[A method of tracheal intubation tried in a patient with multicentric reticulohistiocytosis]

A 48-year-old woman had suffered from multiple destructive arthritis, skin nodules and skin ulcer of bilateral legs caused by multicentric reticulohistiocytosis for 16 years. Skin transplantation and total hip joint replacement were scheduled. Tracheal intubation was anticipated to be difficult because of destructive arthritis of the temporomandibular joint. We tried a new method to intubate the trachea through a laryngeal mask. After topical application of 8% lidocaine to the oropharynx, a size 4 laryngeal mask was inserted and its cuff was inflated by 20 ml of air. Anesthesia was induced with 4% sevoflurane in 50% nitrous oxide via laryngeal mask. A fiberscope through a tracheal tube was inserted through the laryngeal mask into the trachea. A tracheal tube with the internal diameter of 6.5 mm, was successfully intubated. This method gave little discomfort to the patient.

[Atropine has little significance as a premedication for spinal anesthesia]

Intramuscular atropine 0.5 mg as an anticholinergic premedicant for spinal anesthesia was studied in 14 patients. Twelve patients of a control group did not receive atropine. No significant difference was found between the groups with regard to changes in blood pressure during spinal anesthesia whose analgesic level reached T4. A significant difference was found between the groups with regard to changes in heart rate during spinal anesthesia, but the incidence of bradycardia below 60 beats.min-1 was similar between the groups. Intramuscular atropine 0.5 mg as a premedicant offered little vagal blockade of the heart during spinal anesthesia.

Intraarterial combined immunochemotherapy for unresectable hepatocellular carcinoma: preliminary results

An important objective for patients with unresectable hepatocellular carcinoma (HCC) is the development of effective chemotherapy. We administered a combination of biological response modifiers and anticancer agents to 24 patients with unresectable HCC. Each case had an implanted infuser port which was connected to a catheter placed in the hepatic artery for the intraarterial (i.a.) administration of chemotherapy. The following agents were administered to each patient: recombinant interleukin-2 (800,000 JRU/day infused i.a. continuously for 6 days/week); OK-432 (5 KE injected i.a. twice in 4 weeks and i.m. three times per week); Adriamycin (10 mg injected i.a. twice in 4 weeks); cyclophosphamide (300 mg injected i.a. twice in 4 weeks), and famotidine (40 mg/day administered orally). Objective response was assessed according to tumor size measured by computed tomography and angiography before and after treatment. We observed a complete response (CR) in 4, partial response (PR) in 3, minor response (MR) in 7, no change (NC) in 7, and progressive disease (PD) in 3. The response rate (CR+PR+MR) was 58.3%. The overall 2-year survival rate was 52%. The 2-year survival rate of the responders (CR+PR+MR) was 80%, while that of the non-responders (NC+PD) was 0%. There was a significant difference between the responders and non-responders in respect to survival rate (P < 0.05). The percentages of CD25+ cells, CD56+ cells, and Leu7-CD16+ cells and NK activity in the peripheral blood showed a significant increase following the regimen. Serum levels of tumor necrosis factor alpha TNF alpha rose after the initiation of OK-432. TNF alpha levels were higher in the responders than in the non-responders. Adverse effects included high fever (all patients) and severe transient hypotension (15 patients) that was controlled by conservative therapy. Combined immunochemotherapy administered intraarterially may be a new strategy for treating unresectable HCC.

Elevation of transforming growth factor alpha in cat aqueous humor after corneal endothelial injury

PURPOSE

To determine if a scrape injury to cat corneal endothelial cells increases the level of mitogenic proteins such as transforming growth factor alpha (TGF alpha) in aqueous humor.

METHODS

Aqueous humor of cats was collected at 0, 2, 6, and 24 hours after wounding the endothelium by contact with a cannula tip. Aqueous humor samples collected from sham-wounded cats served as controls. Aqueous humor samples were analyzed for levels of protein, for mitogenic activity using incorporation of tritiated thymidine by cultures of bovine corneal endothelial cells, and for immunoreactive TGF alpha protein using a specific radioimmunoassay.

