Involvement of brown adipose tissue in subcutaneous fat necrosis of the newborn

BACKGROUND

Subcutaneous fat necrosis (SCFN) of the newborn is a rare condition that manifests within days after birth. The interscapular region, axillae and shoulders are the most commonly affected sites, corresponding to anatomic sites of brown adipose tissue (BAT) in newborns.

OBJECTIVE

We postulated a specific involvement of BAT in SCFN and searched for brown adipocytes at affected sites.

METHODS

Biopsy specimens were immunostained with antibodies against uncoupling protein 1 (UCP-1) and examined by electron microscopy. We also examined BAT by (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography and computed tomography (PET-CT) scanning.

RESULTS

A few cells in biopsy specimens from two patients bound antibodies against UCP-1, and brown adipocytes were detected at several stages of degeneration. PET-CT scans revealed lower uptake of (18)F-FDG at major sites of SCFN.

CONCLUSION

SCFN and BAT can be found at the same sites, suggesting a pathophysiological connection.

Heat shock protein 47 (HSP47) antisense oligonucleotides reduce cardiac remodeling and improve cardiac function in a rat model of myocardial infarction

BACKGROUND

Cardiac remodeling after acute myocardial infarction is regulated by components of the extracellular matrix. The 47 kD heat shock protein 47 (HSP47) is a collagen-specific molecular chaperone that plays a major role during procollagen processing and/or secretion.

OBJECTIVE

The purpose of the study was to determine whether HSP47 inhibition can mitigate ligated left anterior descending (LAD) coronary artery-induced myocardial infarction in rats.

METHODS

Rats were randomly divided into four experimental groups and subjected to the following treatments: 1) intravenous (IV) administration of saline; 2) ligation of the LAD coronary artery; 3) ligation of the LAD coronary artery + IV administration of HSP47 antisense oligonucleotides; or 4) IV administration of HSP47 antisense oligonucleotides. We investigated cardiac histopathology, performed immunoblot and immunohistochemical analyses, and examined cardiac function.

RESULTS

Rats with ligated LAD coronary artery experienced upregulation of HSP47 expression, remodeling of the left ventricle, and cardiac dysfunction. In contrast, rats with ligated LAD coronary artery treated with HSP47 antisense oligonucleotides had significantly reduced HSP47 expression, cardiac remodeling, and improved cardiac function. Intravenous (IV) administration of HSP47 antisense oligonucleotides alone had no effect on cardiac morphology.

CONCLUSION

The data strongly support the idea that changes in the extracellular matrix and its components are important determinants of cardiac remodeling after myocardial infarction.

Neutrophil elastase inhibitor (sivelestat) reduces the levels of inflammatory mediators by inhibiting NF-kB

OBJECTIVE

Sivelestat sodium hydrate (sivelestat) is a specific synthetic inhibitor of neutrophil elastase (NE). Various studies suggest that sivelestat treatment reduces inflammation. In this study, we tested the hypothesis that sivelestat acts as an inhibitor of inflammatory mediators and prevents nuclear factor-kB (NF-kB) activation.

METHODS

In the presence and absence of sivelestat, the mouse macrophage cell line RAW 264.7 was stimulated with lipopolysaccharide (LPS) and the levels of inflammatory mediators (TNF-alpha, IL-6 and high mobility group box 1 (HMGB1)) and nitrite in the cell supernatant were measured, along with inducible nitric oxide synthase (iNOS) expression.

RESULTS

While LPS administration increased the secretion of inflammatory mediators and nitric oxide (NO), sivelestat decreased the secretion of these mediators. Cell signaling studies demonstrated that sivelestat decreased NF-kB activation by inhibiting IkB phosphorylation.

CONCLUSION

Sivelestat may inhibit the various inflammatory mediators through NF-kB inhibition.

Comparison of effects of total enteral versus total parenteral nutrition on ischemia/reperfusion-induced heart injury in rats

BACKGROUND

The long-term effect of nutrition on cardiac function remains to be elucidated. One possible link is the newly discovered gastric hormone ghrelin, which has been reported to be cardioprotective.

AIM

The present study examined whether total enteral nutrition (TEN) and total parenteral nutrition (TPN) differ in their modulation of ghrelin production and their effects on cardiac function after ischemia/reperfusion injury.

METHODS

Rats received isocaloric parenteral or enteral nutrition through implanted vascular catheters or gastrostomy tubes. TEN was administered in a conventional (TEN-C) or immunonutrition (TEN-I) form. After 7 days, serum ghrelin levels were determined by enzyme-linked immunosorbent assays and myocardial function was assessed using the Langendorff isolated heart technique.

RESULTS

TEN-I animals had significantly higher plasma ghrelin levels than the other groups. After ischemia/reperfusion injury, left ventricular developed pressure decreased in animals receiving TPN when compared to animals receiving TEN-I. Animals receiving TPN also had significant reductions in their maximal rates of increase and decrease in left ventricular pressure when compared to animals receiving TEN-I (unpaired t test, p < 0.05).

CONCLUSION

TEN-I increases serum levels of ghrelin, which protects cardiac function after ischemic/reperfusion injury. Because TEN-I more effectively protects cardiac function, we recommend it for long-term nutritional support.

Changes in cell culture temperature alter release of inflammatory mediators in murine macrophagic RAW264.7 cells

OBJECTIVES

To examine whether moderate changes in cell culture temperature influence the production of various cytokines and associated mediators of inflammation.

METHODS

We performed lipopolysaccharide (LPS) stimulation of the murine macrophagic RAW264.7 cell line under hyperthermic (40 degrees C), normothermic (37 degrees C) and hypothermic (34 degrees C) conditions. We then measured the levels of heat shock protein 70 (HSP70), heat shock factor protein (HSF) and nuclear factor-kB (NF-kB) dimers (p50 and p65) in the cells, and the levels of high mobility group box 1 (HMGB1) and the cytokines tumor necrosis factor-alpha (TNF-alpha), interleukin 1beta (IL-1beta) and interleukin 6 (IL-6) in the culture supernatants.

