Pituitary-adrenal and parasympathetic function in chronic schizophrenic patients with postoperative ileus or hypotension

We studied the relationship between parasympathetic, sympathetic and pituitary-adrenal functions in chronic schizophrenic patients with complications such as postoperative paralytic ileus and hypotension during anaesthesia. Plasma epinephrine, norepinephrine (NE), adrenocorticotropin (ACTH), cortisol and the coefficient of variation (CV) of the R-R intervals on the electrocardiogram (ECG) as parasympathetic parameter were measured in schizophrenic and control patients. The CV value of the R-R interval on the ECG before the start of anaesthesia was significantly decreased to 2.3 +/- 0.2 in the schizophrenic patients as compared with 3.5 +/- 0.3 of the control patients. The CV value of the R-R interval on the ECG in schizophrenic patients with postoperative paralytic ileus was more diminished to 1.6 +/- 0.2. The CV values in schizophrenic patients with and without hypotension during anaesthesia were similar and we could not find any significant difference. Chronic schizophrenic patients developed a decrease in NE, ACTH and cortisol responses to surgical stress, while there were no significant differences in these hormonal changes between those patients with and without paralytic ileus and hypotension during anaesthesia. In conclusion, the CV value of the ECG R-R interval may be correlated inversely with the expectancy of postoperative ileus in chronic schizophrenic patients. Their suppressed pituitary-adrenal function and sympathetic system may be indirectly associated with the paralytic ileus and hypotension.

Acute myeloid leukaemia with trilineage myelodysplasia complicated by masked diabetes insipidus

We describe a rare case of acute myeloid leukaemia with trilineage myelodysplasia complicated by central diabetes insipidus. In the present case, diabetes insipidus was masked by corticosteroid deficiency due to hypopituitarism and clinical symptoms presented after administering methylprednisolone. Although the remission of leukaemia was not achieved by chemotherapy, excessive urinary output was well-controlled by nasal administration of 1-desamino-8-D-arginine vasopressin (DDAVP) during the course.

Sevoflurane stimulates inositol 1,4,5-trisphosphate in skeletal muscle

Inositol 1,4,5-triphosphate (IP(3)) plays an important role in excitation-contraction coupling and malignant hyperthermia in skeletal muscle. We investigated whether sevoflurane affects IP(3) formation in L(6) skeletal muscle cells and studied the mechanisms that modulate IP(3). Sevoflurane stimulated IP(3) production from a basal level of 78.4 +/- 6.1 to 730.0 +/- 53.1 pmol. mg. protein(-1) in 2 mM of sevoflurane in a dose-dependent manner. A dose of 10 microM of U73122 (a phospholipase C antagonist) significantly decreased 0.8 mM of sevoflurane-stimulated IP(3) production from 387. 8 +/- 24.7 to 247.8 +/- 19.8 pmol. mg. protein(-1). A dose of 100 microM of (p-amylcinnamoyl) anthranilic acid (a PLA(2) antagonist) also significantly decreased sevoflurane-stimulated IP(3) production to 282.0 +/- 24.0 pmol. mg. protein(-1). Exposure to 1 microM of genistein and tyrphostin A23 (tyrosine kinase inhibitors) significantly decreased sevoflurane-stimulated IP(3) production to 241.0 +/- 35.3 and 267.4 +/- 32.9 pmol. mg. protein(-1). Sevoflurane-stimulated IP(3) production was significantly decreased by 10 microM of 8-(N,N-diethylamino) octyl-3,4-5-trimathoxybenzoate (an intracellular calcium antagonist) and 100 microM and 1 mM of guanosine 5'-O-(2-thiodiphosphate) (GDPbetaS), a guanosine 5'triphosphate-binding protein inhibitor. Elevation of IP(3) production was significantly higher in halothane than in sevoflurane and isoflurane at the same concentration of 0.8 mM. We conclude that sevoflurane-stimulated IP(3) production involves phospholipase C, phospholipase A(2), tyrosine kinase, and guanosine 5'triphosphate-binding protein and the stimulation is associated with concentration of intracellular ionized calcium.

IMPLICATIONS

Inhaled anesthetics increase intracellular ionized calcium in the skeletal muscle cell and the ionized calcium increase is partly released from the intracellular store by inositol 1,4,5-triphosphate (IP(3)) formation. IP(3) plays an important role in excitation-contraction coupling and malignant hyperthermia. We studied whether sevoflurane affects IP(3) formation and the mechanisms that modulate IP(3).

