Involvement of IL-18 and soluble fas in patients with postoperative hepatic failure

We measured the levels of tumor necrosis factor alpha (TNF-alpha), interleukins (IL)-6 and -18, and soluble Fas (sFas) in 11 patients with postoperative hepatic failure and assessed whether IL-18-mediated apoptosis is involved in the onset of liver dysfunction. The serum TNF-alpha, IL-18, and sFas levels were significantly higher in patients with sepsis as a complication than in those without sepsis. The TNF-alpha and IL-18 levels were significantly higher in nonsurvivors than in survivors. Significant correlations were observed between TNF-alpha and IL-6, between TNF-alpha and IL-18, and between TNF-alpha and sFas levels. These results showed that Fas-mediated hepatocyte apoptosis functions as an important mechanism responsible for the onset of postoperative hepatic failure in humans. They especially suggested that IL-18 and TNF-alpha function both as apoptosis-promoting factors and as apoptosis-inhibiting factors, depending on the conditions to which hepatocytes are subjected.

Cytokine removal by plasma exchange with continuous hemodiafiltration in critically ill patients

The effectiveness of plasma exchange (PE) with continuous hemodiafiltration (CHDF) in the treatment of critically ill patients was evaluated based on changes in cytokine levels. Twenty-six patients with acute hepatic failure were treated with PE (PE group) or PE and CHDF (PE+CHDF group), and the levels of cytokines such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-8 were determined before and after treatment. Bilirubin levels were significantly lower after treatment in both the PE and PE+CHDF groups. There were no significant differences in TNF-alpha levels before and after treatment in the PE group, but the TNF-alpha level was significantly lower after treatment in the PE+CHDF group. There were no significant differences in the IL-6 levels before and after treatment in both the PE and PE+CHDF groups. There were no significant differences in IL-8 levels before and after treatment in the PE group, but the IL-8 level was significantly lower after treatment in the PE+CHDF group. PE with CHDF therapy was given to 5 patients with acutely aggravated autoimmune diseases, 2 patients with hemorrhagic shock and encephalopathy syndrome, and 3 patients with thrombotic microangiopathy. The results suggested that PE with CHDF therapy are useful in critically ill patients with suspected hypercytokinemia.

M phase-specific expression and phosphorylation-dependent ubiquitination of the ClC-2 channel

Cl(-) channel activities vary during the cell cycle and are thought to play various roles including regulation of cell volume. We have shown previously that ClC-2 channels are directly phosphorylated and functionally regulated by the M phase-specific cyclin-dependent kinase p34(cdc2)/cyclin B. We investigate here to determine whether the expression levels of ClC-2 channel protein vary during the cell cycle. Immunoblot and immunocytochemical analyses of cells cycle-synchronized by serum depletion/replenishment reveal that ClC-2 channel protein is expressed predominantly at M phase in cells with two nuclei and a clear constriction ring, whereas RNA blot analysis shows that ClC-2 mRNA expression does not change during the cell cycle. Ubiquitin assays reveal that the ClC-2 channels are ubiquitinated at M phase, whereas the magnitude of ubiquitination is suppressed by incubation with olomoucine, an inhibitor of p34(cdc2)/cyclin B, and it is almost completely abolished in ClC-2 channels having an S632A mutation, which cannot be phosphorylated by p34(cdc2)/cyclin B, indicating that ubiquitination of ClC-2 channels requires phosphorylation by M phase-specific p34(cdc2)/cyclin B. Regulation at the post-transcriptional level, including phosphorylation-dependent ubiquitination, may contribute to M phase-specific expression of ClC-2 channels. Cell cycle-dependent regulation of expression at the protein level in addition to the regulation of function suggests that the ClC-2 channel plays a physiological role in the cell cycle.

A cross-cultural comparison of critical care delivery: Japan and the United States

OBJECTIVE

To compare the utilization and outcomes of critical care services in a cohort of hospitals in the United States and Japan.

DESIGN

Prospective data collection on 5,107 patients and detailed organizational characteristics from each of the participating Japanese study hospitals between 1993 and 1995, with comparisons made to prospectively collected data on the 17,440 patients included in the US APACHE (acute physiology and chronic health evaluation) III database.

