of the MPG neurons was decreased during the GABAd, whereas it was increased during the GABAh. The GABAd could be further separated into the early component (early GABAd) with a duration of 27 +/- 5 s (mean +/- SE; n = 11) and the late component (late GABAd) with a duration of 109 +/- 11 s (n = 11). The duration of the GABAh was 516 +/- 64 s (n = 11). The effects of GABA (5-500 microM) in producing the depolarization and the hyperpolarization were concentration-dependent. GABA (5-30 microM) induced only late depolarizations. The early component of the depolarization appeared when the concentration of GABA was >50 microM. Muscimol produced only early depolarizing responses. Baclofen (100 microM) had no effect on the membrane potential and input resistance of MPG neurons. Bicuculline (60 microM) blocked the early GABAd but not the late GABAd and the GABAh. Application of picrotoxin (100 microM) with bicuculline (60 microM) blocked both the late GABAd and the GABAh. CGP55845A (3 microM), a selective GABAB receptor antagonist, did not affect the GABA-induced responses. cis-4-Aminocrotonic acid (CACA, 1 mM) and trans-4-aminocrotonic acid (TACA, 1 mM), selective GABAC receptor agonists, produced late biphasic responses in the MPG neurons. The duration of the CACA responses was almost the same as those of the late GABAd and GABAh obtained in the presence of bicuculline. Imidazole-4-acetic acid (I4AA, 100 microM), a GABAC receptor antagonist, depressed the late GABAd and the GABAh but not the early GABAd. I4AA (100 microM) and picrotoxin (100 microM) also suppressed the biphasic response to CACA. The early GABAd and the late GABAd were reversed in polarity at -32 +/- 3 mV (n = 7) and -38 +/- 2 mV (n = 4), respectively, in the Krebs solution. The reversal potential of the GABAh was -34 +/- 2 mV (n = 4) in the Krebs solution. The reversal potentials of the late GABAd and the GABAh shifted to -20 +/- 3 mV (n = 5) and -22 +/- 3 mV (n = 5), respectively, in 85 mM Cl- solution. These results indicate that the late GABA(d) and the GABAh are mediated predominantly by bicuculline-insensitive, picrotoxin-sensitive GABA receptors, GABAC (or GABAAOr) receptors, in neurons of the rat MPG.

Specific inhibition of TH2-type cytokine production from human peripheral T cells by terfenadine in vitro

BACKGROUND

Cytokine imbalance is thought to be one of the causes for allergic diseases. The effect of anti-allergic drugs on cytokine production from T cells should be examined in a convenient way.

OBJECTIVES

To study the in vitro effect of terfenadine, a prototype non-sedating H1 receptor antagonist, on cytokine production from activated T cells.

METHODS

T cells were cultured in the presence of terfenadine on anti-CD3 mAb and anti-CD26 mAb-coated wells, anti-CD3 mAb and anti-CD28 mAb-coated wells, and anti-CD3 mAb wells with PMA. T-cell proliferation, along with the concentrations of interleukin (IL) -2, interferon (IFN) -gamma, IL-4, and IL-5 were measured.

RESULTS

Terfenadine inhibited T-cell proliferation and IL-4 and IL-5 production under each costimulatory condition tested, whereas it had no effect on IL-2 and IFN-gamma production.

CONCLUSIONS

These results indicate that terfenadine has a specific inhibitory effect on TH2-type cytokine production induced by several ways of costimulatory activation.

Decreased dipeptidyl peptidase IV enzyme activity of plasma soluble CD26 and its inverse correlation with HIV-1 RNA in HIV-1 infected individuals

Human plasma contains soluble CD26/dipeptidyl peptidase IV (sCD26/DPPIV) although its physiological significance remains unclear. To determine whether the plasma sCD26 levels have clinical relevance in HIV-1 infected individuals, the concentration and DPPIV enzyme activity of plasma sCD26 were measured. While there is no significant difference between the plasma levels of sCD26 in 90 HIV-1 infected individuals and in 79 uninfected controls, specific DPPIV enzyme activity of sCD26 was significantly decreased HIV-1 infected individuals (P < 0.0001). Specific DPPIV enzyme activity was correlated with the levels of CD4+ T cells (r = 0.247; P < 0.02), CD8+ T cells (r = 0.236; P < 0.03), and adenosine deaminase (r = 0.227; P < 0.05) and had an inverse correlation with HIV-1 RNA (Spearman's r = 0.474; P = 0.0012). Furthermore, recombinant sCD26 enhanced the in vitro PPD-induced response of lymphocytes from HIV-1 infected individuals with decreased specific DPPIV enzyme activity. These results suggest that the specific DPPIV enzyme activity of plasma sCD26 may contribute to the immunopathogenesis of HIV infection.

