Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations

Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.

Percutaneous radio-frequency mandibular nerve rhizotomy guided by CT fluoroscopy

We describe a new method for radio-frequency mandibular nerve rhizotomy under CT fluoroscopy. A patient with cancer had severe intractable and drug-resistant pain in his left mandibular region. Because he had an anatomic deformity due to cancer invasion and radiation therapy, we planned a mandibular nerve rhizotomy under CT fluoroscopic imaging. The needle was advanced to the mandibular nerve just caudal to the foramen ovale under real-time CT fluoroscopy, avoiding the cancer region. Pain scores of the patient were reduced after the nerve rhizotomy, without any complications.

Current perception thresholds of patients with long-term administration of maprotiline

The purpose of this study was to evaluate sensory nerve function using current perception thresholds (CPTs) in patients who were administrated maprotiline. Twelve patients with post-herpetic neuralgia and 20 control subjects were studied. The patients with post-herpetic neuralgia were given a daily dose of 60 mg of maprotiline and were maintained at the same dose for 6 months. Twenty control subjects were randomly selected from healthy volunteers. ACPT test was used for quantitative assessment of A beta, A sigma, and C fiber transmission, which are associated with pain, by three (2000, 250, and 5 Hz) different frequencies of electric stimulation. CPTs of 5, 250, and 2000 Hz in patients with post-herpetic neuralgia 2 months after administration of maprotiline were 141.7 +/- 17.3 for 5 Hz, 120.8 +/- 12.9 for 250 Hz, and 256.4 +/- 18.0 for 2000 Hz, which were significantly (P < 0.01) higher than those (67.0 +/- 9.1 for 5 Hz, 73.4 +/- 7.0 for 250 Hz, and 191.3 +/- 20.2 for 2000 Hz) before treatment and than those (35.3 +/- 15.8, 62.0 +/- 18.9, and 198.9 +/- 15.8) of control subjects. An increase in CPT for 5 Hz at 2 months after administration of maprotiline correlated (r = 0.71, p = 0.01) with a decrease in pain score. There were no correlations between an increase in CPT and changes in Hamilton Depression Scale (HAMD) values until 3 months after maprotiline treatment. However, we found that an increase in CPT for 5 Hz at 6 months after maprotiline treatment correlated (r = 0.68, p = 0.015) with a decrease in HAMD values. In conclusion, administration of 60 mg maprotiline significantly increased current perception thresholds at 2 months after the administration.

Plasma proinflammatory cytokine response to surgical stress in elderly patients

We investigated the change of plasma cytokines concentrations in elderly patients during lower abdominal surgery. Plasma interleukin (IL-)6 concentrations (68.0+/-15.4 and 36.1+/-20.7 pg/ml) in elderly patients at 24 h and at 3 days after surgery were significantly higher than those (35.1+/-21.5 and 18.6+/-10.6 pg/ml) of young adults. Plasma IL-6 concentrations (92.3+/- 31.9 pg/ml) in elderly patients anesthetized with propofol and fentanyl were significantly higher at the end of the operation than that (57.9+/-36.7 pg/ml) of elderly patients anesthetized with sevoflurane and fentanyl. In conclusion, elderly patients have an increased and delayed IL-6 response to surgical trauma compared with young adults. Plasma IL-6 production after surgical trauma in elderly patients with total intravenous anesthesia with propofol was significantly higher than that in elderly patients with sevoflurane anesthesia.

Effect of epidural analgesia on postoperative paralytic ileus in chronic schizophrenia

BACKGROUND AND OBJECTIVES

Postoperative paralytic ileus is frequently encountered in chronic schizophrenic patients who undergo abdominal surgery. We investigated whether epidural analgesia with local anesthetics minimizes postoperative ileus in schizophrenic patients who are treated long term with antipsychotic drugs.

METHODS

We measured the VAS pain after surgery and the time that elapsed before the first passage of flatus and/or feces after the end of surgery in schizophrenic patients provided analgesia with systemic buprenorphine (group A) and schizophrenic patients receiving epidural analgesia with local anesthetics (group B).

RESULTS

The frequency of patients who did not pass flatus and/or feces for more than 120 hours postoperatively was significantly higher in group A. Postoperative pain scores of group A at 8 and 24 hours after the end of anesthesia were 36.0 +/- 12.8 and 31.7 +/- 10.7 (0 to 100 mm scale), which were significantly higher than 25.4 +/- 13.2 and 20.5 +/- 9.4 scores in group B.

