Does indocyanine green accurately measure plasma volume independently of its disappearance rate from plasma in critically ill patients?

OBJECTIVE

To determine whether plasma volume determined by the indocyanine green (ICG) dilution method (PV-ICG) is equally accurate independently of its disappearance rate from plasma in the critically ill.

DESIGN

Retrospective clinical investigation.

SETTING

Intensive care unit of a university teaching hospital.

PATIENTS AND METHODS

192 adult patients were initially enrolled. The PV-ICG and the initial distribution volume of glucose (IDVG) were calculated utilizing a one-compartment model by simultaneous administration of ICG 25 mg and glucose 5 g on the first day of measurement in each patient. Twenty-one patients were excluded from the study because of a higher PV-ICG/IDVG ratio (> 0.45) indicating apparent overestimation of the PV-ICG associated with the generalized protein capillary leakage. The remaining 171 patients were divided into four groups according to the magnitude of their disappearance rate of ICG from plasma (Ke-ICG).

RESULTS

Convergence was assumed consistently in each ICG or glucose decay curve, even in the lower Ke-ICG less than 0.10/min. The relationship between the two volumes was not statistically different among groups.

CONCLUSIONS

The results suggest that the measurement of the PV-ICG can be equally accurate independently of its disappearance rate from plasma unless there is generalized protein capillary leakage.

Mimicry of CD40 signals by Epstein-Barr virus LMP1 in B lymphocyte responses

The effect of the Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) on the activation and differentiation of normal B cells was investigated. B cells of transgenic mice expressing LMP1 under the control of immunoglobulin promoter/enhancer displayed enhanced expression of activation antigens and spontaneously proliferated and produced antibody. Humoral immune responses of LMP1 transgenic mice in CD40-deficient or normal backgrounds revealed that LMP1 mimics CD40 signals to induce extrafollicular B cell differentiation but, unlike CD40, blocks germinal center formation. Thus, these specific properties of LMP1 may determine the site of primary B cell infection and the state of infection in the natural course of EBV infection, whereas subsequent loss of LMP1 expression may affect the site of persistent latent infection.

Antioxidants from Lespedeza homoloba. (I)

The stems of Lespedeza homoloba yielded eight new and three known phenolic compounds. Their structures have been elucidated on the basis of their spectral data. These compounds had strong antioxidative activity against lipid peroxidation in the rat brain homogenate test. 3,9-Dihydroxypterocarp-6a-en and lespedezol A2 showed significant antiallergic activity in allergic (type I) mice.

An aberrant left subclavian artery aneurysm with right aortic arch: report of a case

The case of a 41-year-old man who developed an aneurysm in his aberrant left subclavian artery is described. The patient had a right aortic arch. After a successful aortosubclavian artery bypass, symptoms due to brain ischemia disappeared. This is a very rare disease that is sometimes associated with an aortic anomaly, therefore the optimal therapeutic procedure need to be carefully selected, including the operative indications and approach.

p57(Kip2) is degraded through the proteasome in osteoblasts stimulated to proliferation by transforming growth factor beta1

Cyclin-dependent kinase inhibitory proteins are negative regulators of the cell cycle. Although all the cyclin-dependent kinase inhibitory proteins may be involved in cell cycle control during a differentiation process, only p57(Kip2) is shown to be essential for embryonic development. However, the role of p57 in the control of the cell cycle is poorly understood. Using osteoblasts derived from the calvaria of rat fetus, we show that p57 is accumulated in cells starved by low serum. Cyclin-dependent kinase 2 activity was suppressed in these cells with a significant amount bound to p57. Treatment of the cells with transforming growth factor beta1 dramatically reduced the amount of p57, resulting in an activation of cyclin-dependent kinase 2 activity and the stimulation of cell proliferation. The decrease in p57 was inhibited by treating the cells with proteasome inhibitors, Z-Leu-Leu-Leu-aldehyde or lactacystin, but not with Z-Leu-Leu-aldehyde, which is an inhibitor of calpain, indicating that p57 is degraded through the proteasome pathway. p57 was also shown to be ubiquitinated in vitro. Because transforming growth factor beta1 not only stimulates the growth but also inhibits the differentiation of the cells in this system, our results may suggest a possible involvement of p57 in the control of osteoblastic cell proliferation and differentiation.