RESULTS

Levels of HMGB1, IL-1beta, IL-6, and TNF-alpha, as well as NF-kB dimers (p50 and p65), were all reduced following LPS stimulation at 40 degrees C and 34 degrees C compared with those at 37 degrees C. Levels of HSP70 and HSF increased at 40 degrees C and 34 degrees C.

CONCLUSIONS

The application of moderate hyperthermia and hypothermia after LPS-induced cell activation attenuated the inflammatory response and reduced the likelihood of cell damage. These findings suggest that moderate temperature changes modulate the inflammatory response and could be a useful therapy against sepsis.

Olprinone improves diaphragmatic contractility and fatigability during abdominal sepsis in a rat model

BACKGROUND

Respiratory failure with diaphragmatic fatigability is common in patients suffering sepsis or septic shock. However, the development and progress of diaphragmatic fatigability remains poorly understood, and no method has been established to treat fatigability. In this study, we hypothesize that neutrophil activation contributes to the development of diaphragmatic fatigability. We also sought to investigate whether a phosphodiesterase inhibitor, olprinone, improves diaphragmatic fatigability associated with abdominal sepsis and inhibits an increase in myeloperoxidase activity in diaphragmatic muscle.

METHODS

Male Wistar rats were randomly assigned to a sham group, coecal legation perforation group (CLP), and a phosphodiesterase inhibitor (PDE) pretreated group. At 16 h after surgical procedure, the left hemidiaphragm was removed for the measurement of diaphragmatic contractility and fatigability. In addition, for the measurement of serial changes in myeloperoxidase activity, the right hemidiaphragm was also removed at 4, 8 or 16 h after the surgical procedure in each group.

RESULTS

In a septic model involving rats, we observed that diaphragmatic muscles were fatigable and myeloperoxidase activity increased. We also demonstrated that intraperitoneal administration of olprinone improves diaphragmatic fatigability and inhibits an increase in myeloperoxidase activity induced by abdominal sepsis.

CONCLUSION

Olprinone represents a potential therapy for cases of respiratory failure with diaphragmatic fatigability resulting from inhibition of neutrophil activation.

Association between minor physical anomalies and lateral ventricular enlargement in childhood and adolescent onset schizophrenia

OBJECTIVE

The primary purpose of this study was to investigate the association between morphological abnormalities of brain and minor physical anomalies (MPAs) in childhood and adolescent onset schizophrenia.

METHOD

Twenty-seven patients who had been diagnosed with schizophrenia according to DSM-IV criteria before 18 years of age were included in the study. MPAs were evaluated with the modified version of Waldrop scale (WS) by Green et al. Morphological abnormalities of brain was evaluated with ventricular-brain ratio (VBR) by using cerebral magnetic resonance imaging (MRI) examination.

RESULTS

A significant positive correlation was observed between WS scores and VBRs.

CONCLUSION

This result indicates a relationship between MPAs and lateral ventricular enlargement, and supports neurodevelopmental etiology in childhood or adolescent onset schizophrenia.

Analgesic effects of flecainide on postherpetic neuralgia

Sodium channel blockers have been reported to be effective in relieving neuropathic pain. However, although intravenous lidocaine has proved to be effective, in some patients oral mexiletine fails to produce adequate pain relief. In this study, we investigated the analgesic effect of flecainide, a long-lasting antitachyarrhythmic drug, on postherpetic neuralgia. Twenty patients with postherpetic neuralgia received an intravenous infusion of flecainide and 15 (75%) of those who achieved pain relief subsequently received oral flecainide. The patients were assessed using a 100 mm visual analog scale 1 month after treatment. Significant improvement compared with the pretreatment reading was found. This study suggests that the action of flecainide in blocking the sodium channel is potent and long-lasting and that, like the intravenous formulation, the oral formulation has a stable analgesic effect on postherpetic neuralgia.

Tetra-butyl ammonium attenuates evoked release of acetylcholine from mouse hemidiaphragm preparation

Tetra-butyl ammonium is a homologous member of mono-quaternary ammonium salts, and it has been reported to have a property of nondepolarizing neuromuscular relaxant. However, no neurochemical evidences exist that tetra-butyl ammonium may interfere with quantal release of acetylcholine from motor nerve terminals. In this study, using the neurochemical method, we investigated the effect of tetra-butyl ammonium on stimulation-evoked release of acetylcholine from mouse hemidiaphragm preparation. The preparation was loaded with [3H]choline (5 microCi/ml). Low concentrations of tetra-butyl ammonium (10(-5) M) had no effects. On the other hand, at concentrations of 4x10(-5) and 10(-4) M, this compound significantly reduced the [Ca2+]o-dependent release of acetylcholine from phrenic nerves. This finding indicates that tetra-butyl ammonium possesses a presynaptic inhibitory effect on acetylcholine release from the phrenic nerve terminal.

[Anesthetic management of a patient with Cockayne's syndrome]

Cockayne's syndrome is a disease of childhood characterized by mental retardation and premature aging. An 11-year-old girl with Cockayne's syndrome underwent general anesthesia for acute appendicitis. Although we had expected the difficulty of intubation because of her small jaw with limited movement, we could visualize her vocal cord, and intubate easily. High peak airway pressure was needed to ventilate her lung after intubation suggesting decreased lung compliance for this syndrome. We have to consider anesthetic problems resulting not only from pediatric but also from geriatric anesthesia for the management of this syndrome.