CONCLUSIONS

Epidural analgesia with local anesthetics in chronic schizophrenic patients undergoing abdominal surgery minimizes postoperative ileus compared to patients receiving systemic buprenorphine.

Effects of the aminopeptidase P inhibitor apstatin on bradykinin-induced inositol 1,4,5-triphosphate in neonatal rat cardiomyocytes

We investigated the effect of apstatin (an aminopeptidase P inhibitor) on bradykinin-induced inositol 1,4,5-triphosphate (IP3) formation and glucose uptake in isolated neonatal rat cardiomyocytes. Apstatin enhanced bradykinin-induced IP3 formation in a dose-dependent manner. We found that 1 microM Hoe 140 (a bradykinin B2-receptor antagonist) significantly decreased the potentiation of bradykinin-induced IP3 production by 5 microM apstatin from 781.8+/-67.2 to 127.4+/-33.0 pmol/mg protein; 5 microM apstatin increased bradykinin-induced glucose uptake from 197.0+/-25.5 to 297.3+/-64.0 pmol/h per milligram of protein. The stimulation of glucose uptake with apstatin was blocked to 132.5+/-26.2 pmol/h per milligram of protein by 1 microM Hoe 140. We conclude that apstatin stimulates bradykinin-induced IP3 formation and glucose uptake by preventing the degradation of bradykinin.

Endocrine response to surgical stress in three patients over 100 yr

PURPOSE

To report the change of plasma epinephrine, norepinephrine, cortisol, plasma renin activity, plasma aldosterone and plasma atrial natriuretic peptide during general anesthesia in three centenarian patients.

CLINICAL FEATURES

Three patients aged 101, 101 and 102-yr, underwent a screw fixation of femoral fracture under general anesthesia. Plasma concentrations of epinephrine, norepinephrine, cortisol, renin activity, aldosterone and atrial natriuretic peptide were measured before the induction of anesthesia, 15 min after incision and 60 min after the end of surgery. Plasma epinephrine concentrations in the three patients increased from 419, 344 and 377 pg x ml(-1) before anesthesia to 688, 534 and 478 pg x ml(-1) 15 min after skin incision. Plasma norepinephrine concentrations increased markedly from 408, 513 and 606 pg x ml(-1) before anesthesia to 2950, 1864 and 1574 pg x ml(-1) 15 min after skin incision. The cortisol response to surgery was similar to that of young adults. Plasma aldosterone and renin activity was low throughout anesthesia. Plasma atrial natriuretic peptide increased from 353, 367 and 109 pg x ml(-1) before induction to 479, 487 and 168 pg x ml(-1) 15 min after skin incision.

CONCLUSION

Plasma norepinephrine concentration in patients over 100 yr increased markedly during anesthesia, while plasma renin activity and aldosterone were lower.

Plasma inflammatory cytokine response to surgical trauma in chronic depressed patients

We investigated inflammatory cytokine response in chronic depressed patients during abdominal surgery. Twenty-five major depressed patients (Group D) and twenty-five patients (Group C) as the control were studied. Plasma interleukin 6 (IL-6), interleukin 8 (IL-8) and tumour necrosis factor-alpha (TNF-alpha) concentrations were measured before and at 15 min after induction of anesthesia, the end of surgery, 24 h and 3 days after the operation. Plasma IL-6 concentrations in Group D at the end of the operation and 24 h after surgery were significantly lower than those of Group C. The plasma IL-6 concentration (87.1+/-55.3 pg/ml) of patients scoring more than 18 points in the Hamilton depression-rating score at the end of the operation was significantly higher than 57.5+/-76.7 pg/ml of patients scoring less than 18 points. Plasma IL-8 concentration (6.1+/-3.2 pg/ml) in Group D at the end of the operation was significantly lower than 8.7+/-4.2 pg/ml of Group C. We conclude that plasma IL-6 and IL-8 response to surgical trauma is inhibited in chronic depressed patients. The IL-6 response to surgical trauma is depending on the clinical state of depression.