Glucose dilution can detect fluid redistribution following phentolamine infusion in dogs

OBJECTIVE

We have recently reported that the initial distribution volume of glucose (IDVG) reliably measures the central extracellular fluid (ECF) volume in the presence of fluid gain or loss. However, it is not clear if IDVG consistently reflects central-ECF volume when redistribution of fluid occurs in the absence of fluid gain or loss. This study was designed to investigate changes in fluid volumes during phentolamine infusion in dogs.

DESIGN

Prospective animal study.

SETTING

Institutional animal research laboratory.

SUBJECTS

Fourteen anesthetized and ventilated mongrel dogs.

INTERVENTIONS

Anesthetized animals were mechanically ventilated and received infusions of normal saline (n = 7) or phentolamine (10 microg kg min) (n = 7). Plasma volume was estimated using the indocyanine green (ICG) dilution method (PV-ICG) and IDVG was calculated using a one-compartment model by simultaneous administration of ICG 0.5 mg/kg and glucose 100 mg/kg before, during, and after infusion of either drug.

MEASUREMENTS AND RESULTS

PV-ICG during infusion was not different between groups. However, IDVG significantly decreased (P < 0.05) following phentolamine infusion when compared with normal saline infusion.

CONCLUSION

Our results suggest that IDVG rather than PV-ICG consistently measures central extracellular fluid volume, even when redistribution of fluid occurs.

Inhibition of the cortisol response to surgical stress in chronically depressed patients

STUDY OBJECTIVE

To evaluate whether the pituitary-adrenal and catecholamine response to surgical stress is modified in chronically depressed patients.

DESIGN

Prospective, controlled study.

PATIENTS

25 ASA physical status I and II depressed patients taking chronic antidepressant therapy and 25 control patients undergoing orthopedic surgery of the extremities.

INTERVENTIONS

All patients received anesthesia induction with thiopental 5 mg/kg and suxamethonium 1 mg/kg intravenously (IV) and were maintained with 1.5% to 2.0% isoflurane in nitrous oxide (70%) and oxygen (30%).

MEASUREMENTS AND MAIN RESULTS

Plasma cortisol concentration (27.7 +/- 3.6 microg/dL) in chronic depressed patients at 60 minutes after the skin incision was not significantly higher than that (23.9 +/- 2.7 microg/dL) before the induction, although plasma cortisol concentration in the control group significantly increased. Plasma norepinephrine concentration at 60 min after the skin incision in depressed patients with more symptoms of depression was significantly higher than that of patients with less symptoms of depression.

CONCLUSION

The cortisol response to surgical stress in depressed patients was inhibited and norepinephrine response to surgical stress was increased in depressed patients with more symptoms of depression.

Effects of angiotensin-converting enzyme inhibitors on glucose uptake

We investigated the effect of angiotensin-converting enzyme inhibitors on glucose uptake regulation as well as the effect of bradykinin (BK) on glucose uptake and its regulation by using inhibitors of phospholipase C, BK B2 receptor, protein kinase C, phosphatidylinositol 3-kinase, tyrosine kinase, and intracellular Ca(2+). We measured 2-deoxyglucose uptake by using L(6) skeletal muscle cells. In the presence of 1 nmol/L of insulin, 1 micromol/L of enalaprilat enhanced insulin-induced glucose uptake from 89.2+/-8. 1 to 138.0+/-13.6 pmol/h per mg protein. The stimulation of glucose uptake with enalaprilat was blocked to 92.7+/-7.8 pmol/h per mg protein by 10 micromol/L HOE 140 (a BK B2 receptor antagonist). In the presence of 1 nmol/L of insulin, exposure to 10 micromol/L BK stimulated glucose uptake from 89.2+/-8.1 to 171.6+/-10.1 pmol/h per mg protein. However, in the absence of insulin, BK could not enhance glucose uptake. One hundred nanomoles per liter of tyrphostin A-23 and genistein, which are tyrosine kinase inhibitors, significantly decreased the BK-induced glucose uptake from 142.0+/-8.4 to 87.6+/-6. 4 and 85.2+/-7.3 pmol/h per mg protein, respectively. BK-induced glucose uptake was inhibited significantly by 10 micromol/L U73122 (a phospholipase C antagonist) from 142.0+/-8.4 to 95.7+/-9.5 pmol/h per mg protein. One and 20 micromol/L of TMB-8 (an intracellular calcium antagonist) significantly decreased BK-induced glucose uptake from 142.0+/-8.4 to 108.0+/-9.6 and 100.8+/-11.4 pmol/h per mg protein. Angiotensin-converting enzyme inhibitors enhanced insulin-induced glucose uptake via the BK B2 receptor. BK-stimulated glucose uptake is related to phospholipase C, tyrosine kinase, and an increase in intracellular calcium.