Flecainide reverses neuropathic pain and suppresses ectopic nerve discharge in rats

We investigated effects of flecainide, a Class IC sodium channel blocker, in the rat chronic constrictive injury (CCI) and ectopic nerve discharge models. In the behavioral evaluation, 2, 6, and 12 mg/kg flecainide were intravenously given to the CCI model, and a dose-dependent analgesic effect was shown on both thermal hyperalgesia and tactile allodynia. In the electrophysiological evaluation using the ectopic nerve discharge model produced by saphenous neurectomy, i.v. administration of 2, 6, and 12 mg/kg flecainide suppressed spontaneous discharge at the peripheral nerve level in a dose-dependent fashion as with the behavioral evaluation, but flecainide did not affect nerve conduction at the dose of 12 mg/kg.

Effects of zinc acetate on splenocytes of endotoxemic mice: enhanced immune response, reduced apoptosis, and increased expression of heat shock protein 70

Immune function is markedly attenuated in endotoxemia. Zinc is involved in the regulation of cellular functions and maintenance of immune function, and its level in the serum is low in endotoxemia. We mainly investigated the effects of zinc acetate (ZA) on splenocytes in mice with endotoxemia. After we confirmed increased plasma zinc level by ZA treatment, C57BL/6 mice were randomly divided into four groups: 10 control mice received 500 microL saline solution as vehicle; 10 control mice received ZA at 3 mg/kg body weight; 20 endotoxemic mice received a 40 mg/kg lethal dose of lipopolysaccharide (LPS); 20 mice received ZA followed by LPS as the above dose. In vivo, we confirmed that ZA pretreatment did not significantly affect the plasma cytokine level in endotoxemic mice. In vitro, splenocytes from ZA-plus-LPS mice showed drastic effects, in that ZA abrogated LPS-induced suppression of cellular proliferation and production of interleukin-2 and interferon-gamma. The percentage of apoptotic splenocytes was significantly reduced in ZA-plus-LPS mice (23.4%) as compared with LPS mice (41.6%). Furthermore, the expression of HSP-70 mRNA in splenocytes was strongly enhanced in both ZA and ZA-plus-LPS mice, especially in the latter group. Finally, studies monitoring survival rates for 6 days showed that LPS caused 100% mortality while ZA-plus-LPS mice showed 75% survival. Our results suggest that zinc normalized the immune response and reduced apoptosis of splenocytes. These changes were probably caused by increased synthesis of HSP-70 by splenocytes, which might enhance survival of mice with LPS-induced endotoxemia.

Neutrophilia and granulocyte colony-stimulating factor levels after cardiopulmonary bypass

PURPOSE

The precise mechanism of neutrophilia after cardiac surgery is unknown. Granulocyte colony stimulating factor (G-CSF) can increase the number of leukocytes. The purpose of this study was to evaluate the relationship between serum G-CSF levels and peripheral blood leukocyte counts after cardiac surgery.

METHODS

We prospectively studied 10 patients undergoing cardiac surgery (coronary artery bypass grafting) using cardiopulmonary bypass (CPB). Plasma G-CSF levels and neutrophil count were measured before induction of anaesthesia, at the end of surgery, and on the first postoperative day. These changes were compared with those in patients undergoing non-cardiac major surgery (control group).

RESULTS

At the end of surgery, G-CSF levels increased (P < 0.01) in both groups, but were higher in the control than in the cardiac group (3,250 +/- 690 vs 194 +/- 29.5 pg ml(-1), respectively, mean +/- SEM, P < 0.01). On the first postoperative day, G-CSF levels were still high in both groups, and were still higher in the control (710 +/- 179 vs 122 +/- 19.9, respectively, P < 0.01). However, neutrophilia was greater in the cardiac group than in the control. G-CSF response correlated positively with neutrophilia in the control group (r = 0.656, P < 0.05) but not in the cardiac group.

CONCLUSIONS

Our results indicate that changes in leukocyte count following cardiac surgery are unique to patients undergoing CPB. G-CSF plays an important role as the mediator of neutrophilia after non-cardiac surgery, but not after cardiac surgery with CPB.

Unwashed shed blood infusion causes deterioration in right ventricular function after coronary artery surgery

We investigated right ventricular function after infusion of unwashed shed blood collected from mediastinal and chest tube drainage. Changes in thromboxane B2 (TXB2) and 6-keto-PGF1 alpha, which are stable metabolites of thromboxane A2 (TXA2) and prostacyclin respectively, were also investigated. The amount of infused shed blood was 484 +/- 76 ml (mean +/- SD). Right ventricular ejection fraction decreased rapidly after the infusion and did not return to its original level until 120 minutes later (P < 0.05). Mean pulmonary artery pressure rose after infusion of the shed blood (P < 0.05). The TXB2 level in the unwashed shed blood was about 20,000 times higher than the preoperative plasma level. The plasma TXB2 level at 30 minutes after the infusion was significantly elevated (P < 0.05), and at 120 minutes it had returned to the original level. Unwashed shed blood may contain vasoactive substances that induce the release of TXA2 and increase right ventricular afterload.

Brain imaging in childhood- and adolescence-onset schizophrenia associated with obsessive-compulsive symptoms

OBJECTIVE

Childhood- and adolescence-onset schizophrenic patients with obsessive-compulsive symptoms (OCS) constitute a specific subgroup of schizophrenia. We performed magnetic resonance imaging in this group seeking evidence of neurodevelopmental insults.

METHOD

Thirty-two schizophrenic patients were compared with 19 controls. Schizophrenic subjects were divided into 15 patients with OCS (SOCS+ group; onset at 15.5 +/- 1.6 years) and 17 without OCS (SOCS- group; onset at 15.3 +/- 1.3 years). Areas of the hippocampus, frontal lobe, corpus callosum and putamen were analysed morphometrically.

RESULTS

The left hippocampus was significantly smaller in the SOCS+ group than in the SOCS- and control groups.