RESULTS

The average protein level in aqueous humor obtained before wounding was low (0.5 mg/ml), increased 26-fold at 2 hours after injury (13 mg/ml), then progressively decreased at 6 hours (8 mg/ml) and 24 hours (2 mg/ml). Levels of mitogenic activity of aqueous humor samples collected 2, 6, and 24 hours after wounding were 2-fold, 2.5-fold, and 0.6-fold higher, respectively, compared to the level of mitogenic activity measured in aqueous humor collected before wounding (0 hours) or in aqueous humor collected from sham-wounded eyes. TGF alpha concentration in aqueous humor collected before endothelial wounding was low (6.8 ng/ml), increased 14-fold 2 hours after wounding (97.4 ng/ml), then progressively decreased at 6 hours (63.3 ng/ml) and 24 hours (35.5 ng/ml) after wounding. TGF alpha concentrations in aqueous humor collected from sham-wounded eyes at 2 hours (9.5 ng/ml) and 6 hours (5.3 ng/ml) were not significantly different from prewound levels. Detergent extracts of bovine corneal endothelial cells contained substantial levels of TGF alpha immunoreactive protein (20 ng/mg protein).

CONCLUSIONS

Wounding of cat endothelium causes a rapid increase in mitogenic proteins in aqueous humor including TGF alpha, which may act by an autocrine mechanism to stimulate endothelial wound healing.

[Postoperative pain therapy: a survey of patient attitudes to postoperative pain relief]

We surveyed the attitudes of general surgical patients to the management of their postoperative pain relief. Elective surgical patients (n = 232) were asked postoperatively about their experienced pain which was expressed according to verbal pain scale, the duration of experienced pain, satisfaction with pain relief and medication, and expectations of pain on the 5th to 7th postoperative day. Thirteen percent of the patients had no pain, 47% of whom had no rest pain but pain on moving or coughing, 32% of whom had rest and moving pain, and 0.4% of whom experienced horrible and excruciating pain. Duration of postoperative pain was 2.5 +/- 1.9 days, and 76% of the patients experienced pain only for 3 postoperative days. Results of the interviews indicated that 80% of these patients were satisfied with their postoperative pain relief. Although 80% expressed satisfaction, 39% of whom did have rest pain. In the patients with continuous epidural infusion of buprenorphine and 0.25% bupivacaine, incidence of complained rest pain was significantly low compared with those with intermittent i.v. and/or im injection of analgesics on demands of patients. Lag between patient's demand and nurse's response concerning medication correlated significantly to the satisfaction. There was no relation between satisfaction and age, the nature of operation or sex. Fifty-two percent of the patients reported that degree of experienced pain had been less than expected preoperatively. In conclusion, 80% of the patients were satisfied, but our postoperative pain therapy was still insufficient because 39% of them had rest pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of pulmonary edema based on extravascular thermal volume in dogs

To establish criteria of pulmonary edema by extravascular thermal volume (ETV), ETV and a roentgenogram of the thorax were compared in normal and experimental hydrostatic pulmonary edema dogs. ETV was measured by the double indicator dilution technique using heat as a diffusible indicator and sodium ions as a non-diffusible indicator (thermal-Na method). Mean ETV in 14 dogs under physiologic conditions was 8.20 +/- 1.44 ml/kg. Comparison of ETV with the roentgenogram indicated the density of thoracic the roentgenogram to increase when ETV exceeded 11 ml/kg. Pulmonary edema was recognized clearly in the thoracic roentgenogram at more than 15 ml/kg of ETV. Further increase in ETV did not occur with additional radiographic change. ETV was significantly (P < 0.01) correlated with arterial oxygen tension (PaO2) but not statistically correlated with colloid oncotic pressure (COP), pulmonary arterial wedge pressure (PAWP) or PAWP-COP. Measurement of ETV would thus, appear to be a reliable method for evaluating the severity of pulmonary edema, which has been difficult to diagnose by roentgenography and should facilitate the early diagnosis and management of pulmonary edema.