CD26/dipeptidyl peptidase IV differentially regulates the chemotaxis of T cells and monocytes toward RANTES: possible mechanism for the switch from innate to acquired immune response

CD26, a 110 kDa cell surface glycoprotein, exhibits dipeptidyl peptidase IV (DPPIV; EC 3.4.14.5) enzyme activity and plays an important role in T cell co-stimulation. In the present study, the function of CD26/DPPIV in transendothelial migration was examined using beta-chemokines as chemoattractants. When soluble recombinant CD26 (sCD26/DPPIV+) was added to the transendothelial chemotaxis system, chemotactic migration of T cells toward RANTES was significantly enhanced. Addition of sCD26 to 50 ng/ml of RANTES enhanced the migratory response by a factor of two compared to RANTES alone, whereas mutant soluble CD26 (mCD26), lacking the DPPIV enzyme activity, had no enhancing effect on RANTES-induced T cell migration. In the process of analyzing the mechanisms of the enhancement of T cell migration by sCD26, we showed that RANTES was cleaved by sCD26 under physiologic conditions at the precise site characteristic of its enzyme specificity. However, synthesized RANTES which lacks two N-terminal amino acids showed a chemotactic activity equivalent to full-length RANTES on T cells. Furthermore, addition of sCD26 showed enhancement of T cell migration induced by both forms of RANTES. In contrast to T cells, the truncated RANTES is inactive in chemotaxis of purified monocytes and supplement of sCD26 but not mCD26 reduced the migratory response of monocytes to RANTES. These results suggest that CD26/DPPIV differentially regulate the chemotactic response of T cells and monocytes to RANTES.

GABAC receptors mediate slow membrane potentials in neurons of the rat major pelvic ganglia

Effects of gamma-aminobutyric acid (GABA) on the neuronal membrane of the rat major pelvic ganglia (MPG) were studied using intracellular recording techniques, in vitro. Application of GABA (100 microM) to MPG neurons induced a depolarization (GABAd) associated with a decreased membrane input resistance and a slow hyperpolarization (s-GABAh) associated with an increased membrane input resistance. The GABA depolarization had two phases, a fast depolarization (f-GABAd) and a subsequent slow depolarization (s-GABAd). Bicuculline (60 microM) blocked the f-GABAd but not the s-GABAd and s-GABAh. Picrotoxin (100 microM) blocked all the GABA responses. Imidazole-4-acetic acid (I4AA, 100 microM), a GABAc receptor antagonist, depressed the s-GABAd and s-GABAh, but did not block the f-GABAd. Cis-4-aminocrotonic acid (CACA), a GABAc receptor agonist, produced a depolarization followed by a hyperpolarization in MPG neurons. I4AA (100 microM) depressed the CACA-induced responses. It was concluded that GABAA receptors mediate the f-GABAd and that GABAc receptors mediate the s-GABAd and s-GABAh, in neurons of the rat MPG.

Negative regulation of the anti-human immunodeficiency virus and chemotactic activity of human stromal cell-derived factor 1alpha by CD26/dipeptidyl peptidase IV

Stromal cell-derived factor 1alpha (SDF-1alpha) is a chemokine that has been shown to prevent infection of T-tropic HIV strains and is a possible substrate of CD26/dipeptidyl peptidase IV (DPPIV). In this study, we show that SDF-1alpha was cleaved at the N-terminal region by CD26/DPPIV and as a result the inhibitory activity of SDF-1alpha against HIV infection disappeared. Moreover, the chemotactic activity of SDF-1alpha also disappeared specifically by DPPIV activity of recombinant soluble CD26. These results suggested that dissemination of T-tropic HIV strains in vivo may be facilitated by CD26/DPPIV via inactivation of functional SDF-1alpha.