Supplemental intraoperative oxygen augments antimicrobial and proinflammatory responses of alveolar macrophages

BACKGROUND

The first goal was to test the hypothesis that 100% inspired oxygen maintained for approximately 8 h intraoperatively is not associated with impaired pulmonary oxygenation. The authors also tested the hypothesis that intraoperative inhalation of 100% oxygen augments proinflammatory and antimicrobial responses of alveolar macrophages during anesthesia and surgery.

METHODS

The authors studied patients administered 100% oxygen (n = 30) and 30% oxygen (n = 30) during propofol-fentanyl general anesthesia. Alveolar macrophages were harvested by bronchoalveolar lavage immediately, 2, 4, and 6 h after induction of anesthesia, and at the end of surgery. The authors measured "opsonized" and "unopsonized" phagocytosis and microbicidal activity. RNA was extracted from harvested cells and cDNA was synthesized. The expression of interleukin(IL)-1beta, IL-6, IL-8, interferon-gamma (IFN-gamma) and tumor necrosis factor alpha (TNF-alpha) was measured by semiquantitative polymerase chain reaction.

RESULTS

Gene expression of all proinflammatory cytokines except IL-6 increased fourfold to 20-fold over time in both groups. However, expression of TNF-alpha and IL-8, IFN-gamma, and IL-6 and IL-1beta was 2-20 times greater in patients administered 100% than in those administered 30% oxygen. Unopsonized and opsonized phagocytosis and microbicidal activity decreased progressively, with the decreases being nearly twice as great during inhalation of 30% oxygen versus 100% oxygen.

CONCLUSION

Inhalation of 100% oxygen improved intraoperative decreases in phagocytic and microbicidal activity possibly because expression of proinflammatory cytokines was augmented. These data therefore suggest that intraoperative inhalation of 100% oxygen augments antimicrobial and proinflammatory responses in alveolar macrophages during anesthesia and surgery.

[New study on the history of anesthesiology (2)--who is the first Japanese to write a scientific paper for the journal "Anesthesiology"?]

The beginning of modern anesthesiology in Japan dates back to 1950 when Dr M. Saklad of Rhode Island Hospital came to Japan to give his lectures on endotracheal anesthesia and related procedures. Since then, many Japanese surgeons visited the United States to learn anesthesiology in depth and they began to write their papers for foreign journals. According to my survey of the journal "Anesthesiology" from Vol 1 (1940) through Vol 21 (1960), I found 12 scientific papers written by Japanese. The first paper by Japanese appeared in this journal published in 1955 entitled as "Observations on the action of thiopental (Pentothal) on the laryngeal reflex" by Akira Horita et al. He was born in the United States in 1928 as a son of Japanese immigrants. He was graduated from the University of Washington at Seattle to become professor or pharmacology. The first paper based on studies performed in Japan by Japanese authors appeared in 1956. It was entitled as "The spread of drugs used for spinal anesthesia" by Kitahara et al. This paper is the English translation of their Japanese paper which appeared in Nippon Rinsho Geka Ikai Zasshi entitled as "Basic Study on Spinal Anesthesia in 1953".

[New studies on the history of anesthesiology (1)--A newly discovered truth on Woolley and Roe case after an interval of 50 years]

A famous medical accident that is widely known as Woolley and Roe case occurred on Oct 13th, 1947 at the Chesterfield Royal Hospital, England. The patients Albert Woolley and Cecil Roe underwent minor operations under spinal anesthesia using cinchocaine to develop spinal cord myelopathy with paralisis of bilateral legs. Both patients sued Dr James M. Graham, the anesthetist, and the Ministry of Health. Seven years later, Dr Graham and the Ministry of Health were given a verdict of not guilty, because three judges unanimously accepted the phenol theory proposed by a witness Prof Macintosh of Oxford University. He allged that phenol entered into the ampoule of cinchocaine through invisible cracks. Thus the plaintiffs were not compensated. Recentry Dr Hutter of Nottingham University found no validity of phenol theory and also no possibility of invisible cracks. Syringes and needles for spinal anesthesia were used to be sterilised by water-boiling steriliser, and mineral acid was used for descaling the deposition of line at that time. Dr Hutter concluded that the severe spinal myelopathy occurred both in Woolley and Roe would have been caused by mineral acid which was conveyed into their subarachnoidal space by acid-contaminated syringes and needles.

