[Susceptibilities of bacteria isolated from patients with lower respiratory infectious diseases to antibiotics (1997)]

The bacteria isolated from the patients with lower respiratory tract infections were collected by institutions located throughout Japan, since 1981. Ikemoto et al. have been investigating susceptibilities of these isolates to various antibacterial agents and antibiotics, and analyzed some characteristics of the patients and isolates from them each year. Results obtained from these investigations are discussed. In these 17 institutions around the entire Japan, 512 strains of presumably etiological bacteria were isolated mainly from the sputa of 440 patients with lower respiratory tract infections during the period from October in 1997 to September in 1998. MICs of various antibacterial agents and antibiotics were determined against 100 strains of Staphylococcus aureus, 81 strains of Streptococcus pneumoniae, 85 strains of Haemophilus influenzae. 71 strains of Pseudomonas aeruginosa (non-mucoid strains), 27 strains of Pseudomonas aeruginosa (mucoid strains), 33 strains of Moraxella subgenus Branhamella catarrhalis, 17 strains of Klebsiella pneumoniae etc., and the susceptibilities of these strains were assessed except for those strains that died during transportation. S. aureus strains for which MICs of oxacillin (MPIPC) were higher than 4 micrograms/ml (methicillin-resistant S. aureus: MRSA) accounted for 55.0%. The frequency of the drug resistant bacteria decreased comparing to the previous year's 67.3%. Arbekacin (ABK) and vancomycin (VCM) showed the most potent activities against MRSA. Imipenem (IPM) and panipenem (PAPM) of carbapenems showed the most potent activities with MIC80S of 0.063 microgram/ml against S. pneumoniae. The frequency of penicillin (PC)-intermediate S. pneumoniae (PISP)+PC-resistant S. pneumoniae (PRSP) had decreased gradually, that is, in 1995 the frequency of it was 40.3%, but that was 30.9% in 1997. Against H. influenzae and M.(B.) catarrhalis, all the drugs showed good activities. But the sensitive strains of them against ceftazidime (CAZ) had decreased in 1997, compared those in 1995 and 1996. Meropenem (MEPM), IPM and tobramycin (TOB) showed the most potent activity against P. aeruginosa (mucoid strains). And TOB and ciprofloxacin (CPFX) showed the most potent activities against P. aeruginosa (non-mucoid strains). All drugs except ampicillin (ABPC) were more active against K. pneumoniae in 1997 than that in 1996. Also, we investigated year to year changes in the characteristics of patients, their respiratory infectious diseases, and the etiology. The examination of age distribution indicated that the proportion of patients with ages over 70 years was 45.5% of all the patients showing a slight increase year by year. About the proportion of diagnosed diseases, not so particular changes were recognized as follows: Bacterial pneumonia and chronic bronchitis were the most frequent with 33.6% and 29.1%, respectively. Number of strains isolated from patients before administration of antibiotics were more than those after administration of them in chronic bronchitis, but these had reversed in bacterial pneumonia. The tendency in bacterial pneumonia had been acknowledged since 1995. The increase of S. aureus and P. aeruginosa (both mucoid and non-mucoid strains) isolated after administration of antibiotics, has suggested the decrease of the susceptibility of these strains against antibiotics. Administration of antibiotics has changed the results of the frequency of isolation of bacterial species. Bacterial isolations before administration of antibiotics were as follows: S. pneumoniae 24.5%, H. influenzae 21.4%, S. aureus 18.4% and P. aeruginosa 12.2%. The frequencies of S. aureus decreased after antibiotics administration over 15 days, but the frequencies of P. aeruginosa was not affected. The frequencies of P. aeruginosa was 47.8% after administration over 15 days. From patients administered antibiotics of penicillins and cephems. S. aureus was mainly detected with 31.7-58.3%, and from patients administere

[A case of endotracheal tube obstruction caused by pneumoperitoneum during laparoscopic cholecystectomy]