[Rapid induction of anesthesia with inhalation of sevoflurane]

Induction of anesthesia with inhalation of sevoflurane was evaluated in 45 patients. Inhalation anesthesia was induced by a single vital capacity breath followed by spontaneous breathing. The compositions of anesthetic gases were as follows: 5% sevoflurane in oxygen, 5% sevoflurane in 67% nitrous oxide and oxygen, and 7% sevoflurane in 67% nitrous oxide and oxygen. The time (mean +/- SEM) necessary for the loss of consciousness was 85 +/- 6, 56 +/- 4, and 42 +/- 3 seconds, and breathing frequency was 8 +/- 1, 5 +/- 0.6, 1.4 +/- 0.2, in each composition of anesthetic gasses, respectively. Changes in blood pressure and heart rate were relatively small. The technique was found to be acceptable to all of the patients studied. We conclude that the technique of single breath induction with sevoflurane is a safe and acceptable alternative to intravenous induction in cooperative adult patients.

[Serum nitroglycerin concentrations during extracorporeal circulation with a membrane oxygenator incorporated with a cardiopulmonary bypass circuit]

The effect of a cardiopulmonary bypass circuit (CPB) on serum nitroglycerin (TNG) concentrations was studied in eight patients scheduled for cardiac surgery. The CPB consisted of polyvinyl chloride tubes and polypropyrene membrane oxygenator. TNG was administered intravenously at a rate of 1 microgram.kg-1.min-1 after induction of anesthesia. Blood samples were obtained from the radial artery, central vein, venous inlet of the CPB, and arterial outlet of the CPB. No significant difference in serum TNG concentration was found between the venous inlet of the CPB and arterial outlet of the CPB. Serum TNG concentration tended to increase during complete extracorporeal circulation. This suggests that the hypothermic inhibition of TNG metabolism may be greater than the adsorption of TNG by the CPB.

Partial improvement of Olmsted syndrome with etretinate

An 11-year-old Japanese boy with Olmsted syndrome was seen at our clinic. He had a sharply marginated, painful keratoderma with a red border on his palms and soles. Flexion contractures of the fingers were also observed. Hyperkeratotic plaques were present below the lower lip, on the elbows and knees, and in the sacral area. Localized alopecia, leukokeratosis on the tongue, shortness of stature, and laxity of the large joints corresponded to the clinical features of Olmsted syndrome. Treatment with etretinate was effective for the palms and fingers, but resulted in no improvement of the keratoderma of the soles. Because of periosteal thickening of the tibia, presumably caused by etretinate, therapy was terminated one year after it began.

[Comparison of the severity of postoperative pain in patients after thoracic, upper abdominal or lower abdominal surgery]

Different factors influence the severity of postoperative pain. Personality and cultural factors as well as anxiety and fear modify the degree of postoperative pain. The site of surgery is also a major determinant. We evaluated the severity of postoperative pain in patients after three different surgeries, thoracic, upper abdominal and lower abdominal surgeries, from 24 h to 72 h postoperatively. Thirty patients were divided into three groups: thoracic, upper abdominal and lower abdominal groups (n = 10, respectively). All patients received continuous epidural infusion of 0.25% bupivacaine (2 ml.h-1) and buprenorphine (0.2 mg x 24 h-1). Additional analgesics were given when the patient complained of pain. Analgesia was evaluated by 100 mm visual analog scale and demands of analgesics. Pain scores at rest were not different among three groups. Pain after lower abdominal surgery tended to be less severe compared with that after thoracic surgery. Demands of analgesics were not different among three groups at any evaluated point. Pain after thoracic surgery was consistent during 72 postoperative hs, but in the upper and lower abdominal surgery groups pain at 72 hs was significantly weaker than that at 24 hs. We conclude that postoperative pain was not different among the three surgery groups, but pain after upper and lower abdominal surgery decreased more rapidly compared with that after thoracic surgery.