[Abnormal Q wave in the right precordial leads unmasked during right bundle branch block in a patient with anteroseptal myocardial infarction: a case report]

Electrocardiography in a 77-year-old woman showed small R waves in leads V1-V3 3 hours after the onset of acute anteroseptal myocardial infarction. Abnormal Q waves appeared in leads V1-V3 only during intermittent right bundle branch block. The normal septal force disappeared after transmural septal infarction and a small force of right ventricle origin became apparent as a small R wave in V1. Right bundle branch block delayed activation of right ventricle, and thereby deleted the initial R wave and unmasked the Q wave of the septal infarction. Appearance of a Q wave in leads V1-V3 with right bundle branch block should not be assumed to reflect the extension of myocardial infarction.

Gamma-ray induced hepatocarcinogenesis in p53-deficient mice

BACKGROUND

Mutations in the p53 gene are frequent genetic alterations in human hepatocellular carcinoma (HCC), but, little is known of the molecular genetic changes that occur during murine hepatocarcinogenesis.

MATERIALS AND METHODS

To characterize the properties of constitutive p53 deficiency that contribute to liver tumor development, a total of 168 F1 mice of two different strains (C3H, which are susceptible to hepatocarcinogenesis and MSM [Mus. M. molossinus] with a single null p53 allele) were exposed to a single 3-Gy dose of whole-body gamma-irradiation at 4 weeks of age and observed for a period of 360 days. The genotype of the mice and the p53 spectrum of the tumors were investigated by polymerase chain reaction (PCR) analysis.

RESULTS

Thirty-five gamma-ray-induced HCCs were obtained as a result of this experiment. 11 (40%) of the mice with liver tumor were wild-type for p53. All liver tumors examined retained the wild-type p53 allele, indicating that p53 itself may not be a target for radiation-induced alteration. Only two p53-deficient mice in the liver tumor group developed thymic lymphomas. The p53-deficient mice showed no significant differences in the number, size, or growth rate of HCC or in the apparent development of HCC.

CONCLUSION

These results indicate that p53 deficiency does not enhance the rate of development or degree of malignancy of radiation-induced HCC in mice but may instead favor the development of multiple primary cancers.

Smoking decreases alveolar macrophage function during anesthesia and surgery

BACKGROUND

Smoking changes numerous alveolar macrophage functions and is one of the most important risk factors for postoperative pulmonary complications. The current study tested the hypothesis that smoking impairs antimicrobial and proinflammatory responses in alveolar macrophages during anesthesia and surgery.

METHOD

The authors studied 30 smoking and 30 nonsmoking patients during propofol-fentanyl general anesthesia. Alveolar immune cells were harvested by bronchoalveolar lavage immediately and 2, 4, and 6 h after induction of anesthesia and at the end of surgery. The types of alveolar immune cell and macrophage aggregation were determined. The authors measured opsonized and unopsonized phagocytosis. Microbicidal activity was determined as the ability of the macrophages to kill Listeriamonocytogenes directly. Finally, RNA was extracted from harvested cells and cDNA was synthesized by reverse transcription. The expression of interleukin 1beta, 6, and 8, interferon gamma, and tumor necrosis factor alpha were measured by semiquantitative polymerase chain reaction using beta-actin as an internal standard.

RESULTS

The fraction of aggregated macrophages increased significantly over time in both groups, whereas phagocytosis of opsonized and nonopsonized particles and microbicidal activity of alveolar macrophages decreased significantly. The changes, though, were nearly twice as great as in patients who smoked. Gene expression of all proinflammatory cytokines in alveolar immune cells except interleukin 6 increased 2- to 20-fold over time in both groups. The expression of interleukin 1beta, interferon gamma, and tumor necrosis factor alpha, however, increased only half as much in smokers as in nonsmokers.