CONCLUSION

Reduced size of the left hippocampus in the SOCS+ group supports a neurodevelopmental etiology in this subgroup.

[Anesthetic management of a child with Lenz dysplasia associated with panhypopituitarism]

We present a child with Lenz dysplasia associated with panhypopituitarism. Lenz dysplasia is characterized by small eyeball, small head, hydronephrosis, cleft lip and palate, and mental retardation. A 12 month-old boy with Lenz dysplasia was scheduled for plasty of the lip and basis of the nasal cavity under general anesthesia. We had to pay attention for airway management and hormone supplementation. Anesthesia was induced with sevoflurane and nitrous oxide in oxygen. Tracheal intubation was facilitated with vecuronium bromide. We had no difficulty in airway management. Since this patient could not release enough endogenous cortisol in response to the stress of surgery, we supplemented hydrocortisone after anesthesia induction. Urine output and serum electrolyte concentrations were carefully monitored during surgery because of the impaired ADH response. We encountered no complications in the anesthetic management of this patient.

[Effects of loprinone hydrochloride on hemodynamics and respiratory oxygenation in patients after cardiac surgery]

Loprinone hydrochloride (Lop), a phosphodiesterase fraction III inhibitor and positive inotrope, was recently released in Japan. We evaluated its dose-related effects on hemodynamics and oxygenation as as well as on plasma levels of Lop in ten patients after cardiac surgery. Immediately after admission to the intensive care unit, baseline hemodynamics and arterial blood gas data were obtained; patients with inotropic support, were given 0.1, 0.2, 0.3 microgram.kg-1.min-1.lop over 1 hour incrementally, and additional data were obtained. CI increased significantly from baseline (2.1 +/- 0.3 l.min-1.m-2) to 3.2 +/- 0.8 at 0.3 microgram.kg-1.min-1. Systemic vascular resistance decreased significantly from baseline (2853 +/- 439 dynes.sec.cm-5.m-2) to 1554 +/- 440 at 0.3 micrograms. kg-1.min-1, and mean arterial pressure also decreased significantly from baseline. There were no significant changes in heart rate (HR), central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP), or PaO2.FIO2(-1) in patients over the period evaluated. Plasma levels of Lop rapidly increased to 27.8 ng.ml-1 (effective level; 20 ng.ml-1) at 0.3 microgram.kg-1.min-1. In this study, Lop was shown to effectively increase CI in patients after cardiac surgery with no significant changes in HR, CVP, PAOP or PaO2/FIO2. Thus, Lop has a beneficial effect in the treatment of patients with low cardiac output immediately after cardiac surgery.

[Anesthetic management for a patient with pure autonomic failure]

Pure autonomic failure is characterized by orthostatic hypotension, sweating disorder, urinary incontinence, and syncope. A 64 year-old man with pure autonomia failure was scheduled for suprapubic prostatectomy. We monitoring direct arterial pressure and inserted pulmonary artery catheter prior to the induction of anesthesia. General anesthesia was induced with diazepam 10 mg, fentanyl 0.3 mg, and vecuronium 8 mg for tracheal intubation. Anesthesia was maintained with sevoflurane (0.2-1.5%), 60% nitrous oxide in oxygen supplemented with intermittent epidural anesthesia. During anesthesia, blood loss was immediately replaced with banked blood because autonomic failure could not compensate hypovolemia well. Epidural anesthesia in this patient was considered to cause less hypotension than in patients with normal autonomic function. Therefore, we think epidural anesthesia is a useful anesthesia method for patients with pure autonomic failure. The emergence from anesthesia was smooth and no complications were seen during the perioperative period.

A study of cognitive development and behavior problems in mentally retarded children

Cognitive development in seventy-one mentally retarded children (19 autistic, 52 non-autistic; aged 7-19 years) from a school for handicapped children was studied, using Ohta's scale for evaluating cognitive development level based on language comprehension (Ohta's stage), and other developmental scales. Behavior problems were also examined. The present study reports on the utility of Ohta's stage in non-autistic children, and the relationship between cognitive development level and behavior problems in mentally retarded children. In non-autistic children, there were temporal correlations between Ohta's stage and other development scales (a standard developmental test, speech development, symbolic play development, imitation development), suggesting that in non-autistic children as well, Ohta's stage may serve well as a scale for cognitive development, and reflect symbolic representational functioning. In non-autistic children, most behavior problems in feeding, elimination and sleeping, hyperkinesis, hypokinesis, stereotyped behaviors, self-injurious behavior and licking were closely associated with cognitive development level, and were more often noted in children of lower cognitive development level rather than only in the severely mentally retarded children. Some behavior problems may often occur in the sensorimotor period and hardly occur in the symbolic representational period.

Porphyromonas gingivalis fimbria-stimulated bone resorption is inhibited through binding of the fimbriae to fibronectin

Our most recent study demonstrated that fibronectin is one of the Porphyromonas gingivalis fimbria-binding proteins. In this present study, we demonstrate with mouse embryonic calvarial cells that P. gingivalis fimbria-stimulated bone resorption is inhibited by human fibronectin. The fibronectin inhibition was dose and culture time dependent and was completely neutralized by antifibronectin antibody. The inhibitory action of fibronectin depended on fimbrial interaction with the heparin-binding and cell-attachment domains in the fibronectin structure.

Glucose intolerance during prolonged sevoflurane anaesthesia

PURPOSE

The effects of prolonged sevoflurane anaesthesia on insulin sensitivity were investigated by two successive intravenous glucose tolerance tests (IVGTT) in eight patients who underwent prolonged surgery.

METHODS

The first IVGTT was administered (25 g glucose as 20% dextrose in water iv) over two minutes 35 min after initiation of surgery. Arterial blood samples were obtained at 0, 5, 10, 30, 60, and 120 min after glucose administration for blood glucose and plasma insulin determination. A second IVGTT was performed six hours following the initiation of surgery.