A 56-year-old man with cholecystolithiasis was scheduled for laparoscopic cholecystectomy. Anesthesia was induced with pentazocine and propofol i.v., and the trachea was intubated using vecuronium i.v. Anesthesia was maintained with 70% nitrous oxide and 1-3% sevoflurane in oxygen, and vecuronium was used for muscle relaxation. The lungs were mechanically ventilated with a tidal volume of 600 ml and a respiratory rate of 8 cycles.min-1. Following induction of carbon dioxide pneumoperitoneum, blood pressure, PETCO2 and peak inspiratory pressure gradually increased. PETCO2 increased from 33 mmHg to 48 mmHg despite increase in the respiratory rate to 20 cycles.min-1. By 45 minutes after the beginning of surgery, PETCO2 had increased to 60 mmHg, and ventilation of the lungs was impossible. Bronchofiberscopy revealed obstruction of the endotracheal tube by tracheal mucosa. The endotracheal tube was then drawn out by 2 cm with slight recovery of ventilation. After 1 h 16 min of surgery, it was observed that the patient had developed pneumoscrotum and subcutaneous emphysema extending from femoral area, abdomen, and thorax to the right neck. Chest rentogenography revealed a slight tracheal shift and subcutaneous emphysema. One hour after the end of surgery, PaCO2 was 48.9 mmHg under spontaneous respiration. We speculate that the pneumoperitoneum shifted the tracheal carina cephalad, causing obstruction of the endotracheal tube. Our findings show that displacement of the endotracheal tube must be carefully monitored during laparoscopic cholecystectomy.

Usefulness of the [13C]-urea breath test for detection of Helicobacter pylori infection in fasting patients

Most of the reported [13C]-urea breath test procedures use a test meal, which is believed to assist in the spread of the [13C]-urea solution into the entire stomach, as results without a test meal may mainly reflect urease activity in the antrum.Yet, procedures for the [13C]-urea breath test and interpretation of the obtained 13C excess value have not been well established. We carried out the present study to validate the usefulness of the [13C]-urea breath test in fasting subjects and to establish cut-off values. [13C]-Urea breath tests were performed on 258 Helicobacter pylori-positive and 151 -negative subjects (247 H. pylori positive and 26 negative prior to any H. pylori cure treatment and 125 H. pylori negative and 11 positive after undergoing H. pylori cure treatment). The breath test procedure was performed under the following conditions: an 8 h fast, mouth washing before and after dosing, administration of 100 mg [13C]-urea, collection of breath sample in a plastic bag, a baseline and a 20 min sampling point and subject in a sitting position. Delta-13C at the 20 min sampling point in H. pylori-positive and -negative subjects was 31.0+/-1.25 and 1.6+/-0.11%, respectively. Although the mean delta13C value was greatest in duodenal ulcer or ulcer scar patients, there were no significant differences among mean delta13C values in the various diseases. From Receiver Operator Characteristic curves and calculation of accuracy of the test, a cut-off value of 5.0% is considered to be appropriate for diagnosis of H. pylori infection, which provides 96.7% specificity and 96.5% sensitivity, suggesting that the [13C]-urea breath test in the fasting state is as effective in detecting the presence of H. pylori as other reported methods.

Marginal irregularity of flat elevated type of colorectal tumor as a marker of malignant potential

BACKGROUND

The malignant potential of superficial elevated type tumors is still controversial. Because biopsy specimens alone are sometimes not sufficient for diagnosis due to histologic heterogeneity within the tumor, other clinical parameters for evaluation of the degree of malignancy would be helpful.

METHODS

A new morphometric parameter, the "F-circle," which represents the irregularity of the tumor margin, was studied in 115 endoscopically recognized superficial, flat, elevated type colorectal tumors without a central depressed area with respect to histologic evaluation of the degree of malignancy.

RESULTS

The mean F-circle values of adenomatous lesions with mild or moderate atypia, severe atypia, and adenocarcinoma were 0.709+/-0.115, 0.619+/-0.149, and 0.536+/-0.133, respectively.

CONCLUSION

The superficial elevated type of colorectal tumor having more marginal irregularity had a greater malignant potential, and the F-circle may be a useful clinical parameter for evaluation of the degree of malignancy.