CONCLUSION

Smoking was associated with macrophage aggregation but markedly reduced phagocytic and microbicidal activity-possibly because expression of proinflammatory cytokines was reduced in these patients. Our data thus suggest that smokers may have a limited ability to mount an effective pulmonary immune defense after anesthesia and surgery.

Cardiopulmonary bypass produces greater pulmonary than systemic proinflammatory cytokines

Cardiopulmonary bypass (CPB) impairs pulmonary endothelial injury in part by increasing expression of adhesion molecules that results in neutrophil influx. Although numerous proinflammatory cytokines up-regulate these responses, the extent to which systemic and pulmonary proinflammatory cytokines increase remains unknown. We therefore examined systemic and pulmonary gene expression and production of proinflammatory cytokines during CPB. Bronchoalveolar lavage and peripheral blood sampling were performed just after the induction of anesthesia and at the end of surgery in 80 patients undergoing CPB. RNA was extracted from harvested cells and cDNA was synthesized by reverse transcription. The expression of interleukin (IL)-6, IL-8, and tumor necrosis factor-alpha (TNF-alpha) was measured by semiquantitative polymerase chain reaction using beta-actin as an internal standard. We also measured these cytokines in cultured alveolar macrophages and plasma monocytes in standard medium alone, or in the presence of lipopolysaccharide. We found 2- to 20-fold increases in gene expression for these cytokines in both plasma and alveolar leukocytes at the end of surgery. However, the increases were 4-8 times greater in alveolar than plasma leukocytes. Alveolar macrophages obtained at the end of surgery produced 1.5-3 times more IL-6, IL-8, and TNF-alpha than those obtained at the beginning (P < 0.0001). Although plasma monocytes produced more IL-8 at the end of surgery (P < 0.001), TNF-alpha and IL-6 did not increase. The production of all cytokines was 1.5-3 times greater in alveolar macrophages obtained at the end of surgery than in plasma monocytes obtained simultaneously (P < 0.005). Our data thus suggest that CPB provokes a greater pulmonary than systemic inflammatory response.

Neutrophil number and interleukin-8 and elastase concentrations in bronchoalveolar lavage fluid correlate with decreased arterial oxygenation after cardiopulmonary bypass

Atelectasis is a major cause of decreased arterial oxygenation after cardiopulmonary bypass (CPB). There is a close relationship between atelectasis and inflammatory responses. We therefore tested the hypothesis that neutrophil number and the concentrations of proinflammatory cytokines and elastase in plasma and bronchoalveolar lavage fluid correlate with changes in arterial oxygenation. Bronchoalveolar lavage was performed just after the induction of anesthesia and at the end of surgery in 80 patients undergoing CPB. Peripheral blood was sampled simultaneously. Arterial oxygenation was quantified by PaO(2)/fraction of inspired oxygen (FIO(2)) and intrapulmonary shunt (Q(s)/Q(t)). PaO(2)/FIO(2) and Q(s)/Q(t) decreased significantly at the end of surgery, whereas neutrophil number, interleukin (IL)-6, IL-8, tumor necrosis factor-alpha, and elastase concentrations in the lavage fluid increased significantly. The increase in neutrophil count from the lavage fluid correlated significantly with the increases in IL-8 and elastase concentrations. The increase in neutrophil number and IL-8 and elastase concentrations in the lavage fluid correlated significantly with PaO(2)/FIO(2) and Q(s)/Q(t) at the end of surgery. In contrast, none of the plasma values correlated with these variables. Significant correlation between immune mediators and decreased arterial oxygenation suggests that inflammatory responses in the distal airway are strongly related to a decrease in arterial oxygenation after CPB.