Human parvovirus B19 as a causative agent for rheumatoid arthritis

Human parvovirus B19 (B19) DNA was detected in the synovial tissues in 30 of 39 patients with rheumatoid arthritis (RA), and infrequently in those with osteoarthritis and traumatic joints. On the other hand, the expression of the B19 antigen VP-1 was specific (27/27) in RA synovium with active synovial lesions, but not in osteoarthritis and controls. The target cells of B19 were macrophages, follicular dendritic cells, T cells, and B cells, but not synovial lining cells in the synovium. B19-negative bone marrow cells, tonsil cells, and macrophage cell line U-937 cells became positive for the expression of VP-1, and more productive for interleukin 6 and tumor necrosis factor alpha when cocultured with RA synovial cells. The expression of VP-1 and the production of interleukin 6 and tumor necrosis factor alpha was significantly inhibited by the addition of neutralizing antibody for B19, suggesting that B19 detected in RA synovial cells is infective. B19 is involved in the initiation and perpetuation of RA synovitis, leading to joint lesions.

Somatic mutation in autoantibody-associated VH genes of circulating IgM+IgD+ B cells

Naive B cells expressing IgM and IgD on their surface have no or little somatic mutations in V genes. We have demonstrated that the human IgM+IgD+B cell clone (0-81), which expresses nephritogenic idiotypes, produces IgM anti-DNA antibodies which show monospecificity to DNA. Using a DNA probe which specifically links to the VH gene of antibody 0-81, we identified the counterpart germ-line V gene of 0-81, V3-7, which appears to be used by pathogenic autoantibodies in humans. Clone 0-81, which may belong to naive B cells in terms of cell phenotype, uses a somatically mutated V3-7 gene. We further studied DNA sequences of V3-7 genes in circulating IgM+IgD+B cells from normal subjects and patients with systemic lupus erythematosus (SLE). The results revealed that rearranged V3-7 genes in IgM+IgD+B cells from patients with SLE contained somatically mutated sequences at significantly increased frequencies. These data indicate an abnormal maturation of B cells in autoimmune states that may be associated with an escape of self-reactive B cells from the elimination process in the germinal center.

Laparoscopic mesh repair of a reducible obturator hernia using an extraperitoneal approach

We present a case of an 84-year-old woman with nonstrangulated, reducible obturator hernia treated with laparoscopic total extraperitoneal prosthetic hernia repair. Preoperative diagnosis was made based on the clinical findings. The patient's postoperative recovery has been uneventful, without complications. When a nonstrangulated obturator hernia is diagnosed preoperatively, this procedure is likely to be successful.

Determination of adenosine deaminase binding domain on CD26 and its immunoregulatory effect on T cell activation

CD26, a 110-kDa cell surface glycoprotein, exhibits dipeptidyl peptidase IV enzyme activity and plays an important role in T cell costimulation. In the present study, we examined both the exact adenosine deaminase (ADA) binding domain on CD26 and the functional consequences of mutated CD26 transfectants that were deficient for cell surface ADA. Using CD26 deletion, human-rat swap, and point mutations, we found that the residues of L340, V341, A342, and R343 on the CD26 molecule were essential amino acids for ADA binding. When these amino acids were mutated and transfected into Jurkat cells, the resultant CD26 transfectants expressed only CD26, not ADA, on the cell surface. The amount of IL-2 produced by wild-type and mutated CD26 transfectants was almost the same following stimulation with anti-CD3 plus PMA. However, the mutated CD26 transfectants were much more sensitive to the inhibitory effect of adenosine on IL-2 production than were the wild CD26 transfectants. These data suggest that ADA on the cell surface does not directly involve T cell activation. Conversely, CD26 alone does not result in modulating the inhibitory effect of adenosine. Only the ADA bound to CD26 on the cell surface was functional and could counteract the inhibitory effect of elevated extracellular adenosine.