Relapsed duodenal ulcer after cure of Helicobacter pylori infection

We report a patient--a 42-year-old man--who had suffered from recurrent duodenal ulcer for about 20 years. Successful curative therapy for Helicobacter pylori infection was performed for 2 weeks with new triple omeprazole, anoxicillin, clarithromycin (OAC) treatment in October 1995, and cure of the infection was repeatedly confirmed by histology, culture, and the 13C urea breath test. One month after the curative therapy, recurrence of a small duodenal ulcer was observed and in February another duodenal ulcer and reflux esophagitis occurred, with severe symptoms, despite the continuous administration of ranitidine. None of the examinations to reconfirm cure of the infection revealed the presence of H. pylori. As the patient experienced continual psychological stress and smoked more frequently during the recurrent episode and had not used nonsteroidal anti-inflammatory drugs, stress and smoking appeared to play important roles in the relapse of duodenal ulcer in this patient after cure of H. pylori infection.

[Susceptibilities of bacteria isolated from patients with lower respiratory infectious diseases to antibiotics (1996)]

The bacteria isolated from the patients with lower respiratory tract infections were collected by institutions located throughout Japan, since 1981. Ikemoto et al. have been investigating susceptibilities of these isolates to various antibacterial agents and antibiotics, and characteristics of the patients and isolates from them each year. Results obtained from these investigations are discussed. In 16 institutions around the entire Japan, 557 strains of presumably etiological bacteria were isolated mainly from the sputa of 449 patients with lower respiratory tract infections during the period from October 1996 to September 1997. MICs of various antibacterial agents and antibiotics were determined against 98 strains of Staphylococcus aureus, 93 strains of Streptococcus pneumoniae, 84 strains of Haemophilus influenzae, 84 strains of Pseudomonas aeruginosa (non-mucoid strains), 17 strains of Pseudomonas aeruginosa (mucoid strains), 31 strains of Moraxella subgenus Branhamella catarrhalis, 21 strains of Klebsiella pneumoniae etc., and the drug susceptibilities of these strains were assessed except for those strains that died during transportation. 1) S. aureus S. aureus strains for which MICs of oxacillin (MPIPC) were higher than 4 micrograms/ml (methicillin-resistant S. aureus) accounted for 67.3%. The frequency of the drug resistant bacteria increased comparing to the previous year's 52.7%. Arbekacin (ABK) and vancomycin (VCM) showed the highest activities against both S. aureus and MRSA with MIC80s of 1 microgram/ml. 2) S. pneumoniae Imipenem (IPM) and panipenem (PAPM) of carbapenems showed the most potent activities with MIC80s of 0.063 microgram/ml. Faropenem (FRPM) showed the next potent activity with MIC80 of 0.125 microgram/ml. The other drugs except erythromycin (EM), clindamycin (CLDM) and tetracycline (TC) were active against S. pneumoniae tested with MIC80s of 8 micrograms/ml or below. 3) H. influenzae The activities of all drugs were potent against H. influenzae tested with MIC80s of 4 micrograms/ml or below. Cefotiam (CTM), cefmenoxime (CMX), cefditoren (CDTR) and ofloxacin (OFLX) showed the most potent activities with MIC80s of 0.063 microgram/ml. 4) P. aeruginosa (mucoid strains) Tobramycin (TOB) showed the most potent activity against P. aeruginosa (mucoid strains) with MIC80 of 1 microgram/ml. Ceftazidime (CAZ), cefsulodin (CFS), IPM, gentamicin (GM), ABK and ciprofloxacin (CPFX) showed the next potent activities, with MIC80s of 2 micrograms/ml. The MIC80s of the other drugs ranged from 4 micrograms/ml to 16 micrograms/ml. 5) P. aeruginosa (non-mucoid strains) TOB and CPFX showed the most potent activities against P. aeruginosa (non-mucoid strains) with MIC80s of 1 microgram/ml. The MIC80s of piperacillin (PIPC) and cefoperazone (CPZ) were 16 micrograms/ml in 1995, and they were 64 micrograms/ml in 1996. 6) K. pneumoniae All drugs except ampicillin (ABPC) were active against K. pneumoniae. CMX, cefpirome (CPR), cefozopran (CZOP) and carumonam (CRMN) showed the most potent activities against K. pneumoniae with MIC80s of 0.125 microgram/ml. The MIC80s of the other drugs ranged from 0.25 microgram/ml to 2 micrograms/ml. 7) M.(B) catarrhalis Against M.(B.) catarrhalis, all drugs showed good activities with MICs of 4 micrograms/ml or below. IPM and minocycline (MINO) showed the most potent activities with MICs of 0.063 microgram/ml. Also, we investigated year to year changes in the characteristics of patients, their respiratory infectious diseases, and the etiology. Patients' backgrounds were examined for 557 isolates from 449 cases. The examination of age distribution indicated that the proportion of patients with ages over 60 years was 71.0% of all the patients showing a slight increase over that in 1994. Proportions of diagnosed diseases were as follows: Bacterial pneumonia and chronic bronchitis were the most frequent with 35.9% and 30.3% respectively. They were followed by bronchiectasis with a proportion of 10.