The effects of various GTP analogues on microtubule assembly

We synthesized 27 GTP analogues with modification or substitution at positions C2, C6, C8 and ribose moiety to investigate their effect on microtubule (Mt) assembly. It was found that C2 and C6 are both functional for the analogues supporting Mt assembly. It was surprising to find that 2-amino- ATP (n2ATP) substantially supports assembly, and that the appearance of the assembled Mts was indistinguishable from those assembled in the standard GTP assembly buffer solution. Furthermore, 2-amino dATP and dGTP are even more potent than GTP in supporting assembly. The substitution of oxo group at C6 with reactive thiol largely reduced the activity of the analogue to support assembly. When free rotation of the glycosidic linkage of GTP was blocked by the introduction of sulfur atom between C8 and C2' of ribose moiety, it resulted in total suppression of assembly. Purine nucleoside triphosphate was found to support assembly better than GTP, and even more efficient was 2-amino purine nucleoside triphosphate. Interestingly, their deoxy-type analogues were totally inhibitory. Although 2-amino 8-hydroxy ATP and other analogues supported assembly much better than did GTP, their diphosphate analogues were totally incapable of supporting assembly. Finally, bulky fluorescent probes were introduced at C3' of ribose moiety (Mant-8-Br-GTP or Mant-GTP) to visualize the fluorescent signal in assembled Mts. Even in this case, the number of most protofilaments was found to be 14, consistent with that found in Mts assembled in GTP standard buffer solution.

Our treatment of cleft lip and cleft palate

Our principle in cleft lip and cleft palate repair is all-round personal treatment. That is, treatment concentrates not only on cleft lip and cleft palate repair, but also considers the patient comprehensively in terms of his or her personality. In this report, we present patients with cleft lips and/or cleft palates for whom we performed surgical treatments in the past 25 years. We performed primary operations for 402 patients and secondary operations for 120. Cleft lip and cleft palate should be managed with consideration for otolaryngeal aspects as well as plastic surgical ones because of the nature of the disease. We therefore treated our patients from the standpoints of both medical fields, and gained much appreciation from parents whose children suffered from the congenital anomaly.

Twenty years of statistics and observation of facial bone fracture

We analyse the details of patients with facial bone fractures who visited us from 1993 to 1997, and compare past cases treated from 1978 to 1992. From 1993 to 1997, the total numbers of patients and fractures were 633 and 697, respectively. Thus, we had 127 patients and 139 fractures annually. The number of patients has increased over the years. The highest occurrence rate of facial bone fracture was in the nasal bone (half of all), followed by the malar bone, blowout fractures and the mandibular bone. The rate was the lowest in the maxillary bone. The ratio of males to females was 7:3. Facial bone fractures were most often seen in the 10-29 age group.

Surgical treatment for greater sphenoid wing fracture (orbital blow-in fracture)

The authors present 2 patients with greater sphenoid wing fractures that were treated surgically. This type of fracture is classified as a blow-in fracture of the lateral orbital wall. The first patient was a 16-year-old boy who was involved in a motor vehicle accident. Computed tomography (CT) disclosed a medial displacement of the inner wall of the greater sphenoid wing of the left orbit. He was unconscious for 3 days. After he recovered consciousness, he presented limited abduction of the left eye with diplopia in all gaze directions and mild left proptosis. Although these symptoms did not improve for 1 week, displaced bone fragments of the greater sphenoid wing were removed via the lateral orbital approach. The patient had a good postoperative course with progressive improvement in eye movement over the next several weeks. The second patient was a 22-year-old man whose face was hit in a fight. CT disclosed medial displacement of the inner wall of the greater sphenoid wing of the left orbit. Although the patient also presented limited abduction of the left eye on admission, this symptom improved gradually. However, diplopia in all gaze directions and mild left proptosis did not improve. Therefore, the displaced inner wall of the greater sphenoid wing was reduced via the lateral orbital approach. The patient showed a good postoperative course with progressive improvement over the next several weeks. This type of orbital fracture, which is classified as an orbital blow-in fracture, is relatively rare. This type of greater sphenoid wing fracture is caused by buckling of the orbital wall secondary to severe compression of the orbital rim. Surgical treatment using the lateral orbital approach through a hemicoronal skin incision afforded a wider operative field and better cosmetic result.