Production of functional human selenocysteine-containing KDRF/thioredoxin reductase in E. coli

In a previous study, we reported the isolation of a cDNA encoding KDRF (KM-102-derived reductase like factor) from the human bone marrow-derived stromal cell line KM-102. Analysis of the sequence of this cDNA revealed it to be the previously reported human thioredoxin reductase cDNA. Human thioredoxin reductase, which was recently isolated from human lung adenocarcinoma NCI-H441 cells as a selenocysteine-containing selenoprotein, and its substrate thioredoxin are thought to be essential for protecting cells from the damage caused by reactive oxygen species. To obtain the selenocysteine-containing recombinant KDRF/thioredoxin reductase, we introduced a secondary structure, which is identical to the selenocysteine insertion signal of Escherichia coli formate dehydrogenase H mRNA, downstream of the TGA in the KDRF/thioredoxin reductase cDNA and expressed it in E. coli. As a result, a significant amount of selenocysteine was incorporated into the C-terminus of the KDRF/thioredoxin reductase protein. The selenocysteine-containing KDRF/thioredoxin reductase showed reducing activities toward human and E. coli thioredoxin, whereas non-selenocysteine-containing KDRF/thioredoxin reductase showed no enzyme activity. Our results suggest that this strategy will be applicable to the production of other mammalian selenocysteine-containing selenoproteins in E. coli.

Experimental use of a transportable hyperbaric chamber durable for 15 psi at 3700 meters above sea level

A transportable hyperbaric chamber durable for 15 psi of pressure was used to treat a patient suffering from moderate acute mountain sickness at 3700 m above sea level. The symptoms were ameliorated a few minutes after pressurization in the chamber. After a 20-minute stay in the chamber, the patient was completely free of symptoms. Since the chamber can be inflated by using compressed air from a cylinder, no strenuous work was required of the operators. This transportable chamber seems to be useful for the treatment of high-altitude disorders at around 3000 m above sea level.

Identification and C-terminal characterization of proteins from two-dimensional polyacrylamide gels by a combination of isotopic labeling and nanoelectrospray Fourier transform ion cyclotron resonance mass spectrometry

We propose a novel method for the identification and C-terminal characterization of proteins separated by two-dimensional polyacrylamide gel electrophoresis (2D-PAGE). Proteins were digested in a gel in a buffer solution containing 50% 18O-labeled water, and mixtures of 18O/16O-labeled peptides were analyzed by nanoelectrospray Fourier transform ion cyclotron resonance mass spectrometry (FT-ICR MS). This method was evaluated using horse skeletal muscle myoglobin as the model protein in SDS gel. The high resolution of FT-ICR MS minimized the overlapping of peptide peaks and facilitated identification of the C-terminal peptide, which was done by observing the undisrupted isotope peak pattern. As well, with its low ppm-level high mass accuracy, it can rapidly and reliably identify the in-gel-separated protein and determine its C-terminal by peptide mass fingerprinting alone. Therefore, this method should be applicable to routine and high-throughput proteome studies. Here, the method was applied to the analysis of rat liver proteins separated by 2D-PAGE. The C-termini of eight proteins were successfully identified out of 10 randomly picked Coomassie brilliant blue-stained spots. The feasibility and limitations of this approach are reported in this paper.

Exercise-induced cerebral deoxygenation among untrained trekkers at moderate altitudes

The pathophysiology of altitude-related disorders in untrained trekkers has not been clarified. In the present study, the effects of workload on cardiovascular parameters and regional cerebral oxygenation were studied in untrained trekkers at altitudes of 2700 m and 3700 m above sea level. We studied 6 males and 4 females at each altitude, and their average ages were 31.3+/-7.1 y at 2700 m and 31.2+/-6.8 y at 3700 m, respectively. The resting values of heart rate and mean blood pressure were not significantly different at 2700 m and 3700 m than at sea level. However, increases in these values after exercise were more prominent at high altitudes (heart rate increase = 51.6% at 2700 m and 70.4% at 3700 m; mean blood pressure increase: 19.0% at 2700 m and 17.2% at 3700 m). In addition, post-exercise blood lactate concentration was significantly higher at 3700 m than at sea level or at 2700 m (i.e., 7.6 mM at 3700 m, 3.8 mM at 2700 m, and 4.17 mM at 0 m, respectively). Exercise induced an acute reduction in the arterial oxygen saturation value (SpO2) at 2700 m and 3700 m (i.e., 11.2% reduction at 2700 m and 9.4% at 3700 m), whereas no changes were observed at sea level. The resting values of regional oxygen saturation (rSO2)--measured by a near infra-red spectrophotometer at sea level, 2700 m, and 3700 m-were nearly identical. Exercise at sea level did not reduce this value. In contrast, we observed a decrease in rSO2 after subjects exercised at 2700 m and 3700 m (i.e., 26.9% at 2700 m and 48.1% at 3700 m, respectively). The rSO2 measured 2 min and 3 min after exercise at 3700 m was significantly higher than the preexercise value. From these observations, we concluded that alterations in cardiovascular parameters were apparent only after an exercise load occurred at approximately 3000 m altitude. Acute reduction in cerebral regional oxygen saturation might be a primary cause of headache and acute mountain sickness among unacclimatized trekkers.