[Patient-controlled analgesia with epidural pethidine or buprenorphine plus bupivacaine for postoperative analgesia]

We evaluated the efficacy of epidural patient-controlled analgesia (PCA) with pethidine or buprenorphine plus 0.25% bupivacaine for postoperative analgesia after laparotomy with a midline incision under general anesthesia. Twenty patients were randomly allocated to two groups. In one group (PCEA-P group; n = 10), epidural pethidine plus 0.25% bupivacaine by PCA with 5 mg of pethidine and 2.5 ml of 0.25% bupivacaine bolus with a lockout interval of 20 min was added to a continuous epidural infusion of 0.25% bupivacaine (2 ml.h-1) plus pethidine (100 mg.24h-1) for 72 h. In the other group (PCEA-B group; n = 10), epidural buprenorphine plus 0.25% bupivacaine by PCA with 0.03 mg of buprenorphine and 2.5 ml of 0.25% bupivacaine bolus with a lockout interval of 20 min was added to a continuous epidural infusion of 0.25% bupivacaine (2 ml.h-1) and buprenorphine (0.6 mg.24 h-1) for 72 h. Analgesia was evaluated by 100 mm visual analog scale and verbal descriptor scale. In PCEA-B group, 90% of the patients did not complain of pain at rest, and in PCEA-P group, all the patients did not complain of pain at rest for 72 h. There were no significantly different analgesic effects between PCEA-P and PCEA-B for 48 h. The average doses of epidural PCA were 1.9 mg.kg-1.24 h-1 of pethidine, and 0.012 mg.kg-1.24 h-1 of buprenorphine, respectively. We conclude that PCEA-P and PCEA-B were effective for postoperative pain to the same degree for the first 48 h, but PCEA-P was superior to PCEA-B for the last 24 h.

[Continuous epidural buprenorphine for postoperative pain relief in patients after lower abdominal surgery]

Postoperative analgesia with epidurally injected buprenorphine and its side effects were investigated in 100 patients who had received lower abdominal surgery. All patients received initially 8 ml of bupivacaine and 0.1 mg of buprenorphine. Following bolus epidural injection, five different groups of 20 patients each received either bupivacaine alone (group A), 5 micrograms.ml-1 buprenorphine.bupivacaine mixture (group B), 8 micrograms.ml-1 buprenorphine.bupivacaine mixture (group C), 12 micrograms.ml-1 buprenorphine.bupivacaine mixture (group D), or 15 micrograms.ml-1 buprenorphine.bupivacaine mixture (group E) by a portable disposable device at a rate of 1 ml.h-1 for 48 h. The analgesic efficacy in group E was superior to those in groups A, B, C or D. No significant difference in the incidence of side-effect was found among groups C, D, E. We conclude that a dose of a approximately 15 micrograms.h-1 might be optimal for postoperative pain relief after lower abdominal surgery.

[Spread of spinal anesthesia with 0.5% isobaric bupivacaine]

The effects of age, weight, height, weight.height ratio, and body mass index on the spread of spinal anesthesia with 3.0 ml of 0.5% isobaric bupivacaine was examined in 185 patients. No significant correlation was found between the spread of analgesia and the age, weight, height, weight.height ratio, or body mass index. A significant correlation was found between the decrease in mean arterial pressure and the height of sensory analgesia (rho = -0.21, P < 0.05) as well as the aging (rho = -0.35, P < 0.001).

[The spread of spinal anesthesia in young patients]

We have studied the spread of spinal anesthesia with Neo-percamine S, containing hyperbaric dibucaine, in 20 younger patients (13-18 yr) and 20 older patients (22-61 yr). In younger patients, 2.17 +/- 1.7 (mean +/- SD) ml of the anesthetic solution blocked 19.4 +/- 1.7 spinal segments. In older patients, 2.22 +/- 0.18 ml of the solution blocked 16.3 +/- 0.18 spinal segments. Spinal anesthesia higher than T3 level was observed in 45% of the younger patients, whereas such level of spinal anesthesia was not observed in the older patients. Our results suggest that hyperbaric dibucaine solution for spinal anesthesia may have a tendency to produce an unexpectedly extensive spread of anesthesia in young patients.

Effect of age on extradural dose requirement in thoracic extradural anaesthesia

We have investigated the effect of age on thoracic extradural dose requirements in 62 patients aged 20-79 yr. Fifteen millilitre of 2% mepivacaine was administered at a constant rate (1 ml s-1) by syringe pump through an extradural needle at the T9-10 interspace. A mean of 15.5 (SD 4.2) spinal segments were blocked 15 min after completion of the administration. The extradural dose requirement decreased with increasing age (r = -0.7, P < 0.001), the requirement in the elderly (60-79 yr) being about 40% smaller than that in young adults (20-39 yr).