The effects of epidural morphine on cardiac and renal sympathetic nerve activity in alpha-chloralose-anesthetized cats

BACKGROUND

Epidural morphine yields postoperative pain relief and hemodynamic stability. However, the effects of epidural morphine on sympathetic tone are unclear. This study was designed to elucidate the effects of epidural morphine on cardiac (CSNA) and renal (RSNA) sympathetic nerve activity by direct measurement in anesthetized cats.

METHODS

Thirty mongrel cats anesthetized with alpha-chloralose were randomly assigned to one of the following five groups: control (0.2 ml/kg thoracic epidural normal saline; n=5); thoracic epidural morphine (n=9); lumbar epidural morphine (n=6); vagotomized, sinoaortic denervated, thoracic epidural morphine (n=5); or intravenous morphine (n=5). Mean arterial pressure (MAP), heart rate (HR), CSNA, and RSNA were measured 0, 15, 30, 60, 90, and 120 min after saline or morphine (200 microg/kg) administration and 15 min after reversal with 200 microg naloxone given intravenously.

RESULTS

In the control group, no changes in measured variables were found after either thoracic epidural saline or intravenous naloxone. Thoracic and lumbar epidural morphine both significantly reduced MAP, HR, CSNA, and RSNA 30 through 120 min after morphine administration (P < 0.05). These changes were reversed by intravenous naloxone. Changes after thoracic epidural morphine administration in vagotomized, baroreceptor-denervated cats were similar to those in intact cats. Intravenous morphine produced no significant changes except for a decrease in MAP, which was reversed by intravenous naloxone.

CONCLUSION

In contrast to intravenous morphine, thoracic and lumbar epidural morphine both inhibited cardiac and renal sympathetic nerve activity and consequently reduced MAP and HR in alpha-chloralose anesthetized cats.

The effects of intrinsic nitric oxide on cardiac neural regulation in cats

In this study, we aimed to elucidate the effects of intrinsic nitric oxide (NO) on cardiac neural regulation. Twenty-two cats were anesthetized with 1.5% isoflurane and allocated to Group I (intact; n = 7), Group D (denervated baroreceptors and vagi; n = 8), or Group B (autonomic blockade with i.v. hexamethonium, propranolol, and atropine; n = 7). Cardiac sympathetic nerve activity (CSNA), mean arterial pressure (MAP), sinus heart rate (HR), and A-H and H-V intervals during pacing (150 bpm) were measured before and after i.v. administration of a NO synthase inhibitor, NG-nitro-L-arginine (L-NNA, 30 mg/kg) and after reversal with an excessive dose of L-arginine (300 mg/kg), before and during intermittent electrical stimulation of the posterior hypothalamus. L-NNA significantly increased MAP in Groups I and B, but not in Group D. L-NNA significantly decreased HR and lengthened A-H in Group I, but not in other groups. L-arginine further decreased HR and lengthened A-H unexpectedly. The reasons for these findings could not be determined in this study. L-NNA did not change CSNA. Hypothalamic stimulation did not potentiate L-NNA-induced changes in CSNA, hemodynamic variables, and atrioventricular conduction. In conclusion, intrinsic NO may modulate atrioventricular conduction and sinus rate through a vagal cholinergic, rather than a nonautonomic mechanism.

IMPLICATIONS

Elucidating the roles of intrinsic nitric oxide (NO) on cardiac neural regulation is important. In intact, vagotomized, and baroreceptor-denervated or pharmacologically autonomic blockaded cats, an NO synthesis inhibitor was administered, and atrioventricular conduction and cardiac sympathetic neural discharge were measured. The results suggest a vagal cholinergic mechanism of intrinsic NO.