Intraoperative modulation of alveolar macrophage function during isoflurane and propofol anesthesia

BACKGROUND

Alveolar macrophages are a critical part of the defense against pulmonary infection. Thus the authors determined time-dependent changes in alveolar macrophage functions in patients having surgery who were anesthetized with isoflurane or propofol.

METHODS

Patients anesthetized with propofol (n = 30) or isoflurane (n = 30) during orthopedic surgery were studied. Alveolar macrophages were harvested by bronchoalveolar lavage immediately, and 2, 4, and 6 h after induction anesthesia and at the end of surgery. The fraction of aggregated and nonviable macrophages was determined. Then phagocytosis was measured by ingestion of opsonized and unopsonized particles. Finally, microbicidal activity was determined as the ability of the macrophages to kill Listeria monocytogenes directly.

RESULTS

Demographic and morphometric characteristics of the patients given propofol and isoflurane were similar, as were their levels of pulmonary function and hemodynamic responses. The fraction of alveolar macrophages ingesting opsonized and unopsonized particles, and the number of particles ingested, decreased significantly over time, with the decrease slightly but significantly greater during isoflurane anesthesia. Microbicidal function decreased progressively during anesthesia and surgery, with the decrease almost twice as great during isoflurane compared with propofol anesthesia. The fraction of aggregated macrophages and recovered neutrophils increased over time in the patients given each anesthetic.

CONCLUSIONS

Pulmonary immunologic function changed progressively during anesthesia and surgery. The data from this study suggest that pulmonary defenses are modulated by the type of anesthesia and by the duration of anesthesia and surgery.

Plasma dehydroepiandrosterone sulfate in unipolar major depression. Short communication

We investigated plasma dehydroepiandrosterone sulfate (DHEAS) and cortisol levels in 12 patients with unipolar depression and 11 matched normal controls. The depressed patients showed significantly higher values of plasma DHEAS and cortisol than the controls. After 4 weeks of treatment with antidepressants (mainly clomiplamine), the high plasma DHEAS levels recovered. This finding showed the possible relationship between plasma DHEAS levels and depression, as well as cortisol levels.

Osteolipoma in the parapharyngeal space

We report our experience in managing a 58-year-old Japanese woman with a rare parapharyngeal interstitial cell tumor. Her main complaint was that of a submandibular swelling, which was diagnosed as osteolipoma histologically after resection.

A study of intestinal dysfunction induced by restraint stress in rats

BACKGROUND

The pathogenesis of intestinal dysfunction induced by stress has not been established. We tried to clarify possible causal mechanisms of irritable bowel syndrome.

METHODS

An experimental model of intestinal dysfunction was designed using loading restraint stress in rats. A cannula was inserted into the origin of the duodenum or colon, with the other end leading to the skin. To provide intestinal content, a semi-solid colored marker was used for monitoring intestinal transit. After 1 week the marker was injected into the intestine through the cannula under unanesthetized wakefulness.

RESULTS

Under restraint stress, transit in the small intestine was suppressed, but actual suppression took place only in the upper half, where the contents normally moved fast. Transit time in the colon was reduced by restraint stress. This reduction was attributed to the disappearance of the stagnant region, which was present under normal conditions.

CONCLUSIONS

These results suggested that restraint stress affects the function of the pacemaker site of the intestine.