Evaluation of erythropoietin production in dogs with reduced functional renal tissue

This study was designed to determine the quantity of functional renal tissue needed to maintain homeostasis of red blood cell production by evaluating the erythropoietin (EPO) production response to phlebotomic stimulation in the 1/2- and 1/4-kidney dogs surgically prepared. The results showed that the reduction in functional renal tissue caused a decrease in EPO production, which led to the delay in recovery from anemia. In the anemic progress stage, the plasma EPO level showed a transition proportional to the quantity of functional renal tissue immediately after the operation for tissue reduction. The 1/2-kidney dog group still kept such proportional relation even in the recovery stage. Thus, the half of the normal renal tissue was considered sufficiently contributory to EPO production needed to maintain homeostasis of red blood cell production. However, the 1/4-kidney dog group precipitously decreased in plasma EPO level in the recovery stage and fell into an extremely unfavorable anemia. This indicated that homeostatic maintenance in erythropoiesis would be impossible more below a quarter of normal renal tissue. These findings disclosed that reduction in functional renal tissue quantity would sensitively influence homeostatic maintenance of red blood cell production through the decrease in EPO production, even if it does not affect renal function concerned with urine production.

Left ventricular wall thickness in normal mongrel dogs

To clarify the normal value of ventricular wall thickness we directly measured the ventricular wall thickness of 50 normal mongrel dogs of one year old. Because of a wide range in body weight from 6.0 to 16.0 kg of these 50 dogs, we selected 34 dogs weighing 8 to 12 kg to calculate the mean ventricular wall thickness as normal value of one year old. The results obtained were as follows; (1) The mean and standard deviation of the left ventricular wall thickness was 7.1 +/- 1.2 mm at anterior, 6.3 +/- 1.6 mm at posterior, 7.1 +/- 1.3 mm at lateral, 10.3 +/- 1.8 mm at the interventricular septum, and that of the right ventricular wall thickness was 3.4 +/- 1.0 mm. (2) Although any site of the ventricular wall thickness correlated significantly to heart weight, only the anterior left ventricular wall and interventricular septum barely correlated to body weight. (3) There was no significant correlation between arterial blood pressure and the ventricular wall thickness. Further study should be necessary to clarify influences of aging on the ventricular thickness and to determine the criteria of ventricular hypertrophy.

[Effect of age on dose requirement for lumbar epidural anesthesia]

In 161 patients, aged 19-75 yr and subjected to epidural anesthesia for extracorporeal shock wave lithotripsy, the relationships between the spread of lumbar epidural analgesia with 10 ml of 2% mepivacaine and age, height, weight, weight/height ratio, and body mass index were studied. The highest correlation was found between the age and the spread (r = 0.67, P < 0.001). The next higher correlation was found between the height and the spread (r = -0.32, P < 0.001). The lowest but a statistically significant correlation was found between the body mass index and the spread (r = 0.16, P < 0.05). A strong inverse linear relationship was found between the age and the epidural dose requirement (r = -0.59, P < 0.001).

Stress hormone responses to major intra-abdominal surgery during and immediately after sevoflurane-nitrous oxide anaesthesia in elderly patients

We studied the responses of plasma epinephrine, norepinephrine, adrenocorticotropic hormone (ACTH), cortisol, and antidiuretic hormone (ADH) during and immediately after sevoflurane-nitrous oxide anaesthesia supplemented with vecuronium in seven elderly patients (mean 76.6 +/- 1.7 SEM) who underwent major intra-abdominal surgery. The plasma concentrations of norepinephrine, ACTH, cortisol, and ADH increased in response to surgical procedures (P < 0.05). The plasma concentration of ADH increased to a peak concentration of 189.1 +/- 20.7 pg.ml-1 30 min after skin incision (P < 0.05). The plasma concentrations of epinephrine, norepinephrine, ACTH, and cortisol increased to peak concentrations of 408.6 +/- 135.5 pg.ml-1, 635.7 +/- 167.8 pg.ml-1, 222.6 +/- 48.0 pg.ml-1, and 113.6 +/- 67.5 micrograms.dl-1, respectively immediately after tracheal extubation (P < 0.05). We conclude that, in the elderly patients, the responses of stress hormones to major intra-abdominal surgery were preserved during sevoflurane-nitrous oxide anaesthesia sufficient to prevent increases in arterial pressure and heart rate. The strongest responses of epinephrine, norepinephrine, ACTH, and cortisol were elicited immediately after tracheal extubation.