RESULTS

The disappearance rate of glucose (k-value) for the first IVGTT was 0.887 +/- 0.436 (mean +/- SD) %.min-1, and 0.784 +/- 0.289 for the second IVGTT. Both k-values are lower than the normal value. The maximum insulin response to glucose (delta IRI-delta BS-1) of the second IVGTT was lower than the first IVGTT (0.124 +/- 0.092 vs 0.071 +/- 0.056, P < 0.05). The total insulin output of the first IVGTT was higher than the second IVGTT (1.161 +/- 830 vs 568 +/- 389 microU.min.ml-1, P < 0.05).

CONCLUSION

Glucose intolerance is enhanced by diminished insulin output in response to blood glucose elevation during prolonged anaesthesia and surgery.

The clinical features of Tourette's disorder with obsessive-compulsive symptoms

Twenty-three patients with Tourette's disorder (13 with obsessive-compulsive symptoms [OCS] and 10 without) were comparatively investigated. In contrast to OCS-free Tourette's disorder patients, those with OCS were found to be characterized by (i) a higher incidence of volatile temper, (ii) a higher incidence of compulsive tics, (iii) a higher incidence of perinatal disorders and brain wave abnormalities, (iv) a higher severity as rated using the Severity Scale, and (v) a higher prevalence of complications, especially of developmental disorders. Of the subjects with OCS-accompanied Tourette's disorder, approximately half had developed OCS by the onset of tics. These findings suggest the likelihood that OCS-accompanied Tourette's disorder is more strongly associated with organic cerebral disorders, independently of sites of tic disorders, than is OCS-free Tourette's disorder.

Continuous monitoring of ventilatory mechanics during one-lung ventilation

OBJECTIVE

The Ultima SV respiratory monitor can be used to monitor the intraoperative effects of the lateral decubitus position and one-lung ventilation on ventilatory mechanics.

METHODS

Eight patients with esophageal cancer who required one-lung ventilation for esophagectomy and reconstruction were enrolled in the study. We monitored pressure-volume or flow-rate-volume loops continuously throughout the operation. Respiratory parameters were evaluated closely during five conditions of ventilation: two-lung ventilation in the supine position, two-lung ventilation in the lateral decubitus position, dependent one-lung ventilation in the lateral decubitus position, nondependent one-lung ventilation in the lateral decubitus position, and dependent one-lung ventilation in the lateral decubitus position with the chest opened. Respiratory rate was controlled at 10 breaths/min, and tidal volume was kept constant (10 ml/kg) during surgery.

RESULTS

Peak inspiratory pressure increased to 29.0 +/- 9.0 (mean +/- SD) cm H2O in the dependent one-lung in the lateral decubitus position with the chest opened (p < 0.01). Dynamic compliance decreased to 29.4 +/- 4.9 ml/cm H2O in the dependent one-lung in the lateral decubitus position with the chest opened (p < 0.01). The changing configuration of the loops also offered additional and instantaneous information during one-lung ventilation.

CONCLUSIONS

One-lung ventilation caused several changes in the whole respiratory system (lung, thorax, and endotracheal tube). Continuous monitoring of flow-rate-volume or pressure-volume loops with in-line spirometry provided comprehensive information regarding parameters in one-lung ventilation.

Respiratory mechanics and arterial blood gases during and after laparoscopic cholecystectomy

PURPOSE

The purpose of this study was to assess the effects of increased intra-abdominal pressure due to CO2 insufflation on the mechanical characteristics of the respiratory system and arterial blood gases during and after laparoscopic cholecystectomy.

METHODS

Respiratory mechanics and arterial blood gases were examined in 12 patients undergoing laparoscopic cholecystectomy with CO2 insufflation. Respiratory mechanics were continuously monitored with in-line spirometry. In the recovery room, PaCO2 was measured in this group at 30 min and compared with PaCO2s in 23 patients who had undergone open cholecystectomy retrospectively, to evaluate the effects of insufflation on CO2 elimination.

RESULTS

Minute ventilation was decreased by about 500 ml.min-1 during abdominal insufflation. Dynamic lung compliance decreased from 49.6 +/- 4.7 to 30.7 +/- 2.3 (mean +/- SEM) ml.cmH2O-1 with abdominal insufflation (P < 0.005), and returned to 45.1 +/- 3.1 after the release of pneumoperitoneum. Peak inspiratory pressure increased from 15.9 +/- 0.9 to 18.9 +/- 1.0 cmH2O with abdominal insufflation (P < 0.05). Arterial blood gas determinations indicated a decrease in arterial pH, with CO2 retention during insufflation and in the recovery room (P < 0.05). PaCO2 of the laparoscopic patients was higher than that of the open patients in the recovery room.

CONCLUSION

The results indicate that respiratory acidosis was caused during CO2 insufflation for laparoscopic cholecystectomy, that was due to (1) decreased compliance, (2) increased CO2 load and (3) insufficient ventilation. Accumulated CO2 during laparoscopic cholecystectomy increased PaCO2 level in the recovery room.

Clinical features of childhood-onset schizophrenia with obsessive-compulsive symptoms during the prodromal phase

Thirty-nine patients with schizophrenia, diagnosed according to DSM-III-R, who were under 15 years of age, were studied in two groups; 16 subjects with obsessive-compulsive symptoms during the prodromal phase, and 23 with no obsessive-compulsive disorders. The group with obsessive-compulsive symptoms during the prodromal phase was characterized by a higher ratio of males, higher incidences of perinatal and brain computed tomography (CT) abnormalities, fewer hereditary factors, longer duration of the prodromal phase, and a higher incidence of insidious onset and negative symptoms compared with the group without such prodromal symptoms. Schizophrenic patients with obsessive-compulsive symptoms during the prodromal phase were clinically distinct from those without, which suggests the possibility of subtype categorization.