SETTING

Twenty-two Japanese and 40 US hospitals.

PATIENTS

Consecutive, unselected patients from medical, surgical, and mixed medical/surgical ICUs.

MEASUREMENTS

Severity of illness, predicted risk of in-hospital death, and ICU and hospital length of stay (LOS) were assessed using APACHE III. Japanese ICU directors completed a detailed survey describing their units.

MAIN RESULTS

US and Japanese ICUs have a similar array of modalities available for care. Only 1.0% (range, 0.56 to 2.7%) of beds in Japanese hospitals were designated as ICUs. The organization of the Japanese and US ICUs varied by hospital, but Japanese ICUs were more likely to be organized to care for heterogeneous diagnostic populations. Sample case-mix differences reflect different disease prevalence. ICU utilization for women is significantly lower (35.5% vs 44.8% of patients) and there were relatively fewer patients > or = 85 years old in the Japanese ICU cohort (1.2% vs 4.6%), despite a higher per capita rate of individuals > or = 85 years old in Japan. The utilization of ICUs for patients at low risk of death significantly less in Japan (10.2%) than in the United States (12.9%). The APACHE III score stratified patient risk. Overall mortality was similar in both national samples after accounting for differences in hospital LOS, utilizing a model that was highly discriminating (receiver operating characteristic, 0.87) when applied to the Japanese sample. The application of a US-based mortality model to a Japanese sample overestimated mortality across all but the highest (> 90%) deciles of risk. Significant variation in expected performance was noted between hospitals. Risk-adjusted ICU LOS was not significantly longer in Japan; however, total hospital stay was nearly twice that found in the US hospitals, reflecting differences in hospital utilization philosophies.

CONCLUSIONS

Similar high-technology critical care is available in both countries. Variations in ICU utilization reflect differences in case-mix and bed availability. Japanese ICU utilization by gender reflects differences in disease prevalence, whereas differences in utilization by age may reflect differences in cultural norms regarding the limits of care. Such differences provide context from which to assess the delivery of care across international borders. Miscalibration of predictive models applied to international data samples highlight the impact that differences in resource use and local practice cultures have on outcomes. Models may require modification in order to account for these differences. Nevertheless, with large databases, it is possible to assess critical care delivery systems between countries accounting for differences in case-mix, severity of illness, and cultural normative standards facilitating the design and management such systems.

Pneumatic stabilization for flail chest injury: an 11-year study

The use of prolonged mechanical ventilation in the treatment of flail chest injury may increase the incidence of pulmonary morbidity. The aim of this study was to examine the results of performing internal pneumatic stabilization in our hospital. A retrospective review of the medical records of 59 patients with flail chest injury who presented within an 11-year period was conducted. During the second half of the period examined, we routinely adopted three characteristic procedures in the treatment of flail chest injury, namely, pressure support on spontaneous breathing, continuous positive airway pressure via a mask, and respiratory physical therapy by physical therapists. We compared the background, prognosis, and methods of treatment for flail chest injury before and after the introduction of these three procedures. A marked decline in the duration of endotracheal intubation and controlled mechanical ventilation, and in the frequency of pulmonary morbidity, was evident following the introduction of the above procedures.

Effects of milrinone on platelet aggregation in swine with pulmonary hypertension

PURPOSE

The purpose of this study was to investigate whether the effect of milrinone on platelet aggregation was related to the selectivity of vasodilation vasculature in a swine model with PH.

MATERIALS AND METHODS

To induce pulmonary hypertension, we injected two sets of acid-washed glass beads in 15 swine, which were divided into two groups (those receiving milrinone or not) and compared with each other.

RESULTS

The induction of pulmonary hypertension decreased the platelet count and increased the plasma levels of thromboxane B2 and 6-keto-prostaglandin F1alpha.

CONCLUSION

A locally high concentration of prostaglandin I2, at least in part, may produce selectivity of vasodilation in the pulmonary vasculature.