Milrinone attenuates serotonin-induced pulmonary hypertension and bronchoconstriction in dogs

We determined whether milrinone, a phosphodiesterase III inhibitor, attenuates serotonin-induced (5-hydroxytryptamine [5HT]) pulmonary hypertension (PH) and bronchoconstriction. Dogs were anesthetized with pentobarbital (30 mg/kg + 2 mg. kg(-1). h(-1)). Bronchoconstriction and PH were elicited by 5HT (10 microg/kg + 1.0 mg. kg(-1). h(-1)). Pulmonary vascular resistance was used to assess PH. Bronchoconstriction was also assessed by changes in bronchial cross-sectional area obtained from our bronchoscopic method. At 30 min after 5HT infusion started, seven dogs were given milrinone: 0 (saline), 5, 50, 500, and 5000 microg/kg at 10-min intervals. The other 12 dogs were given milrinone 5000 microg/kg 30 min after 5HT infusion, and 5 min later were given propranolol 0.2 mg/kg (n = 6) or saline (n = 6) IV. The 5HT significantly increased percentage of pulmonary vascular resistance to 208% +/- 27% and decreased percentage of bronchial cross-sectional area to 52% +/- 5% of the basal. Milrinone significantly attenuated both PH and bronchoconstriction in a dose-dependent manner. However, -log 50% effective concentration (mean ED(50) in microg/kg) of milrinone for bronchoconstriction: 4.32 +/- 0.13 (47.6) was significantly smaller than that for PH: 3.84 +/- 0.29 (144.9) (P < 0.01). In addition, the spasmolytic effects of milrinone (5000 microg/kg) were not antagonized by propranolol, although this dose significantly increased plasma catecholamines. In conclusion, milrinone attenuates 5HT-induced PH and bronchoconstriction; however, this drug may be more sensitive to phosphodiesterase III in the airway smooth muscle than in pulmonary vascular smooth muscle. In addition, the relaxant effects could not be caused by beta-adrenoceptor activation because beta-blocker did not antagonize.

IMPLICATIONS

We studied the effects of milrinone on serotonin-induced pulmonary hypertension and bronchoconstriction in dogs. Milrinone produces pulmonary vasodilation and bronchodilation, whose effects may not be caused by beta-adrenoceptor activation. In addition, this drug may be more sensitive to phosphodiesterase III in the airway smooth muscle than that in pulmonary vascular smooth muscle.

Detection of capillary protein leakage by indocyanine green and glucose dilutions in septic patients

OBJECTIVE

To determine whether indocyanine green (ICG) and glucose dilutions can detect generalized capillary protein leakage in septic patients without requiring repeated measurements.

DESIGN

Prospective, clinical study.

SETTING

General intensive care unit.

PATIENTS

Twelve consecutive patients who met the criteria of sepsis and 16 consecutive acute myocardial infarction (AMI) patients without any underlying pathology inducing generalized protein capillary leakage.

INTERVENTIONS

Both ICG 25 mg and glucose 5 g were administered simultaneously, to calculate the plasma volume determined by the ICG dilution method (PV-ICG) and the initial distribution volume of glucose (IDVG), on day 1 of sepsis or on day 1 of hospitalization for the AMI patients. The relationship between these two volumes and the PV-ICG/IDVG ratio was evaluated in two patient groups.

MEASUREMENTS AND MAIN RESULTS

Although the IDVG of the two patient groups was not statistically different, the PV-ICG in the septic patients was higher than that in the AMI patients (p < .01). Consequently, the PV-ICG/IDVG ratio in the septic patients was higher than that in the AMI patients (p < .01). Eight of the 12 septic patients had a PV-ICG/IDVG ratio of >0.45, which was not observed in any of the AMI patients. The PV-ICG/IDVG ratio in the septic patients correlated inversely with the total plasma protein concentration (r2 = .46, p < .025) and mean arterial pressure (r2 = .42, p < .05).

CONCLUSIONS

Our results indicate that overestimation of the PV-ICG can occur in septic patients and, further, suggest that simultaneous measurement of the two distribution volumes would help predict generalized capillary protein leakage in septic patients without repeated measurement.

[Anesthesia, department of anesthesiology and anesthesiology--why has anesthesiology not been accepted socially in Japan?]