[The comparison of hypnotic potency of nitrous oxide with that of sevoflurane: evaluation by the middle latency auditory evoked response]

In 10 consented patients (ASA I-II) we quantitated the hypnotic potencies of 0.7 MAC nitrous oxide and 0.7 MAC sevoflurane by measuring auditory evoked response (AER), and compared the hypnotic potency of nitrous oxide with that of sevoflurane at the same MAC. In each patient, measurements of AER waves were performed in the following three stages, 0.7 MAC nitrous oxide, 0.7 MAC sevoflurane and 0.7 MAC nitrous oxide after induction of anesthesia. Analysis of variance was used to compare the hypnotic potencies between two inhaled anesthetics. Pa and Nb latencies with sevoflurane were longer than those with nitrous oxide, and Pa and Nb amplitudes with sevoflurane were greater than those with nitrous oxide. However, we found that there were no statistical significances in our results. In conclusion, nitrous oxide exerts as much hypnotic effect as sevoflurane.

Porphyromonas gingivalis fimbriae induce a 68-kilodalton phosphorylated protein in macrophages

The present study was performed to examine whether Porphyromonas gingivalis fimbriae induce specifically a protein kinase-mediated phosphorylated protein that is involved in the mechanism of signal transduction. The fimbriae induced a 68-kDa phosphorylated protein (pp68) in a dose-dependent manner in mouse peritoneal macrophages. A marked appearance of pp68 was observed 20 min after the initiation of fimbrial treatment. The fimbria-induced pp68 was inhibited dramatically by staurosporine, a potent inhibitor of protein kinase C. pp68 induction was also inhibited by H-7, a potent inhibitor of several types of protein kinase. However, the induction was not inhibited by HA-1004 and H-8, relatively high-affinity inhibitors of protein kinase A. Phorbol myristate acetate and 1-oleoyl-2-acetyl-sn-glycerol, activators of protein kinase C, were able to induce pp68 in mouse peritoneal macrophages. This protein was localized in the cytosolic fraction of fimbria-treated macrophages. pp68 also was induced in fimbria-treated human monocyte-like cells. Finally, we observed that gene expression of the fimbria-induced neutrophil chemoattractant KC was inhibited markedly by staurosporine.

[Perioperative management of the patient with hypertrophic obstructive cardiomyopathy]

We experienced the perioperative management of a patient with hypertrophic obstructive cardiomyopathy, who underwent open heart surgery. We performed three kinds of overload examinations, which included overdrive test using the pacemaker, continuous dopamine infusion with overdrive test and continuous diltiazem infusion with overdrive test, before and after cardio-pulmonary bypass under observation of the cardiac performances with transesophageal echocardiogram. We gained some important and interesting informations about the cardiac reserve of the patient. We could perform adequate perioperative management for the patient, taking the results of overload examinations into consideration.

[Effect of pirenzepine on gastric mucosal blood flow in patients after cardiac surgery]

Effect of pirenzepine on gastric mucosal blood flow (GMBF) in adult patients after coronary artery bypass grafting and mitral and aortic valve replacement was evaluated by using endoscopic laser-Doppler velocimetry. Heart rate, blood pressure and cardiac output increased temporarily after intravenous administration of pirenzepine 20 mg. GMBF also increased with these hemodynamic changes. However, GMBF remained significantly higher even after the decrease of cardiac output. Therefore, the increase in GMBF, which might be due in part to increase in cardiac output, could be explained by pirenzepine's own effect on gastric mucosa. Since the GMBF is one of the most important gastric mucosal defensive factors, pirenzepine may be useful in preventing acute gastric mucosal lesions in patients with low cardiac output.

[Evaluation of a new nitric oxide delivery system during mechanical ventilation]

A new nitric oxide delivery and continuous monitoring system is described. During mechanical ventilation, this new system connected with Siemens Servo 900C ventilator was shown to be able to provide a constant inspired NO concentration (10-100 ppm) using chemiluminescence technique for NO analysis. Gas was analysed at the mixing chamber in front of the ventilator inlet and inspiratory tube connected with the soda-lime carbon-dioxide absorber. Both NO concentrations showed a good correlation (r = 0.99). The actual NO concentration from the NO supply cylinder was 1154 ppm and NO2 concentration was 14 ppm. In mongrel dogs, after 20 minutes of NO inhalation (10-100 ppm), the blood methemoglobin level reached a peak value of 2.2% starting from the pre-inhalation level of 0%. To optimize the safety of the clinical application of NO, its concentration should be measured continuously with chemiluminescence technique.

[Intranasal administration of nitroglycerin solution and nitroglycerin spray during general anesthesia]

Nitroglycerin spray is a newly developed nitroglycerin (TNG) form, which delivers 0.3 mg of TNG with each spray emission. We compared the efficacy of intranasal administration of TNG spray and that of TNG solution during general anesthesia. Nineteen patients were randomly assigned to receive either 0.3 mg TNG solution (Solution group) or 0.3 mg TNG spray (Spray group) intranasally. Peak elevation of plasma TNG occurred 2 min after drug administration in both groups, and the plasma level decreased to an ineffective level after 10 min. The plasma TNG of the spray group was significantly higher than that of the solution group for 3 min. Two min after drug administration, systolic blood pressure decreased significantly in both groups, and this level persisted for 10 min. Diastolic blood pressure also decreased in the spray group, but not in the solution group. Heart rate increased significantly in both groups 2 min after drug administration. Oxygen index (PaO2/FIO2) decreased significantly in both groups, and the level persisted 10 min after administration. Although no significant differences were found between two nitroglycerin forms in any of these hemodynamic and respiratory parameters, nitroglycerin spray may have clinical advantages because of reliability in its effect, ready availability, ease of application and high stability.