Milrinone improves arterial oxygenation in dogs with acute lung injury induced by oleic acid

The aim of the study was to investigate effects of milrinone on pulmonary permeability in dogs with acute lung injury induced by oleic acid. To induce acute lung injury, we administered 0.08 mg/kg of oleic acid to 19 adult mongrel dogs and then measured hemodynamic parameters and performed blood gas analysis. An injection of oleic acid depressed the mean arterial pressure, cardiac index, and arterial oxygenation. Dogs were divided into three groups: six received a bolus of milrinone (50 microg/kg) followed by a continuous (0.5 microg/kg/min, low-dose), seven received a bolus (100 microg/kg) followed by a continuous (1.0 microg/kg/min; i.e., a low-dose twice; high-dose), and six no milrinone (control). Milrinone administration improved the cardiac index and arterial oxygenation and simultaneously depressed the intrapulmonary shunt fraction and the extravascular thermal lung water as extravascular water content of the lung. These changes produced by milrinone are different according to the doses. In conclusion, milrinone acts on the capillary endothelium and inhibits an accumulation in the extravascular water content of the lung, which may induce an improvement in arterial oxygenation. Milrinone may also improve arterial oxygenation through an inhibition of platelet aggregation and chemical mediators that are released from platelets. The latter mechanism also may improve arterial oxygenation, and the exact property responsible for causing the effect of milrinone has not yet been identified.

Cost containment: the Pacific. Japan

The Japanese healthcare system is structured to provide universal healthcare access to the entire Japanese population via a constitutional guarantee. Increasing costs within the Japanese healthcare system are largely attributable to the country's rapidly aging population. Intensive care services are provided primarily in large tertiary care hospitals by a relatively small cadre of dedicated critical care physicians. Triage pressure is high in many Japanese hospitals due to a relatively small proportion of ICU beds. As a result, few patients are admitted to the ICU at low risk of adverse outcome or monitoring. Costs associated with providing critical care are poorly understood because of current hospital cost accounting systems. Critical care costs have only recently become an area of concern. Nevertheless, critical care physicians are taking steps to more fully understand severity of illness, clinical outcome, and utilization of resources in order to effectively guide healthcare policy and resource allocation decisions impacting Japanese critical care.

Changes in the parameters of oxygen metabolism in a clinical course recovering from potassium cyanide

Poisoning with potassium cyanide is usually fatal because of the inhibition of cytochrome oxidase. The parameters of oxygen metabolism in a patient with cyanide poisoning who was admitted in a coma with seizures was monitored. The administration of amyl nitrite and sodium thiosulfate led to a rapid improvement: the parameters reflecting oxygen metabolism improved and the plasma level of cyanide decreased. The patient revived 1 1/2 hours after treatment. The arterial ketone body ratio (AKBR), which is the ratio of acetoacetate to beta-hydroxybutyrate in arterial blood and which reflects the redox state in liver mitochondria, improved dramatically following treatment. Because the AKBR changes in relation to electron transport in liver mitochondria, it seems to be a logical parameter for evaluating the effect of potassium cyanide poisoning on electron transport. The AKBR also reflects the efficacy of treatment for cyanide poisoning.

Effects of milrinone on lung water content in dogs with acute pulmonary hypertension

To evaluate the effects of milrinone (MIL) on hemodynamics and lung water content, we used 10 mongrel dogs with pulmonary hypertension (PH). To induce pulmonary hypertension, we administered two injections of glass beads stirred in saline to dogs. Mean pulmonary arterial pressure (PAP) and pulmonary vascular resistance significantly increased following induction. Milrinone, which inhibits cyclic AMP phosphodiesterase-(PDE) demonstrated pulmonary vasodilation, indicated a reduction in these two parameters. To clarify the drug mechanism, we measured lung water content as extravascular lung thermal volume (ETVL) using a thermo/sodium double-indicator dilution method. The induction of pulmonary hypertension produced a transient reduction in extravascular lung thermal volume. The parameter remained constant following milrinone administration, whereas the control showed a gradual increase. Of the 10 dogs, five were killed to measure gravimetrically the volume of lung water content as a comparison with extravascular lung thermal volume. We concluded that milrinone produced pulmonary vasodilation which induced a reduction in the transmural capillary pressure gradient according to Starling's hypothesis. This study suggests that the reduction in the transmural pressure gradient induced by milrinone may also prevent the re-elevation in extravascular lung thermal volume. Milrinone increases the cyclic AMP level in the endothelium and in the platelet which may affect either directly or indirectly the permeability of capillary endothelium.