An incorrect Japanese terminology of "Masuigaku [symbol: see text]" has been used widely to express "anesthesiology" or "anaesthetics" [symbol: see text] since the first Department of Anesthesiology was established in Tokyo University in 1952. The reason why the nomenclature "Masui-gaku" is wrong is as follows: Japanese nomenclatures for clinical medical sciences should include a Chinese character "Ka [symbol: see text]" such as "nai-ka-gaku" for internal medicine, "ge-ka-gaku" for surgery and "gan-ka-gaku" for ophthalmology. Accordingly the name "Masui-gaku" is erroneous to mean "Anesthesiology" and it should be "Masui-ka-gaku" [symbol: see text]. Thus a big confusion has occurred among lay people as well as many physicians in medical field. "Ma-sui" is etymologically a Japanese word which Dr Seikei Sugita coined when he translated a Dutch edition of J. Schlesinger's monograph on ether anesthesia in 1850. "Ma [symbol: see text]" means analgesia or loss of regional sensation and "Sui [symbol: see text]" means loss of consciousness. Most people consider that "Ma [symbol: see text]" is originated from "[symbol: see text] (Hemp, Asa)" or "[symbol: see text] (Marihuana, Taima)", however, this is definitely incorrect and "Ma [symbol: see text]" of "Ma-sui" has no direct relation with the pharmacological effect of hemp. Thus the misuse of "Masui-ga-ku" might have caused serious academic and social confusions, such as misunderstanding of anesthesiologists as comedical technicians, leading to a poor social acceptance of anesthesiology and anesthesiologists for these fifty years in Japan. To correct this confused situation I would like to ask our colleagues to use correctly these nomenclatures.

[Tracheal mucosal bulla found on tracheal extubation in a patient with pemphigus vulgaris--a case report]

A 49-year-old female with pemphigus vulgaris underwent the removal of a meningioma under general anesthesia. Neither bulla nor erosion was observed on her skin and oral cavity mucosa. She had been on prednisolone 15 mg for six years daily to avoid the recurrence of skin lesion. Anesthesia was induced and maintained with total intravenous anesthesia with propofol and fentanyl. No adverse episodes were encountered during the operative procedure. We checked the tracheal mucosa using bronchofiberscope before extubation. A small bulla was found on the tracheal mucosa, where the cuff of the tracheal tube was located. The trachea was extubated slowly under bronchofiberscopic observation, and no other bullae were found. It would have been formed by mechanical stimulation of the tracheal tube. This case suggests that we have to pay careful attention to the formation of bullae at any part of the body by mechanical stimuli during anesthetic management of patients with pemphigus vulgaris.

A bibliographical study on Shutei Nakagawa's "Mayaku-ko" (a collection of anesthetics and analgesics)--a comparism of four manuscripts

The greatest achievement of Seishu Hanaoka, one of the greatest surgeons in the Edo period, was the innovation of an oral general anesthetic called "Mafutsu-San" and its clinical application, however, the detailed circumstances of the innovation remain unkown to us. Shutei Nakagawa, a close friend of Hanaoka, wrote a small pamphlet entitled "Mayaku-ko" in 1796. This brochure is very important for clarifying the process of Hanaoka's study on the general anesthetic. At present I have found four manuscripts of "Mayaku-ku" which are in the Fujikawa Library of Kyoto University, Soda's Library (Personal Library), the Kyo-u Library of Takeda Pharmaceutical Company, and Matsuki's Library (Author's Library). They are classified bibliographically into two groups. The one includes two manuscripts of the Fujikawa Library and Soda's Library, which describe twenty prescriptions. The other two are the manuscripts of Kyo-u and Matsuki's Libraries describing only fourteen recipes. Among them, the Fujikawa's manuscript is the best, because it has a postscript by Yakushi Mori who transcribed this manuscript from the orginal by Shutei Nakagawa. The Fujikawa manuscript has four illustrations of plants in the end of the manuscript which the other three manuscripts lack. As the original manuscript by Nakagawa was lost in a fire in 1867, it is possible to make an accurate reproduction of the original by bibliographical comparison of four extant manuscripts.

Ketamine inhibits inositol 1,4,5-trisphosphate production depending on the extracellular Ca2+ concentration in neonatal rat cardiomyocytes

We investigated the effect of ketamine on inositol 1,4,5-trisphosphate (IP3) formation in rat cardiomyocytes. After the addition of 1 micromol/L ketamine, IP3 production in the presence of 0.5, 1, 5, 10, and 30 mmol/L Ca2+ significantly decreased from 537.1+/-8.3, 590.7+/-12.9, 690.6+/-7.9, 754.8+/-12.5, and 823.7+/-15.2 pmol/mg protein to 467.0+/-8.3, 483.8+/-11.0, 512.6+/-21.3, 612.1+/-16.9, and 652.6+/-17.3 pmol/mg protein, respectively. When exposed to TMB-8 (a intracellular calcium inhibitor), IP3 production decreased significantly from 347.2+/-27.3 to 283.8+/-20.4 pmol/mg protein in the presence of 1 micromol/L ketamine, but A23187, which increases intracellular calcium, did not affect the inhibition of IP3 production by ketamine. These results demonstrate that ketamine decreases IP3 formation through inhibition of the calcium ion-sensing receptor and that IP3 formation reduced by ketamine is not affected by the alteration of intracellular calcium.