Determination of adenosine deaminase binding domain on CD26 and its immunoregulatory effect on T cell activation

CD26, a 110-kDa cell surface glycoprotein, exhibits dipeptidyl peptidase IV enzyme activity and plays an important role in T cell costimulation. In the present study, we examined both the exact adenosine deaminase (ADA) binding domain on CD26 and the functional consequences of mutated CD26 transfectants that were deficient for cell surface ADA. Using CD26 deletion, human-rat swap, and point mutations, we found that the residues of L340, V341, A342, and R343 on the CD26 molecule were essential amino acids for ADA binding. When these amino acids were mutated and transfected into Jurkat cells, the resultant CD26 transfectants expressed only CD26, not ADA, on the cell surface. The amount of IL-2 produced by wild-type and mutated CD26 transfectants was almost the same following stimulation with anti-CD3 plus PMA. However, the mutated CD26 transfectants were much more sensitive to the inhibitory effect of adenosine on IL-2 production than were the wild CD26 transfectants. These data suggest that ADA on the cell surface does not directly involve T cell activation. Conversely, CD26 alone does not result in modulating the inhibitory effect of adenosine. Only the ADA bound to CD26 on the cell surface was functional and could counteract the inhibitory effect of elevated extracellular adenosine.

Rethinking infant knowledge: toward an adaptive process account of successes and failures in object permanence tasks

Infants seem sensitive to hidden objects in habituation tasks at 3.5 months but fail to retrieve hidden objects until 8 months. The authors first consider principle-based accounts of these successes and failures, in which early successes imply knowledge of principles and failures are attributed to ancillary deficits. One account is that infants younger than 8 months have the object permanence principle but lack means-ends abilities. To test this, 7-month-olds were trained on means-ends behaviors and were tested on retrieval of visible and occluded toys. Means-ends demands were the same, yet infants made more toy-guided retrievals in the visible case. The authors offer an adaptive process account in which knowledge is graded and embedded in specific behavioral processes. Simulation models that learn gradually to represent occluded objects show how this approach can account for success and failure in object permanence tasks without assuming principles and ancillary deficits.

Rethinking infant knowledge: toward an adaptive process account of successes and failures in object permanence tasks

Infants seem sensitive to hidden objects in habituation tasks at 3.5 months but fail to retrieve hidden objects until 8 months. The authors first consider principle-based accounts of these successes and failures, in which early successes imply knowledge of principles and failures are attributed to ancillary deficits. One account is that infants younger than 8 months have the object permanence principle but lack means-ends abilities. To test this, 7-month-olds were trained on means-ends behaviors and were tested on retrieval of visible and occluded toys. Means-ends demands were the same, yet infants made more toy-guided retrievals in the visible case. The authors offer an adaptive process account in which knowledge is graded and embedded in specific behavioral processes. Simulation models that learn gradually to represent occluded objects show how this approach can account for success and failure in object permanence tasks without assuming principles and ancillary deficits.

Preoperative diagnosis of strangulated obturator hernia using ultrasonography

BACKGROUND

Obturator hernia is rarely recognized before surgical intervention, since it is relatively infrequent and its definitive diagnosis is difficult. To change this situation, we introduced ultrasound examination in 1993 for differential diagnosis of strangulated obturator hernia among patients with bowel obstruction of unknown cause.

PATIENTS AND METHODS

Between 1993 and 1995, we encountered 15 patients with suspected obturator hernia based on the presence of bowel obstruction of unknown cause and so-called predisposing factors. These patients underwent ultrasound examinations.

RESULTS

The 4 patients with bowel obstruction caused by strangulated obturator hernia were all correctly diagnosed preoperatively by ultrasonography and were successfully cured by surgery. The time required for diagnosis was shorter than reported previously (average 16.5 h).

CONCLUSIONS

Ultrasonography is useful and reliable for the diagnosis of strangulated obturator hernia and can decrease the morbidity and mortality associated with delayed diagnosis.