A Case of Sclerosing Lymphocytic Lobulitis of the Breast Associated with Diabetes Mellitus

BACKGROUND: The benign breast disease sclerosing lymphocytic lobulitis is thought to result from autoimmune diseases causing insulin-dependent diabetes mellitus (IDDM) due to insulinitis. In cases of sclerosing lymphocytic lobulitis accompanied by IDDM, the clinical term gdiabetic fibrous breast disease hhas been proposed. METHODS: A case of sclerosing lymphocytic lobulitis of the breast is described RESULTS: The patient was a 43-year-old woman diagnosed with non insulin-dependent diabetes mellitus (NIDDM) 8 years previously. Insulin therapy was thought to be necessary because treatment with glibenclamide was not effective. She visited our facility complaining of a lump in her right breast that was 5 cm in diameter, painless, rock-hard, discrete, and irregularly outlined. Biopsy was performed because breast cancer was strongly suggested by its hardness and its irregular internal echo on ultrasonography. Histopathological findings demonstrated marked stromal sclerosis and lymphocyte infiltration in the perivascular and perilobular areas. Sclerosing lymphocytic lobulitis was diagnosed. CONCLUSION: Referring physicians should avoid performing unnecessary repeated biopsies by recognizing this disease entity, which often occurs bilaterally.

A clinicopathological study on combined hepatocellular and cholangiocarcinoma

We clinicopathologically studied 23 surgically resected cases of combined hepatocellular and cholangiocarcinoma (HCC-CC). The frequency of this cancer in our subjects, who had primary liver cancer and who underwent hepatectomy, was 6.3%. The mean age of patients was 64.0 years old and the male: female ratio was 1.9:1. Serum alpha-fetoprotein was positive in 70% of cases and its levels were relatively low (< or = 1000 ng/mL) in most cases. The positive rate of serum carcinoembryonic antigen was 18% and its levels were also low. In regard to hepatitis virus markers, 17% of the 20 combined HCC-CC cases were positive to HBs antigen and 70% were positive to the HCV antibody. Of the 23 combined HCC-CC cases, 9 cases (39%) were associated with liver cirrhosis. Tumours were classified macroscopically into a separated type (HCC and CC are clearly separated 17%), a HCC-predominant type (resembles HCC 49%), and a CC-predominant type (resembles CC 34%). The separated and HCC-predominant types were associated with liver cirrhosis in 50 and 55% of cases, respectively. These cases with liver cirrhosis presented the features of HCC more apparently, while those without liver cirrhosis presented the features of CC. Histologically, all cases were classified into either Type I (HCC and CC were clearly distinguished; 17%), Type II (HCC and CC were contiguous and shared transitional features; 66%), and Type III (cancer cells were able to be evaluated as either HCC or CC and were considered to be an intermediate type; 17%). Immunohistological stains for cytokeratin were useful to distinguish HCC and CC. Specifically, CC was positive to cytokeratin 7 and 19. The tumour, in which HCC and CC were almost indistinguishable, such as Type III), indicates the presence of intermediate tumour cells that can differentiate either to HCC or CC.

Biliary hamartomas simulating multiple hepatic metastasis on imaging findings

We encountered a 62-year-old female with advanced gastric cancer, in whom multiple nodular lesions in the liver, which were depicted as small low density areas, less than 5 mm in diameter, on computed tomography and demonstrated as a heterogenic pattern on ultrasonograms. This patient was suspected to have multiple liver metastases of gastric cancer. She deteriorated gradually and died of respiratory failure due to lung metastasis. At autopsy these hepatic nodular lesions were biliary hamartomas. Biliary hamartoma is a lesion usually identified microscopically, and there have been only 8 cases including ours, which were depicted on images. Along with a remarkable advance in imagings, it should become more important to differentiate biliary hamartoma from malignant hepatic neoplasms on images.