[Clinical course of asthmatics with severe asthma attack]

This study was conducted on 39 patients whose severe attacks of bronchial asthma with disturbance of consciousness required admission to the ICU of our hospital between 1984 and 1989. Among the 39 patients, there were 16 deaths. Most patients collapsed suddenly at home and were taken to our hospital. Arterial blood gas analysis at the time of admission to the ICU revealed that the PaO2 levels were as high as 252.6 +/- 57.6 (mean +/- S.E.) Torr in non-survivors and 221.0 +/- 29.7 Torr in survivors, with no significant difference because of prior oxygen therapy in almost all cases. Systolic blood pressure was 14.8 +/- 10.8 (mean +/- S.E.) mmHg, with marked circulatory disturbance in the fatal cases. Most patients displayed marked disturbance of consciousness, but maintenance of blood pressure led to recovery without sequelae despite marked disturbance of consciousness in most patients.

An initial comparison of intensive care in Japan and the United States

OBJECTIVE

The objective of this study was to compare the utilization of, and outcome from, critical care services in selected medical centers providing secondary and tertiary care in the United States and Japan.

DESIGN

Prospective data collection on 1,292 patients from each of the participating Japanese study hospitals in 1987 to 1989 and compared with the 5,030 patients in the United States 1982 Acute Physiology and Chronic Health Evaluation (APACHE II) database used to develop the APACHE II equation. Detailed organizational characteristics of the participating ICUs and hospitals were also obtained.

SETTING

Data collection took place in the ICUs of 13 U.S. hospitals and six Japanese hospitals.

PATIENTS

Data were collected on consecutive, unselected patients from medical, surgical, and mixed medical/surgical critical care units, with a spectrum of medical and surgical diagnoses.

MEASUREMENTS AND MAIN RESULTS

U.S. and Japanese ICUs have a similar array of diagnostic and therapeutic modalities. Only 2% (range 0.6 to 3.5) of beds in Japanese hospitals were designated to intensive care. The organization of the Japanese and U.S. ICUs varied by hospital. There were significantly fewer women admitted to Japanese ICUs and a substantially lower proportion of low-risk-of-death patients. Despite a rapidly aging population, there were relatively fewer elderly patients with chronic health ailments in the Japanese ICU population (8%) compared with the U.S. cohort (18%).

CONCLUSIONS

In this sample of hospitals, similar high-technology critical care is available in the United States and Japan. Variations in utilization between the two countries represent differences in case mix and bed availability. The APACHE II equation stratified patients in the Japanese patient cohort across the full spectrum of increasing severity of illness.

Comparative effects of dopamine and dobutamine on the pulmonary haemodynamic response to hypoxia in dogs ventilated with a hypoxic gas mixture

1. The effects of dopamine and dobutamine on the pulmonary haemodynamic response to hypoxia were studied in nine anaesthetized dogs under hypoxaemia induced by ventilation with hypoxic gas mixture. 2. From the present study, only dopamine infusion reduced arterial oxygenation during hypoxic hypoxaemia, whereas catecholamine maintained it at the same level during normoxaemia. 3. A redistribution of perfusion to the pulmonary vasculature may be related to a reduction of arterial oxygenation with dopamine infusion during hypoxic hypoxaemia. 4. It is presumed that an increase in pulmonary blood flow would emphasize an inhibition of hypoxic pressor response in the pulmonary vasculature, which may not be a direct effect of dopamine.

[Improving effect of the synthetic protease inhibitor E-3123 on experimental DIC in dogs]