Genotoxicity of ribo- and deoxyribonucleosides of 8-hydroxyguanine, 5-hydroxycytosine, and 2-hydroxyadenine: induction of SCE in human lymphocytes and mutagenicity in Salmonella typhimurium TA 100

The induction of SCE by ribo- and deoxyribonucleosides of 8-hydroxyguanine, 5-hydroxycytosine, and 2-hydroxyadenine was tested using human peripheral blood lymphocytes. All of these compounds caused an increase in SCE frequency. The potency of SCE induction was as follows: 5-OH-C, 5-OH-dC > 8.OH-G > 8-OH-dG > 2-OH-A, 2-OH-dA. These results suggest that the oxidized nucleosides are incorporated into DNA with different efficiencies (or are repaired with different efficiencies) and exhibit genotoxicity in human blood cells. Ribo- and deoxyribo-derivatives of 5-OH-Cyt and 2-OH-Ade also showed mutagenic activity in Salmonella typhimurium TA 100.

Effects of carbon monoxide exposure on serotonergic neuronal systems in rat brain

It is well known that some psychiatric sequelae exist after CO poisoning, but few animal studies on serotonergic neuronal function after CO exposure have been carried out. We investigated the effects of successive carbon monoxide (CO) exposure (6000 ppm, 10 min, 3 repetitions) on serotonergic neuronal systems in rat brain. Serotonin (5-HT) concentrations were significantly decreased only in the frontal cortex from 1 hr to 7 days after CO exposure. 5-Hydroxyindoleacetic acid (5-HIAA) concentrations were significantly increased at 1 hr in all six brain regions measured (frontal cortex, striatum, hypothalamus, hippocampus, midbrain, and pons). 5-HT synthesis, measured by the accumulation of 5-hydroxytryptophan (5-HTP) after the administration of m-hydroxybenzylhydrazine (NSD-1015), was significantly decreased in all regions from 1 hr to 7 days after CO exposure. [3H]Ketanserin (5-HT2A) binding sites in the frontal cortex were not affected by CO exposure. DOI-induced head shakes, a 5-HT2A receptor mediated behavior, were not changed after CO exposure. These findings indicated that CO exposure caused presynaptic serotonergic neuronal dysfunctions that consisted mainly of decreased concentration of 5-HT in the frontal cortex or a decrease of 5-HT synthesis in all six regions, without compensatory hyperfunction of 5-HT2A receptors.

Synthesis of guanosine 5'-triphosphate analogues and their effect on microtubule assembly

More than 20 base-modified analogues of guanosine 5'-triphosphate including 2'-deoxyguanosine derivatives were synthesized and examined their effect on tubulin polymerization into microtubules (Mts). Among those, 2,6-diamino-8-oxopurineriboside 5'-triphosphate (1d), 2,6-diamino-2'-deoxypurineriboside 5'-tri phosphate (1b) and 8-bromoguanosine 5'-tri phosphate (1g) were shown to have remarkable effect to promote microtubule assembly.

Evaluation of intestinal pressure-controlled colon delivery capsule containing caffeine as a model drug in human volunteers