[V gene repertoire and pathogenic autoantibodies]

The studies for autoantibody-associated V genes have failed to find any V gene which might be specific for pathogenic autoantibodies in humans; Namely, both normal subjects and patients have immunoglobulin V genes which can encode autoantibodies. Also single V gene can encode antibodies for both foreign antigens and autoantigens. However, some germline V genes such as V3-7 and VH4-21 are preferentially used for autoantibodies and may be regarded as prototype V genes for autoantibodies. Although somatic mutation in V genes is characteristic in IgG autoantibodies, 0-81 idiotype-positive IgM antibodies, which may be precursor B cells for pathogenic anti-DNA antibody also included many somatic mutations in VH genes, indicating an intrinsic abnormality in B cell development in SLE. Some studies also indicated an abnormal V gene repertoire in autoimmune states. These results may be attributed to dysregulation of autoantibody-associated B cell development.

Different regulatory effects of pentoxifylline on human T cell activation pathways

Pentoxifylline (PTX), a methylxanthine derivative, was examined for its effects on T cell proliferation and cytokine production stimulated by cross-linking anti-CD3 alone, anti-CD3 with PMA, anti-CD3 with anti-CD26, or anti-CD3 with anti-CD28 mAb, respectively. PTX at a 3.5 x 10(-5) M concentration significantly inhibited T cell proliferation and the production of tumor necrosis factor-alpha, interleukin-2, and interleukin-4. Moreover, this effect was selective for stimulation by cross-linking anti-CD3 with PMA, or anti-CD3 with anti-CD26, but not by cross-linking anti-CD3 with anti-CD28. These results suggest that the inhibitory effect of PTX on T cell activation involves the CD3 and CD26, but not the CD28 signal pathway.

Multiple transcripts for rat nucleoside diphosphate kinase alpha isoform are structurally categorized into two groups that exhibit cell-specific expression and distinct translation potential

Rat nucleoside diphosphate (NDP) kinase is composed of two isoforms (alpha and beta) encoded by independent genes. The mRNAs are expressed ubiquitously; however, the level of expression is tissue-dependent and is also up- or down-regulated under certain conditions, including growth stimulation, differentiation, and tumor metastasis. To address the regulatory mechanisms of gene expression for the rat NDP kinase major isoform alpha (an nm23-H2/PuF homologue), we identified the transcription initiation sites in detail by RNase protection and 5'-rapid amplification of DNA ends and located the core promoter region by chloramphenicol acetyltransferase assay. The transcripts, initiated from an extraordinarily wide range of sites, were categorized into two groups; one transcribed from an upstream region was spliced in the untranslated region (group 1), whereas the other initiated in the downstream region was not (group 2). RNase protection demonstrated that the group 1 mRNA was the dominant form present in all tissues except heart and skeletal muscle. In situ hybridization revealed cell-specific expression of these mRNA species. Furthermore, they differed in the translational efficiency (the group 2 alpha > beta > the group 1 alpha). These findings suggest that the regulation of the NDP kinase expression at both transcriptional and posttranscriptional steps could be fundamentally governed by the selection of transcription initiation sites.

[Cell adhesion molecules on lymphocytes and their role on signal transduction]

It has been shown that cell adhesion molecules, which mediate lymphocyte adhesion have an ability to provide costimulation signals in the cells. One of the representative adhesion molecules on T lymphocytes, b1 integrin is comprised by several subunits sharing a common b1 subunits, CD29, which is defined by monoclonal anti-4B4 antibody. We have demonstrated that b1 integrins function as a cell surface receptor for extracellular matrix (ECM) protein, such as collagen and fibronectin. We also found that fibronectin, ligand of b1 integrin, synergized with anti-CD3 antibody to promote proliferation of CD4 T cell in a serum free culture system, and also induced an independent signal which would be distinct from the CD3/TcR-mediated signal pathway of activation through the induction of an AP-1 transcription factor. Recent studies revealed that there is an accumulation of CD4+CD29+ T cells, memory T cells as well as prominent increase of a variety of inflammatory cytokines in the synovial fluid of patients with rheumatoid arthritis (RA). This suggests that b1 integrins may play an important role for the inflammatory mechanism in RA. Regulation of signal transduction mediated by adhesion molecules on lymphocytes may be the possible effective way for controlling the pathological inflammatory process in RA.