[Interleukin-6 and glucocorticosteroid responses to cardiopulmonary bypass]

The responses of interleukin-6 (IL-6), ACTH, cortisol, WBC, CRP to cardiopulmonary bypass (CPB) were studied in 5 patients who underwent elective CABG (N = 4) and AVR (N = 1). IL-6 started to increase from 3 h after the beginning of the operation at which aortic clamp was removed and reached a peak after 4 h at which CPB was withdrawn. ACTH also reached a peak after 4 h. The increase of cortisol started from 2 h when aorta was clamped, which was earlier than that of IL-6. IL-6 and ACTH fell sharply to pre-CPB levels before first postoperative day (1 POD) while cortisol remained high postoperatively. CRP level and WBC counts were maximum at 2 POD. The results suggest that the cortisol response to CPB is not only caused by IL-6, but also by other factors, such as IL-1 and TNF.

[Anesthetic management of a patient for giant pulmonary bulla drainage]

Recently it is claimed that the drainage procedure may be a useful method for giant pulmonary bulla in compromised patients. We reported the anesthetic managements of three patients with giant bulla for these procedures. We chose epidural anesthesia in order to prepare for the postoperative analgesia and the expansion of surgical procedure. In selecting circulatory support method, care was taken to choose dobutamine that would cause no suppression of hypoxic ventilatory drive. There is no doubt that right ventricular function is particularly important in patients with chronic obstructive lung disease. We measured right ventricular ejection fraction by thermodilution method and end-tidal CO2 by nasal cannula. These measurements may be useful methods for perioperative monitoring.

N-acetyl-D-galactosamine inhibits TNF-alpha gene expression induced in mouse peritoneal macrophages by fimbriae of Porphyromonas (Bacteroides) gingivalis, an oral anaerobe

Adherence to host cells is an essential step in the initiation of most infectious diseases. It is well known that bacterial fimbriae may be involved in the adherence. Porphyromonas (Bacteroides) gingivalis is a pathogenic organism of adult periodontitis which is a chronic inflammatory disease. Using an experimental system for fimbria-induced TNF-alpha gene expression in mouse peritoneal macrophages, we examined the role of sugar moieties in the adhesion of P. gingivalis fimbriae to these cells. The fimbriae strongly induced TNF-alpha gene expression in the macrophages, and marked TNF activity toward fibroblasts was observed in culture supernatants of the fimbria-treated cells. The potent expression of TNF-alpha was inhibited by N-acetyl-D-galactosamine, but not inhibited by D-mannose, alpha-lactose, and alpha-L-rhamnose, D-galactose, and N-acetyl-D-glucosamine.

Hemodynamic and oxygen delivery-consumption changes during partial liver resection

The effects of partial liver resection on hemodynamics and the oxygen delivery-consumption relationship were evaluated in ten patients with hepatocellular carcinoma. The cardiac index and oxygen delivery were increased significantly (P < 0.05) at 30 minutes after incision, 30 min after liver resection and in the recovery room. Oxygen delivery decreased significantly (P < 0.05) during liver resection. Oxygen consumption remained low throughout the procedure. We did not discover any flow-dependent change in oxygen consumption. Although our patients persisted a hyperdynamic state throughout surgery, their arterial ketone body ratio remained low. Therefore, it may be necessary to maintain a hyperdynamic state during partial liver resection in order to increase hepatic blood flow.

[Cortisol responses to rapid ACTH test in patients with multiple organ failure]

Cortisol concentrations are usually elevated in sepsis, during major surgery and in burns. Adrenocortical response to stress seems to be essential for survival. To investigate the endogenous adrenocortical response to multiple organ failure, rapid ACTH stimulation tests were used in 15 patients. Patients were divided to nonsurvival group and survival group. Patients in both groups appeared to have increased adrenocortical activity, because basal cortisol concentrations were above normal (non-survival group: 33.8 +/- 13.7 micrograms.dl-1, survival group: 19.1 +/- 3.8). There are no significant differences between the two groups. We could not find absolutely adrenal insufficient patient. Plasma cortisol concentrations increased significantly in patients of both groups following ACTH stimulation. We found poor response to ACTH in two patients in non-survival group with very high basal cortisol concentrations. But there is no significant difference of cortisol response between the two groups. We could not determine whether the high mortality is associated with poor response to ACTH or not.

[Evaluation of blood purification in perioperative acute renal failure]

The technical aspects of blood purification have made a great progress during 1980's. We reviewed our experiences of blood purification for the past six years. Between 1986 to 1991, we treated 48 perioperative patients with acute renal failure (ARF). Four were intraoperative cases and 46 were postoperative cases. Three of four intraoperative patients received major cardiovascular surgery, and hemodialysis was connected directly to ECC in these three cases, and in other one case, ARF was treated with continuous hemofiltration (CHF). There was no intraoperative complication. One patient died of septic multiple organ failure (MOF), but other three patients were discharged uneventfully. Thirty five postoperative ARF patients showed oliguric ARF, and their major causes were LOS (65%) and septic shock (29%). We treated these ARF patients with CHF combined with HD (63%), CHF only (28%) and HD only (9%). There were 21 deaths (60%) in this group and most common cause of death was septic MOF. Eleven postoperative ARF patients showed non-oliguric renal failure, and major cause of this type of ARF was thought to be aortic dissection and relative hypotension (45%). We treated these non-oliguric ARF patient with HD only (73%) and HD combined with CHF (27%). One of these non-oliguric ARF patients died from ARDS.