[Effects of intravenous infusion of isosorbide dinitrate on hemodynamics during anesthesia and surgery]

Ninety nine patients with ischemic changes of the heart on preoperative and intraoperative ECG tracings were studied to evaluate effects of intravenous infusion of isosorbide dinitrate on hemodynamics during anesthesia and surgery. These patients ranging in ages from 24 to 80 years were administered intravenous isosorbide dinitrate at a rate of either 0.5 or 1 microgram.kg-1 x min-1 during anesthesia and surgery. Arterial blood pressure was not influenced with intravenous isosorbide dinitrate at the speed of 0.5 microgram.kg-1 x min-1 during anesthesia and surgery. The arterial pressure of the patients decreased slightly but significantly 30 min after the start of 1 microgram.kg-1 x min-1 of isosorbide dinitrate infusion, but it recovered to the control level at the end of administration of isosorbide dinitrate. Heart rate was unchanged with intravenous isosorbide dinitrate during anesthesia and surgery in both groups, except a mild increase at the end of isosorbide dinitrate infusion of 1 microgram.kg-1 x min-1. Arterial blood oxygen tension showed no decrease during the administration of isosorbide dinitrate and no adverse reactions associated with administration of the drug was detected in this study. Significant improvement of ischemic changes on ECG tracings were observed in about 25% of the patients who received 1 micrograms.kg-1 x min-1 of intravenous isosorbide dinitrate.

[Clinical evaluation of prostaglandin E1 during anesthesia in non-elderly and elderly patients]

The effects of prostaglandin E1 (PGE1) on blood pressure during anesthesia and the postoperative changes in organ functions were examined and compared in 358 cases. Two hundred and eighty patients were under 64 years of age and 128 patients were over 65 years. It was possible to control blood pressure satisfactorily with PGE1 in both non-elderly and elderly groups. However in the elderly group, it was more difficult to control blood pressure with PGE1 under NLA as compared with enflurane anesthesia. In both groups, urinary flow increased during and after the administration of PGE1, and the livers and kidneys showed neither dysfunction nor deterioration after operation. We had very few incidences of side effects with this drug. PGE1 is also considered safe and useful for elderly people during and after surgery.

[The effect of enflurane anesthesia on plasma superoxide dismutase (SOD)-like activity in elderly patients]

Plasma SOD-like activity during enflurane anesthesia was measured according to electron spin resonance in ten elderly patients over 66 years and in nine patients under 64 years. Anesthesia was induced with thiopental 4 mg.kg-1 and succinyl-choline 0.8-1.0 mg.kg-1 intravenously and was maintained with enflurane 1.0-2.0% in nitrous oxide and oxygen. They were ventilated manually throughout the surgery. The mean plasma SOD-like activity before anesthesia was lower in the elderly group compared with the control group. This decreased significantly in the elderly patients on the first and third day after surgery. There was no relationship between plasma SOD like activity and patient age. We conclude that increased superoxide anion production in the post-operative period may affect plasma SOD-like activity.

[Effects of modified NLA with droperidol and eptazocine and surgery on pituitary-adrenocortical function in man]

Effects of modified NLA with droperidol + eptazocine on pituitary-adrenocortical function were evaluated in ten patients who received abdominal hysterectomy. They were premedicated adequately. The induction of anesthesia was started with eptazocine 30 mg iv and thiopental 3-4 mg.kg-1 iv and the trachea was intubated smoothly following succinylcholine 40 mg iv. Then, they were given intravenous droperidol 0.15 mg.kg-1 with inhalation of 70% N2O and 30% O2. Good intraoperative muscle relaxation was obtained by dialferine or pancuronium. Five ml of the venous blood was taken on six occasions as follows; before the anesthetic induction, 5 and 30 minutes after the induction, 30 and 60 minutes after the start of surgery and finally at full recovery from anesthesia in the recovery room. The blood samples were immediately centrifuged and the plasma was separated and stored at -20 degrees C until measurement. Plasma cortisol, ACTH, human growth hormone (HGH) and prolactin (PRL) were measured for evaluation of the anterior pituitary-adrenocortical function. No significant increase in plasma levels of cortisol, ACTH and HGH were observed during anesthesia alone, but they increased significantly during surgery. Plasma levels of PRL increased significantly soon after the induction. These results were similar to those of other neuroleptic anesthesia. The systemic blood pressure and the heart rate were stable during anesthesia and surgery, and plasma eptazocine concentration determined by GC-MS showed that effective concentrations of eptazocine were maintained during surgery. These data suggest that modified NLA with droperidol and eptazocine would deserve a further detailed clinical study.

Effect of anaesthesia and surgery on endocrine function in elderly patients

The effect of halothane-nitrous oxide anaesthesia and abdominal surgery on endocrine function was investigated in 18 elderly patients whose ages ranged from 65 to 77 (mean 69 years). Cortisol levels in plasma increased significantly during anaesthesia and surgery, and the increases were slightly higher than those in young adults. Plasma aldosterone increased and insulin levels did not change during the procedures, and these levels were lower than in younger adults. The endocrine responses in elderly patients were similar in magnitude to those in young adults. Therefore it appears that no special hormonal treatment is necessary for elderly patients undergoing routine surgical procedures.