Pain evaluation in the intensive care unit: observer-reported faces scale compared with self-reported visual analog scale

BACKGROUND AND OBJECTIVES

The visual analog scale (VAS) is a simple and sensitive mean of pain assessment. The faces scale is also a simple, self-reporting method for children. Facial signs of pain have not been used to assess pain in postoperative adult patients in the intensive care unit (ICU).

METHODS

Fifty patients undergoing esophageal cancer surgery by a thoracoabdominal procedure were studied. Epidural opioids, such as morphine or buprenorphine, combined with bupivacaine were administered during and after surgery. Pain measurement was performed by a physician in the ICU using the self-reported VAS 0.5, 1, 2, 4, and 6 hours after tracheal extubation and thereafter every 4 hours during the stay in the ICU. A nurse who was unaware of the patients' VAS scores assessed facial expression as a measure of pain intensity using a five-grade faces scale immediately before pain evaluation by VAS. The VAS was rescaled into five discrete units that would match the five faces scale scores. Weighted kappa statistics were used to establish a relative level of agreement between the five-grade VAS and faces scale.

RESULTS

Good agreement was found between the five-grade VAS and the faces scale 30 minutes and 1 hour after tracheal extubation (weighted kappa values .67 and .62, respectively). The VAS and faces scales were measured 7-13 times per patient during the stay in the ICU, and 518 observations were collected. Although moderate agreement was found between the five-graded VAS and faces scale for all pairs of observation (weighted kappa values .54), less agreement was found between them in patients with moderate pain. In addition, the calculated mean differences between the five-graded VAS and faces scale differed significantly between patients.

CONCLUSION

The faces scale may be useful for pain evaluation in the ICU.

Atypical form of the fourth criterion for transient entrainment

The typical fourth criterion for transient entrainment is defined when both a sudden shortening in conduction interval to and a distinct change in electrogram morphology at a bipolar recording site are demonstrated while performing overdrive pacing of a reentrant tachycardia from a single pacing site at two different constant rates. The purpose of this article was to test the hypothesis that if an intracardiac recording site showing both orthodromic and antidromic capture with entrainment pacing is located suitably distant from the circuit, sudden shortening in conduction interval to that site may occur without any significant change in the bipolar electrogram morphology (i.e., atypical form of the fourth criterion). Atrial overdrive pacing of orthodromic tachycardia was performed in 20 patients with either left anterior (12 patients) or left posterior (8 patients) accessory pathways. We investigated the effects of overdrive pacing from the proximal or distal coronary sinus, specifically effects on the electrogram interval and the electrogram morphology at the right atrial appendage. Overdrive pacing of orthodromic tachycardia from the proximal coronary sinus was performed in 10 of the 12 patients with left anterior accessory pathways; those 10 patients demonstrated the first entrainment criterion at the right atrial appendage site. Overdrive pacing of orthodromic tachycardia at still shorter cycle lengths demonstrated a sudden shortening in conduction interval to the right atrial appendage site. Despite shortening in conduction interval the morphology of the right atrial appendage electrogram was completely or almost identical to that during orthodromic tachycardia, indicating an atypical form of the fourth criterion. This criterion was not demonstrated in patients with left posterior accessory pathways. Thus, atypical fourth entrainment criterion was demonstrated during overdrive pacing of orthodromic tachycardia from the proximal coronary sinus only in patients with left anterior accessory pathways. Demonstration of atypical fourth criterion seems largely dependent on the location of the accessory pathway, the pacing, and the recording sites.

Peripheral primitive neuroectodermal tumor involving the paravertebral and retroperitoneal regions

A rare case of peripheral primitive neuroectodermal tumor (PNET) is reported. A 68-year-old woman complaining of lumbago was admitted to our hospital. Diagnosis was made based on pathological findings characterized by Homer Wright-type rosettes. Ultrastructural examination showed the presence of neurosecretory granules and short cytoplasmic processes, which were highly suggestive of neural differentiation. Chromosomal analysis of the neoplastic cells revealed translocation (11;22)(q24;q12), which is often found in Ewing's sarcoma and Askin tumor. These results strengthen the hypothesis of a common histogenesis for these small round cell tumors, and suggest common oncogenesis for these neoplasms.