Disseminated intravascular coagulation (DIC) is a severe syndrome associated with generalized, intractable bleeding and multiple organ failure. Synthesized protease inhibitors such as gabexate mesilate and nafamostat mesilate show an improving effect on DIC, which develops by a chain reaction involving the coagulation, fibrinolysis, complement and kallikrein systems. Experimental DIC was developed in Beagle dogs by infusion of 150 U/kg tissue thromboplastin (Group I), and the improving effect of a new synthetic protease inhibitor, E-3123, was examined. The following groups of animals were treated with drugs: Group II (n = 4) was given with 5 mg/kg/hr of E-3123; group III (n = 4) was given 10 mg/kg/hr of E-3123; and group IV was given 6 mg/kg/hr of gabexate mesilate (GM). Although improvement of the hemodynamics or peripheral circulation was not apparent, a slight, but insignificant, improvement of lactate/pyruvate was noted in the treated groups. On the other hand, the hemostatic abnormalities such as prolongation of prothrombin time and activated thromboplastin time; decreases of platelet count, fibrinogen and alpha 2-antiplasmin; and increases of fibrin degradation products were significantly improved in the treated groups. These results indicate that E-3123 is effective for improving experimental DIC, and it is suggested that E-3123 is applicable for the treatment of clinical DIC.

Changes in hemodynamics and myocardial metabolism following discontinuation of a dopamine or dobutamine infusion

Hemodynamics and myocardial metabolism were studied in 20 anesthetized dogs following discontinuation of a dopamine (DA) or dobutamine (DB) infusion. Both groups showed significant decreases in HR, AP, dP/dt, CI, MBFI, and MVO2. Discontinuation of DA decreased lactate extraction, whereas this did not occur with DB. The arteriocoronary venous differences in reduction-oxidation electrical potential (delta Eh) decreased significantly immediately following an abrupt discontinuation of the DA infusion, whereas DB maintained delta Eh at a constant level during and following infusion. Thus, aerobic metabolism was maintained following the discontinuation of DB, and anaerobic metabolism in the myocardium was accelerated immediately following discontinuation of the DA infusion. Although the mechanism that produces the differences observed between DA and DB following discontinuation is not understood, it may result from stimulation of alpha 1-receptors in the myocardium, produced by the residual high level of myocardial tissue norepinephrine (NE) following the termination of DA. A high tissue level of NE combined with a low plasma level of DA may cause an oxygen imbalance of the myocardium, demonstrated by an increase in myocardial oxygen demand and by a reduction in coronary blood flow. It is speculated that this mechanism of oxygen imbalance is a possible explanation for the anaerobic metabolism observed following DA discontinuation.

Vasodilatory effects of milrinone on pulmonary vasculature in dogs with pulmonary hypertension due to pulmonary embolism: a comparison with those of dopamine and dobutamine

1. The limited therapeutic role of pulmonary vasodilation reflects lack of their selectivity for the pulmonary vasculature, and many drugs have been evaluated for effectiveness; however, none has gained widespread clinical use. 2. Milrinone (MIL) is a newly synthetized phosphodiesterase inhibitor, which has potent positive inotropic and vasodilatory effects. 3. The present study shows the effects of MIL on the pulmonary circulation in dogs with pulmonary hypertension due to autologous muscle-induced pulmonary embolism, and also demonstrates a comparison with those of dopamine and dobutamine. 4. As MIL showed potent vasodilatory effects on the pulmonary vasculature, it had a potential clinical role in the treatment of pulmonary hypertension.

[Clinical results of selective treatment for flail chest]

A better understanding in pathophysiology of flail chest has brought an evolution to the principles of it's management. The methods of stabilization changed from surgical to pneumatic measures and now, a concept of conservative treatment is recognized. Adhering to our protocol for flail chest, which essentially limits mechanical ventilation, we have prospectively treated 36 patients since 1981. The patient were divided into two groups according to their need for mechanical ventilation. There were 16 patients (44.4%) in a group treated in conservative manner and with no mechanical ventilation (Group A). There were 20 patients (55.6%) in a group treated by mechanical ventilation (Group B). Group A had 6.2% incidence of pneumonia, 3.6 days average stay in ICU and mortality rate of 0%. Group B had 75% pneumonia, 22.5 days average in ICU and 15% mortality. Group B patients required respiratory support for 14 days average, which was not reduced by surgical stabilization. Restrictive pulmonary disturbance in group A was milder than that of group B, and this again was not affected by surgical stabilization. We conclude that 40% of flail chest are controllable without mechanical ventilation and that the result of this conservative therapy is superior to any other treatments.