Selective beta 1-adrenoceptor agonist activity of denopamine and its derivatives in dogs

Cardiovascular effects of intravenously administered denopamine and its derivatives were investigated in anesthetized dogs and their positive inotropic and hypotensive effects were compared. Structure-activity relationships were examined by modifying the methoxy group in ring B and the hydroxy group in ring A in structure II, a ring-fissioned product of trimetoquinol. Almost all test compounds demonstrated positive inotropic and chronotropic effects as well as hypotensive effects which were mediated by beta-adrenoceptors. With modification of the methoxy group in ring B, only 3,4-dimethoxy, 2,3,4-trimethoxy and 3,4,5-trimethoxy derivatives exhibited beta 1-adrenoceptor selectivity. The 3,4-dimethoxy derivative showed the most potent positive inotropic effect and the highest selectivity to beta 1-adrenoceptor. By structural modification of the hydroxyl group in ring A of the 3,4-dimethoxy derivatives, the potency of positive inotropic effect was affected, while beta 1-adrenoceptor selectivity of the derivatives with 3,5-dihydroxy, 3- and 4-monohydroxy groups were essentially maintained. Among beta 1-adrenoceptor selective compounds, the dose ratios between intravenous and intraduodenal administrations of catechol derivatives like isoproterenol were higher than those of non-catechol derivatives. The 4-monohydroxy derivative (racemic denopamine) exhibited the smallest dose ratio with a long-lasting action. Thus, we could identify selective beta 1-adrenoceptor agonists by the structural modification of a selective beta 2-adrenoceptor agonist, trimetoquinol. In this group of compounds, beta-hydroxy moiety was suggested to be requisite to potent beta-adrenoceptor stimulating action and 3,4-dimethoxyphenethyl structure was important for manifestation of beta 1-adrenoceptor selectivity.

[Sevoflurane anesthesia in a patient following renal transplantation]

A 29-year-old male after renal transplantation with aseptic necrosis of the head of the left femur was anesthetized with sevoflurane-nitrous oxide-oxygen for replacement surgery. Anesthesia was induced with N2O 4 l.min-1, O2 2 l.min-1, plus sevoflurane and maintained with N2O4 l.min-1, O2 2 l.min-1 and sevoflurane. Sevoflurane concentrations ranged from 1% to 4%. The serum inorganic fluoride showed the peak level of 38.4 microM.l-1 about 60 minutes after discontinuation of sevoflurane a decrease in serum inorganic fluoride was delayed. Urinary N-acetyl-beta-D-glucosaminidase (NAG), gamma-glutamyl transpeptidase (gamma-GTP) and beta 2-microglobulin (beta 2-m) increased over five postoperative days. NAG and gamma-GTP returned to the preanesthetic level on the 6th postoperative day, but beta 2-m higher than the preanesthetic level lasted for 14 postoperative days. In conclusion, sevoflurane brought about little effect on the transplanted kidney in this patient.

Evaluation of histamine-releasing property of propofol in whole blood in vitro

We examined the property of emulsion form of propofol (ICI 35 868) to release histamine in whole blood in vitro. Heparinized whole blood from 10 healthy volunteers were incubated with medium and propofol at the final concentration of 0, 1, 10 and 100 microg.ml(-1). The concentration of histamine in supernatant fluid after incubation was measured by radioimmunoassay. Histamine release was expressed as the percentage of the concentration of histamine released into supernatant fluid relative to the total cellular histamine content, which was yielded by destroying cell components in the whole blood. Histamine release in the presence of propofol at the concentrations of 1, 10 and 100 microg.ml(-1) were almost the same as histamine release in the absence of propofol. We conclude that emulsion form of propofol has no property to release histamine in whole blood in vitro.