Multiple early esophageal cancers arising from Barrett's esophagus, and a review of cases of early adenocarcinoma in Barrett's esophagus in Japan

A case of early esophageal adenocarcinoma arising in Barrett's esophagus is reported. Many cases of Barrett's esophagus, which is considered a premalignant condition, have been reported in Western countries, but few cases have been reported in Japan. The patient, a 53-year-old man with nausea and vomiting, was a drinker (four glasses wine/day for about 30 years), but did not smoke. He had had a hiatal hernia of the esophagus. Since endoscopic biopsies demonstrated an early adenocarcinoma in Barrett's esophagus, subtotal esophagectomy was performed. In the resected esophageal material, Barrett's esophagus was seen to extend for 12 cm. In addition to the cancer detected preoperatively as a 0-IIc lesion (1.5 cm in diameter), a 0-IIb lesion (1.5 cm in diameter) was also detected in the postoperative survey. Both lesions were well differentiated adenocarcinoma that had invaded only into the lamina propria mucosa. The 23 cases of early adenocarcinoma in Barrett's esophagus that have been reported in Japan were reviewed, and it was learned that the present case is the second of multiple early cancer arising in Barrett's esophagus so far reported in Japan.

[Susceptibilities of bacteria isolated from patients with respiratory infectious diseases to antibiotics (1995)]

The bacteria isolated from the patients with lower respiratory tract infections were collected by institutions located throughout Japan, since 1981. Ikemoto et al. have been investigating susceptibilities of these isolates to various antibacterial agents and antibiotics, and characteristics of the patients and isolates from them each year. Results obtained from these investigations are discussed. In 23 institutions around the entire Japan, 567 strains of presumably etiological bacteria were isolated mainly from the sputa of 459 patients with lower respiratory tract infections during the period from October 1995 to September 1996. MICs of various antibacterial agents and antibiotics were determined against 74 strains of Staphylococcus aureus, 82 strains of Streptococcus pneumoniae, 104 strains of Haemophilus influenzae, 85 strains of Pseudomonas aeruginosa (non-mucoid strains), 18 strains of Pseudomonas aeruginosa (mucoid strains), 52 strains of Moraxella subgenus Branhamella catarrhalis, 25 strains of Klebsiella pneumoniae etc., and the drug susceptibilities of these strains were assessed except for those strains that died during transportation. 1) S. aureus. S. aureus strains for which MICs of oxacillin (MPIPC) were higher than 4 micrograms/ml (methicillin-resistant S. aureus) accounted for 52.7%. Arbekacin (ABK) showed the most highest activity against S. aureus with MIC80 of 0.5 micrograms/ml. Vancomycin (VCM) showed the next highest activity with MIC80 of 1 microgram/ml. These drugs showed the high activities against MRSA with MIC80S of 1 microgram/ml. 2) S. pneumoniae. Most of drugs tested showed potent activities against S. pneumoniae. Imipenem (IPM) and panipenem (PAPM), carbapenems, showed the most potent activity with MIC80S of 0.063 microgram/ml. Cefotaxime (CTX), cefmenoxime (CMX) and cefpirome (CPR) of cephems showed the next most potent activities with MIC80S of 0.25 microgram/ml. Erythromycin (EM) and clindamycin (CLDM) showed low activities with MIC80S 128 micrograms/ml or high. Among these strains, however, 48.8% and 65.9% of respective strains were quite toward sensitive these agents with MICs of 0.063 microgram/ml. 3) H. influenzae. The activities of all drugs were potent against H. influenzae test with all MICs at 4 micrograms/ml or below. Cefotiam (CTM), CMX, cefditoren (CDTR) and ofloxacin (OFLX) showed the most potent activity with MIC90S to 0.063 microgram/ml. 4) P. aeruginosa. (mucoid strains) IPM and tobramycin (TOB) showed the most potent activity against P. aeruginosa (mucoid strains) with MIC80S of 1 microgram/ml. Ceftazidime (CAZ), cefsulodin (CFS) and carumonam (CRMN) showed next potent activity, with MIC80S of 2 micrograms/ml. The MIC80S of the other drugs ranged from 4 micrograms/ml to 32 micrograms/ml. 5) P. aeruginosa (non-mucoid strains). TOB and ciprofloxacin (CPFX) showed the most potent activities against P. aeruginosa (non-mucoid strains) with MIC80S of 1 microgram/ml. The MIC80 of ampicillin (ABPC) was 128 micrograms/ml in 1994, it was 16 micrograms/ml in 1995. 6) K. pneumoniae. All drugs except ABPC were active against K. pneumoniae. CPR and CRMN showed the most potent activities against K. pneumoniae with MIC80S of 0.063 microgram/ml. The MIC80S of the other drugs ranged from 0.125 microgram/ml to 2 micrograms/ml. 7) M. (B.) catarrhalis. Against M. (B.) catarrhalis, all the drugs showed good activities with MIC80S at 4 micrograms/ml or below. And MICs of all strains were 8 micrograms/ml or below. IPM, OFLX and minocycline (MINO) showed the most potent activity with MIC80S of 0.063 microgram/ml. Also, we investigated year to year changes in the characteristics of patients, their respiratory infectious diseases, and the etiology. Patients' backgrounds were examine for 567 isolates from 459 cases. The examination of age distribution found that the proportion of patients with ages over 60 years was 66.3% of all the patients showing a slight increase over that in 1994. Proportion of differe