Selective pulmonary vasodilatory effect of ZSY-27 in dogs with pulmonary hypertension due to pulmonary embolism

The pulmonary vasodilator effect of ZSY-27, a newly synthesized phosphodiesterase inhibitor, was studied in dogs with pulmonary hypertension resulting from autologous muscle-induced pulmonary embolism (PE). A bolus injection of ZSY-27 (1 mg/kg) significantly decreased mean pulmonary arterial pressure from 32 +/- 4 to 24 +/- 5 mm Hg and pulmonary vascular resistance index from 415 +/- 60 to 316 +/- 94 dyne.sec/cm5.m2. ZSY-27 did not change mean arterial pressure. The cardiac index was slightly increased and the systemic vascular resistance index was slightly decreased after ZSY-27 injection, but these changes were not statistically significant. This study suggests that ZSY-27 is a possible therapeutic agent for pulmonary hypertension secondary to PE.

Extracorporeal lung assist for patient with hypercapnia due to status asthmaticus

A 62-year-old female was brought to our emergency room in status asthmatics. She needed mechanical ventilation because of hypercapnia. However, effective mechanical ventilation was difficult because of severe airflow obstruction. Instead of conventional mechanical ventilation, we used extracorporeal lung assist (ECLA) to prevent barotrauma and lung tissue damage, and to reduce the doses of sedatives and muscle relaxants needed.

Impaired effect of dopamine on cardiac output during octopamine infusion

The hemodynamic effects of octopamine (OCT) were studied before and during dopamine (DA) infusion in six normal dogs. Before OCT infusion, DA significantly increased cardiac index (CI) from 3.24 +/- 0.20 to 4.90 +/- 0.30 L/min X m2 and significantly decreased systemic vascular resistance index (SVRI) from 3700.2 +/- 212.5 to 2618.3 +/- 156.6 dyne X sec/cm5 X m2, without changing heart rate. During OCT infusion, DA failed to increase CI or decrease SVRI; however, it significantly increased heart rate from 153.3 +/- 12.9 to 183.0 +/- 17.0 beat/min. This suppression of a DA-related increase in cardiac output may explain why DA is ineffective in those septic patients with elevated plasma OCT levels.

Effect of reduced glutathione on hemodynamic responses and plasma catecholamine levels during metabolic acidosis

The effects of reduced glutathione (GSH) on plasma catecholamine (CA) levels and hemodynamics were studied in seven severely acidotic dogs, before and after dopamine (DA) infusion. Seven other dogs, also acidotic, received lactated Ringer's solution instead of GSH. Although metabolic acidosis decreased cardiac index (CI) in both groups, the decrease was significantly less in the GSH group. The significantly increased systemic vascular resistance index (SVRI) in the control group was suppressed by GSH infusion, although similarly high plasma CA levels were maintained in both groups. This suggests that GSH has certain vasodilating effects not related to adrenosympathetic activity. CI did not improve and DA infusion significantly increased SVRI in the control group, whereas CI increased with a mild decrease of SVRI in the GSH group. The rise of plasma norepinephrine after DA infusion was low in the GSH group compared to the increase in the control group. This study suggests that during acidosis GSH improves hemodynamics and restores the effects of DA on cardiac output.

Plasma catecholamine levels and hemodynamic responses of severely acidotic dogs to dopamine infusion

Changes in plasma catecholamine (CA) levels and hemodynamic responses after a dopamine (DA) infusion of 20 micrograms/kg body weight per min were studied in dogs with a normal acid-base state (pH 7.4, PaCO2 40 torr) and in the same animals after induction of severe metabolic acidosis (pH 7.0, PaCO2 40 torr). DA increased plasma norepinephrine (NE) levels from .487 +/- .109 ng/ml to 3.077 +/- 0.357 ng/ml in the normal acid-base state, and from 1.762 +/- .521 ng/ml to 9.533 +/- 1.403 ng/ml in acidosis. Plasma epinephrine (E) levels in normal and acidotic states were also increased by DA infusion. In the normal acid-base state DA increased myocardial contractility and cardiac index (CI). DA also increased myocardial contractility during acidosis, but the response of CI to DA was abolished. DA significantly decreased systemic vascular resistance index (SVRI) in the normal acid-base state and significantly increased SVRI in acidosis. Acidosis appears to enhance the rate of conversion of DA to NE and E. The failure of DA to increase CI in acidosis may be a result of the increased afterload on the left ventricle.