The delivery ability of a pressure-controlled colon delivery capsule (PCDC) containing caffeine as a test drug was evaluated after oral administration to healthy male human volunteers. The driving force causing PCDC disintegration in the intestinal tract is the physiological luminal pressure which results from peristalsis. Three kinds of PCDCs having different thickness of a water-insoluble polymer membrane was prepared by coating the inner surface of the gelatin capsules with ethylcellulose (EC). The mean thickness were 40 +/- 1 (SE) for type 1, 44 +/- 1 for type 2 and 50 +/- 1 micron for type 3 PCDC, respectively. Caffeine was dissolved with a suppository base (PEGs 400 and 1000) and the capsules were filled. Doses were 15, 45 or 75 mg. After blank saliva samples were obtained, test preparations were orally administered to the volunteers and saliva samples were collected for 1 min intervals hourly from 1 to 10 h in the fasted state study, and from 1 to 20 h and at 25 h in the fed state study. Caffeine concentrations in the saliva samples were analyzed by HPLC. The maximum salivary caffeine excretion rate increased as the oral caffeine dose increased. The maximum salivary caffeine excretion rate increased predominantly compared to the pre-dose level in 75 mg dose study. Therefore, all following studies were performed with this dose. The first appearance time of caffeine into the saliva, TI, was used as a parameter to estimate the disintegration time of test preparations in the gastrointestinal tract. The mean TI of types 1, 2, and 3 PCDCs were 3.0 +/- 0.4, 4.0 +/- 0.4 and 4.5 +/- 0.3 h, respectively. After oral administration of 75 mg caffeine in pain gelatin capsule as a reference preparation, caffeine appeared in the saliva within 0.5 h. The mean hardness of the PCDCs were 1.05 +/- 0.10 (type 1), 1.55 +/- 0.06 (type 2) and 2.08 +/- 0.15 newton (type 3), respectively. There were good correlations between three parameters: EC coating membrane thickness, hardness and TI (determination coefficient r2 = 0.935 between TI and thickness, r2 = 0.998 between thickness and hardness, r2 = 0.958 between hardness and TI). The effect of food intake on the delivery ability was examined with type 3 PCDCs. Food intake prolonged the mean TI, from 4.5 +/- 0.3 to 7.8 +/- 1.3 h. This increase is thought to be ascribed to prolonged gastric emptying time. Comparison with reported colon arrival times indicates that the type 3 PCDC functions in colon delivery of caffeine and is thought to be applicable to other drugs.

[Ulcerative colitis--colon delivery of 5-aminosalicylic acid]

Ulcerative colitis, Crohn's disease and hemorrhage colitis are typical example of colon specific diseases. The targeting of the drugs for these colon specific diseases was attempted by a new technology, where ethylcellulose (EC) was used as pharmaceutical material. Especially, pressure-controlled colon delivery capsule (PCDC) made of EC is a unique system. PCDC was prepared by coating the inner surface of gelatin capsule with water-insoluble polymer, EC. By adjusting the coating thickness of EC membrane to be approximately 40 microns, colon delivery of dug were obtained both in beagle dogs and human volunteers. PCDC containing 5-ASA was prepared and was administered orally to beagle dogs. After administration, 5-ASA appeared into the systemic circulation at 3-5 h which corresponds to the colon arrival time confirmed with sulfasalazine.

Importance of dissolution process on systemic availability of drugs delivered by colon delivery system

The relationship between in vitro drug release characteristics from colon delivery systems and in vivo drug absorption was investigated using three kinds of delayed-release systems. 5-aminosalicylic acid (5-ASA), tegafur (FT) and carbamazepine (CBZ) were selected as model drugs. Pressure-controlled colon delivery capsules (PCC) for liquid preparations, time-controlled colon delivery capsules (TCC) for liquid and solid preparations and Eudragit S coated tablets for solid preparations were used in this study. At first, in vitro dissolution tests for all preparations were performed. Drug release from solid preparations was delayed compared to that from liquid preparations with all three drugs. Next, these preparations were administered to fasted beagle dogs. For 5-ASA, the mean Cmaxs (peak level) of Eudragit S coated tablets and PCC were 5.52 and 16.89 micrograms ml-1, respectively. The mean Tmaxs (time when drug reached peak level) were 3.0 and 5.3 h. AUCs were 22.57 and 48.09 micrograms.h ml-1, respectively. For FT, Cmaxs of Eudragit S coated tablet and PCC were 0.87 and 1.46 micrograms ml-1, and Tmaxs were 7.0 and 6.7 h, respectively. AUCs were 9.73 and 15.55 micrograms.h ml-1 and bioavailabilities were 43.79 and 70.84%. For CBZ, the mean Cmaxs of liquid preparations and solid preparations were 0.37 and 0.22 micrograms ml-1, respectively. The mean Tmaxs were 4.7 and 4.3 h. AUCs were 0.673 and 0.392 micrograms.h ml-1. With liquid preparations, drug was thought to contact to the colonic membrane easily because of lack of interference by stools, and to be absorbed well as compared with solid preparations. From these findings, drug release from colon delivery systems and drug dissolution in the colonic lumen are very important factors for the systemic availability of drugs from the colon delivery systems.