Bupivacaine does not suppress cardiac sympathetic nerve activity during halothane anesthesia in the cat

BACKGROUND

The finding that i.v. lidocaine suppresses cardiac sympathetic nerve activity during 1 MAC halothane, but not during 2 MAC or 3 MAC halothane, suggests that the neurally mediated circulatory effects of i.v. local anesthetics may vary with background autonomic activity. This study aimed to compare the effects of i.v. lidocaine and bupivacaine on cardiac sympathetic nerve activity (CSNA) during normal and high levels of CSNA.

METHODS

Cats were anesthetized with halothane and allocated to three groups. In groups I-L and I-B, sympathetic hyperactivity was induced by electrical stimulation of the posterior hypothalamus. CSNA, heart rate and mean arterial pressure were then measured before and after administration of lidocaine 2 mg.kg BW-1 i.v. (Group I-L, n = 7) or bupivacaine 0.5 mg.kg BW-1 i.v. (Group I-B, n = 7) during 1% halothane anesthesia. In Group II (n = 7), following administration of bupivacaine 0.5 mg.kg BW-1 i.v., CSNA, sinus cycle length (SCL), and subintervals of atrioventricular conduction time (A-H, H-V, and H-S) at pacing were measured during 0.8%, 1.6% and 2.4% halothane anesthesia without sympathetic hyperactivity.

RESULTS

Lidocaine suppressed CSNA hyperactivity and tachycardia significantly in Group I-L, but bupivacaine did not do so in Group I-B. In Group II, bupivacaine did not affect CSNA at any concentrations of halothane, but lengthened SCL, A-H, H-V and H-S intervals significantly at each concentration of halothane.

CONCLUSIONS

We conclude that i.v. bupivacaine, unlike i.v. lidocaine, does not suppress CSNA during either normal or high CSNA under halothane anesthesia although i.v. bupivacaine has stronger depressive effects on cardiac conduction than does i.v. lidocaine during deep halothane anesthesia.

[Two cases of crush syndrome associated with intractable pain]

We describe two patients (a 21-year-old woman and a 26-year-old man) with crush syndrome who were injured by being buried under collapsed buildings in the Kobe-Awaji Earthquake, and thereafter developed severe pain in the affected limbs. On arrival at our ICU 3 days after the injury, sensation and muscular power were completely absent in both patients. Emergent fasciotomy was performed for the woman. In both patients, burning pain and allodynia occurred in the affected legs between 1 and 3 weeks following the injury while sensation and muscular power partially recovered over the same time period. Pain was not effectively controlled by oral or intramuscular analgesics. Continuous epidural analgesia with 0.25% bupivacaine at a rate of 2 ml.h-1 was effective for relieving pain in the woman, but was not effective in the man, for whom supplemental analgesics, transcutaneous nerve stimulation and near infrared radiation were required to relieve pain. We conclude that persistent pain is one of the important complications of crush syndrome, and that early treatment of pain including epidural analgesia is necessary and may improve functional prognosis of affected patients.