Laparoscopic closure for perforation of the sigmoid colon by endoscopic linear stapler

Immediate open surgery has been recommended for the management of perforation during colonoscopic examination. Laparoscopic closure for perforation of the sigmoid colon caused by diagnostic colonoscopy is described. The perforation site was identified in the antimesenteric border of the sigmoid colon by laparoscopic survey, and four ports were inserted in the lower abdomen. The margin of the perforation was lifted by two graspers, and the defect was completely closed using an endoscopic linear stapler. The patient recovered quickly without any associated complications. Postoperative barium enema showed no stenosis or leakage. This method is less invasive and allows earlier recovery of patients with colonic perforation.

[Laparoscopic colo-rectal surgery]

Laparoscopic colorectal surgery was less invasive for patients although it was difficult to perform complete resection of colon combined with regional lymph node. The skillful manner of the laparoscopic surgery was required for the surgical team. The laparoscopic equipments, in order to perform curative dissection of mesenterium and intermediate lymph node, such as Ultrasonic-aspiration surgical unit (USU) or Harmonic scalpel laparoscopic coagulation shears (LCS), were useful for safer dissection of D2 regional lymph node. Meticulous manner of grasping forceps and special dissectors was made sufficient lymph node dissection. The reconstruction of extracorporeal anastomotic technique by hand or valtrac (biofragmentable anastomosis ring) were safer manner for anastomosis after resection of the right side colon. Reconstruction by double stapling technique of linear stapler and circular stapler was admired for anastomosis for left side colonic and rectal surgery. We had safely performed locar resection in 3, partial resection with Do dissection in 2, with D1 dissection in 14, with D2 dissection in 21 and right and left hemicolectomy in 1 each.

A case of pulmonary arteriovenous malformation in a patient with brain abscess successfully treated with video-assisted thoracoscopic resection

A 45-year-old women was admitted to the hospital with a brain abscess due to asymptomatic pulmonary arteriovenous malformation (PAVM). The brain abscess was removed by craniotomy and excision following antibiotic therapy. The stapled wedge excision of the lung with the PAVM was successful under video-assisted thoracoscopic surgery.

Effects of peritoneal insufflation on hepatic and renal blood flow

The effects of peritoneal insufflation with carbon dioxide on hepatic and renal blood flow have not been reported hitherto. We evaluated these effects in a porcine model of abdominal laparoscopic surgery. Seven anesthetized pigs underwent peritoneal insufflation in a step-wise manner to create intraabdominal pressures of 6, 12, 18 and 24 mmHg, and changes in the arterial and venous pressure, arterial blood gases, and hepatic and renal blood flow were monitored. Both the hepatic and renal blood flow decreased as the intraabdominal pressure increased. Therefore, in order to carry out laparoscopic abdominal surgery safely in patients with hepatic or renal impairment, low intraabdominal pressures or noninsufflating techniques are recommended.

Changes in the cardiovascular and respiratory systems during laparoscopic cholecystectomy

The effects of peritoneal insufflation on the cardiovascular and respiratory systems were investigated in eight patients who underwent laparoscopic cholecystectomy. During the operation, intraabdominal pressure was maintained at a constant 12 mm Hg with carbon dioxide. The cardiac index had increased significantly at 20 and 40 min after the start of insufflation (3.6 +/- 0.6, 3.9 +/- 0.8 mL/min, respectively) and after evacuation (4.2 +/- 0.6 mL/min) compared with the control value (3.2 +/- 0.6 mL/min). Mean arterial pressure was significantly increased at 20 min after the start of insufflation (94.6 +/- 11.2 mm Hg) relative to the control value (79.9 +/- 11.1 mm Hg) and remained high after evacuation (101.5 +/- 11.9 mm Hg). Central and femoral venous pressure rose significantly during the operation from baseline values (12 +/- 6 and 4 +/- 4 mm Hg, respectively) to 18 +/- 10 and 11 +/- 6 mm Hg, respectively, at 20 min, and to 18 +/- 10 and 19 +/- 8 mm Hg, respectively, at 40 min after the start of insufflation. These parameters returned to control levels immediately after evacuation. Dynamic lung compliance decreased by 25% as a result of the elevated intraabdominal pressure. These findings demonstrate that some cardiopulmonary changes occur even at an intraabdominal pressure of 12 mm Hg, which up to now has been considered a safe level.