[Perioperative management of a patient with cryoglobulinemia for open heart surgery]

A 57-year-old male with cryoglobulinemia underwent an aortic valve replacement for aortic regurgitation under total intravenous anesthesia with droperidol, fentanyl and ketamine in combination with mild hypothermic cardiopulmonary bypass (esophageal temperature = 34 degrees C). Preoperative steroid therapy with prednisolone of daily dose from 40 to 7.5 mg for six months and plasma exchange (3200 ml) on the day before the operation were performed to attenuate the degree of cryoglobulinemia. He showed an uneventful intraoperative course and there was no postoperative complication associated with cryoglobulinemia.

Drastic genetic instability of tumors and normal tissues in Turcot syndrome

Turcot syndrome is characterized by an association of malignant brain tumors and colon cancer developing in the patient's teens. Since the mechanism of carcinogenesis in Turcot syndrome is still unclear, we analysed genetic changes in tumors from a Turcot patient with no family history of the condition. All tumors, including one astrocytoma, three colon carcinomas, and two colon adenomas, exhibited severe replication error (RER), and all colon tumors showed somatic mutations at repeated regions of TGFbetaRII, E2F-4, hMSH3, and/or hMSH6 genes. Somatic APC mutations were detected in three of three colon carcinomas, and somatic p53 mutations were detected in the astrocytoma and two of three colon carcinomas, both of which showed two mutations without allele loss. We also found that normal colon mucosa, normal skin fibroblasts and normal brain tissue from this patient showed respective high frequencies of RER, in contrast to usual HNPCC patients in which RER was very rare in normal tissues. These results suggest that extreme DNA instability in normal tissues causes the early development of multiple cancer in Turcot syndrome. A missense mutation (GAG to AAG) at codon 705 of hPMS2 gene was detected in one allele of this patient, which was inherited from his mother without tumors. Additional unknown germline mutation may contribute to the genetic instability in normal tissues.

First case of surgical treatment of Farber's disease

Farber's disease (Farber's lipogranulomatosis), which is inherited as an autosomal recessive trait, was first reported by Farber in 1952. We report a case of Farber's disease in a 12-year-old female. Her younger brother was affected with Farber's disease and died of it at 2 years of age. When she first presented, our patient's main clinical features were a shrill voice; subcutaneous nodules; contracture of the joints throughout the body; and granulomas of the oral cavity, the pharynx, and the upper and lower eyelids. Serial radiographs disclosed deformation of the joints throughout the body. Due to the granulomas in her oral cavity, she could take little food orally and therefore was malnourished. We performed a granulectomy under general anesthesia, and her difficulty with feeding and upper airway obstruction improved. There is no specific treatment for Farber's disease, and most patients reported have died by 2 years of age. This is the first reported patient with Farber's disease who has been surgically treated.

[Surgical results of emergency coronary artery bypass grafting: effect of left main trunk lesion]

Emergency coronary artery bypass grafting has higher risk than elective surgery. Furthermore, if a lesion is located at left main coronary artery, the frequency of cardiogenic shock or high risk patient would be greater, and operative results would be worse. Between January, 1989 and December, 1995, 45 patients who underwent emergency CABG were included. Age ranged 44 to 80 years (mean 67 +/- 7.6 years; 31 men, 14 women). Of 45 cases, 12 cases were patients with LMT lesion. Results were analysed by univariate analysis and multivariate logistic analysis. Of 45 emergency cases, 5 were operative death and 3 were hospital death. Mortality rate was 17.8%, which was significantly higher than the mortality of elective CABG (2.8%) during the same period (p < 0.001). A factor that influenced the mortality was acute myocardial infarction (AMI), which was confirmed by both univariate and multivariate logistic analyses. Odds ratio (relative risk) was 12.4 for AMI. Only one patient died in 12 cases with LMT (8.3%). This case was due to complication after catheter intervention possibly caused by MOF. Thus, the relative risk of LMT was not so high (p = n.s). Other factors showed no significant correlation. Although the emergency case of LMT lesion was generally severe, we could have the same result as other emergency surgeries when patients were revascularized as soon as possible.