Bulimia nervosa in a pair of male monozygotic twins

This is a report of a pair of male monozygotic twins meeting the DSM-III-R criteria for bulimia nervosa. At the age of 15, both brothers began to diet and suffered from bulimia. They were admitted to psychiatric hospitals and separated. After admission, their clinical course dramatically changed. The differences in their clinical courses and endocrinological data are suggestive as to the roles of environmental and hereditary factors in the etiology of bulimia nervosa.

[Hemodynamic management of LOS using prolonged VA bypass circulatory assist]

The authors managed five LOS patients using prolonged V-A bypass circulatory assist. Maximum CVP values were under 12 mmHg in three survivors, and 17 mmHg and 20 mmHg in two nonsurvivors. Maximum PCWP values were under 14 mmHg in survivors, and 19 mmHg and 20 mmHg in nonsurvivors. Dopamine was administrated in all cases and norepinephrine was administrated at a rate of less than 0.3 microgram.kg-1.min-1 in survivors, and in two nonsurvivors, norepinephrine was used at a rate of 0.36 and 1.2 micrograms.kg-1.min-1. Before and after disconnection of V-A bypass, the bypass flow of the three survivors were under 1.0 l.min-1 just before disconnection, and immediately after it, the preload did not increase, and the dose of administrated catecholamine increased. V-A bypass time intervals of the three survivors were 71, 42 and 87 hours, and those of the two nonsurvivors were 71 and 43 hours. Maximum bypass flow rate was above 40ml.kg-1.min-1 in four of five patients. The authors discussed the management of the patients' heart and of the V-A bypass machine during the prolonged V-A bypass circulatory assist.

[Coagulation changes during liver resection]

Thrombin-antithrombin III complex (TAT) and plasminogen activator inhibitor (PAI) were measured during liver resection surgery in 8 patients. TAT and PAI activities of patients under liver resection were compared with those of 11 patients under resection of esophageal carcinoma. TAT activity increased during liver resection (P < 0.001) and reached 14 times (P < 0.001) of its control value in the recovery room. PAI activity was very stable during operation, but increased to twice (P < 0.01) of its control value in the recovery room. TAT activity of patients after liver surgery in the recovery room was (P < 0.05) more than twice of that of patients after esophageal surgery. We conclude that hypercoagulable state occurred during liver resection to a greater degree compared with that observed with esophageal surgery, and that its cause might be liver resection itself.

[A comparison of the effects of omeprazole with those of ranitidine on intragastric pH and volume in patients for elective surgeries]

This study compared the effect of omeprazole with those of ranitidine on intragastric secretion during perioperative period. Thirty-one patients were randomly allocated to three groups. Each group received either omeprazole, ranitidine orally or one on the night before surgery. Intragastric pH and volume were measured after induction of anesthesia. Omeprazole group and ranitidine group had a higher mean pH than control group (P less than 0.01). None of the omeprazole group had an aspirate of pH lower than 2.5. One patient (10%) in the ranitidine group and five patients (50%) in the control group and five patients (50%) in the control group had aspirates of pH lower than 2.5. Mean gastric volume was not significantly different among these groups. A single dose of omeprazole 20 mg significantly decreased the number of patients at risk of aspiration pneumonitis.

[Heat conservation during abdominal surgery]

Intraoperative hypothermia is a major problem in anesthetic management. We compared the heat conserving effect of a forced air warming system (Bair Hugger, Augustine Medical Inc.) with that of a warming blanket. Sixteen patients undergoing abdominal surgery were studied. Patients were anesthetized with nitrous oxide and oxygen combined with epidural anesthesia. Patients received tympanic, rectal, bladder and core temperature monitorings. Patients were divided randomly to Bair Hugger group (BH, n = 8) or warming blanket group (WB, n = 8). Temperature were measured every one hour over three hours. The BH group showed significantly higher temperatures than WB group. Bair Hugger system is an efficient way to maintain intraoperative body temperature.

[Intraoperative cardiac output monitoring by the transtracheal Doppler method]

We investigated the cardiac output measured with a transtracheal doppler (TTD) tube in surgical patients and evaluated its usefulness during operations. This tube was located at the point where maximum velocity of blood flow was obtained in the ascending aorta. At this point the cross-sectional area of the ascending aorta was calculated and the cardiac output was obtained by multiplying this area with average blood flow velocity which had been ultrasonically determined. The cardiac output by the TTD method was compared with that of the thermodilution method in 10 patients. The results with both groups showed a direct linear correlation. We obtained the following linear equation: TTD C.O. = 0.61 Thermo C.O. + 1.3 C.O.: cardiac output. The direct correlation coefficient proved to be 0.85 at a risk factor of 0.01. The result suggests that this non-invasive TTD method is easily available and useful in monitoring the intraoperative cardiac output.

[Diuretic effects of aminophylline in patients after cardiac surgery]

Diuretic effects of aminophylline in patients after cardiac surgery were studied by using the local renal thermodilution catheter (Goodman Co. Ltd.). The subjects were 11 patients who underwent cardiac surgery in our hospital. All patients had shown almost normal renal and endocrine function. On the day of operation, we indwelld renal thermodilution catheter into the left renal vein under fluoroscopy. After operation, when the urinary volume decreased below 1 ml.kg-1.hr-1, we administered aminophylline at a rate of 2 ml.kg-1.hr-1. We measured HR, BP, CO, PAP, CVP, renal blood flow, urinary volume, urinary electrolytes, plasma renin activity, angiotensin II, aldosteron, ADH and alpha hANP just before and after infusion of aminophylline. The urine volume, renal blood flow and renal blood flow distribution rate showed significant increases of about 70%, 40% and 35% respectively. But hemodynamic parameters including HR, mean BP and CO increased for 5%, 10% and 8% respectively after administration of aminophylline. In the endocrine system, only angiotensin II increased significantly but aminophylline did not cause any change in endocrine system. The results suggest that diuretic effect of aminophylline is mainly achieved by increasing renal blood flow.