Administration of epidural bupivacaine combined with epidural morphine after esophageal surgery

BACKGROUND

Early tracheal extubation after esophagectomy has been postulated to reduce both morbidity rate and the cost of esophageal surgery. The purpose of this study was to determine the effect of epidural bupivacaine combined with morphine on extubation time, postoperative analgesia, respiration, and hemodynamics in patients undergoing esophagectomy.

METHODS

In a randomized double-blind study, twenty patients undergoing esophageal cancer surgery with a thoracoabdominal procedure were studied. All patients received epidural morphine 2 mg at T6-7 and 2 mg at L3-4 at the beginning of wound closure. Then 3 ml/hr continuous epidural administration of either 0.25% bupivacaine (group Bup, 10 patients) or normal saline solution (group NS, 10 patients) through the catheter inserted at T6-7 was continued for 16 hours, followed by low-dose epidural buprenorphine-bupivacaine.

RESULTS

The time from end of operation to tracheal extubation was 4.4 +/- 6.7 hours in group Bup and 13.7 +/- 7.1 hours in group NS (p < 0.05). All patients in both groups obtained moderate or adequate pain relief (visual analog scale of 21 +/- 27 mm) without serious side effects. There were no significant differences in visual analog scale, score for pain on a deep breath, blood pressure, heart rate, or respiratory rate between the two groups.

CONCLUSIONS

Continuous administration of epidural bupivacaine combined with morphine resulted in good analgesia without any respiratory or hemodynamic depression in patients who had undergone esophagectomy, and early extubation is related to the efficacy of continuous epidural administration of bupivacaine.

[Intraoperative continuous epidural lidocaine combined with preoperative administration of epidural morphine for post-hepatectomy pain relief]

In a randomized double-blind study, the use of continuous epidural lidocaine during surgery combined with preoperative epidural morphine was compared with that of preoperative epidural morphine alone for postoperative analgesia in 20 patients undergoing hepatectomy. Morphine 2 mg was administered through a catheter inserted epidurally at T10-11 before surgery, followed by continuous epidural administration of 1% lidocaine 5ml.h-1 in group Lid (n = 10) or normal saline 5ml.h-1 in group NS (n = 10) during surgery. Anesthesia was maintained with N2O-O2-isoflurane in both groups. On admission to the ICU, the visual analog scale score (VAS; mm) was 20 +/- 7 (mean +/- SE) in group Lid and 38 +/- 10 in group NS, and the number of patient with VAS < or = 30 was 9 in group Lid and 4 in group NS; these differences were significant (P < 0.05). Pain score during mobilization in group Lid was significantly lower than that in group NS (P < 0.05). All patients in both groups had adequate analgesia for the remainder of their stay in the ICU. No patient had any serious adverse effect. We conclude that continuous epidural administration of lidocaine during hepatectomy combined with administration of epidural morphine just before surgery results in better pain relief during the early postoperative period than that obtained with epidural morphine alone, and is without serious side effects.

Agents for the treatment of overactive detrusor. V. Synthesis and inhibitory activity on detrusor contraction of N-tert-butyl-4,4-diphenyl-2-cyclopentenylamine

N-tert-Butyl-4,4-diphenyl-2-cyclopentenylamine ((+/-)-3) was designed to restrict the conformation of terodiline 1 and was synthesized in a 6-step approach starting with diphenylacetaldehyde (10) or in a 4-step approach starting with 2,2-diphenyl-4-pentenoic acid (17). Using di-p-toluoyltartaric acid as a resolving agent, the synthetic (+/-)-3 was resolved into its optically pure forms, (-)- and (+)-3. The (-)-enantiomer (-)-3.HCl (FK584) showed about ten times more potent inhibitory activity on urinary bladder rhythmic contraction in rats (ED30 = 0.18 mg/kg, i.v.) than terodiline (ED30 = 1.9 mg/kg, i.v.), while the (+)-enantiomer (+)-3.HCl showed no inhibitory activity at 1.0 mg/kg i.v. Compound (-)-3.HCl (FK584) has pharmacological properties similar to those of terodiline, as evaluated by in vitro assay and is currently in clinical development for the treatment of overactive detrusor.