IMPLICATIONS

Ketamine has a negative inotropic effect in isolated cardiomyocytes. The negative inotropic effect was associated with a decrease in inositol 1,4,5-trisphosphate production, and the inhibitory action was enhanced depending on the concentration of extracellular Ca2+.

Exposure to cigarette smoke impairs alveolar macrophage functions during halothane and isoflurane anesthesia in rats

BACKGROUND

Smoking alters numerous alveolar macrophage functions and is an important risk factor for postoperative pulmonary complications. The authors therefore tested the hypothesis that smoke exposure impairs antimicrobial and proinflammatory responses in alveolar macrophages during halothane and isoflurane anesthesia with mechanical ventilation.

METHODS

Thirty control rats and 30 rats exposed to cigarette smoke were mechanically ventilated with 1.5 minimum alveolar concentration halothane and isoflurane. Ten smoke-exposed and control animals were assigned to one of three different anesthetic durations (0, 2, and 6 h). The fraction of aggregated cells and cell distribution were determined. Opsonized and unopsonized phagocytosis was measured. Microbicidal activity was determined as the ability to kill Listeria monocytogenes. The expression of interleukin (IL)-1alpha, IL-1beta, IL-6, macrophage inflammatory protein-2, interferon-gamma, and tumor necrosis factor-alpha was measured by semiquantitative reverse-transcription polymerase chain reaction. Pulmonary lavage concentrations of these cytokines were measured by enzyme-linked immunosorbent assay.

RESULTS

During both halothane and isoflurane anesthesia, the fraction of aggregated macrophages increased, whereas unopsonized and opsonized phagocytosis and microbicidal activity decreased significantly over time in both groups. Responses observed in smoke-exposed rats were almost twice as great as those observed in the control rats. Gene expression and production of all proinflammatory cytokines except IL-6 increased 2-20-fold during anesthesia. The increases in IL-1beta, interferon-gamma, and tumor necrosis factor-alpha in the control rats were 1.5-8 times greater than those in the smoke-exposed rats.

CONCLUSION

Antimicrobial and proinflammatory responses of alveolar macrophages during anesthesia were markedly suppressed by smoke exposure. Our data suggest that smoke exposure reduces the efficacy of immune defenses during anesthesia.

Prostaglandin E1 produces spasmolytic effects on histamine-induced bronchoconstriction in dogs

OBJECTIVE

In this study, we evaluated the spasmolytic effect of intravenous prostaglandin (PG) E1 on histamine-induced bronchoconstriction with a direct visualization method using a superfine fiberoptic bronchoscope.

SETTING

A university research laboratory.

SUBJECTS

Mongrel dogs.

INTERVENTIONS

The bronchial cross-sectional area (BCA) of mongrel dogs was measured by a direct visualization method using a superfine fiberoptic bronchoscope. Bronchoconstriction was elicited with histamine (H) infusion: 10 microg/kg iv bolus + 500 microg/kg/h continuous iv. The first protocol (n = 7) was designed to determine the effects of intravenous bolus of PGE1: 0 (saline), 0.01, 0.1, 1.0 and 10 microg/kg on H-induced bronchoconstriction. BCA was assessed before and 30 min after starting the H infusion and 5 min after each dose of intravenous PGE1. The second protocol was designed to determine whether continuous intravenous infusion of PGE1 reverses H-induced bronchoconstriction. In the PG group (n = 6), PGE1 was continuously infused at 0.1 microg/kg/min (20 mL/hr). In the control group (n = 6), saline was administered at a rate of 20 mL/hr iv. BCA was assessed before and 30 min after starting the H-infusion and at 5, 10, 30 and 60 min after commencing the PGE1 or saline infusion. Arterial blood was obtained simultaneously for measurement of plasma concentrations of epinephrine and norepinephrine by gas chromatography mass spectrometry.

MEASUREMENTS AND MAIN RESULTS

In the first protocol, PGE1 produced a dose-dependent increase in the percentage of BCA and 10 microg/kg of PGE1 almost fully reversed the H-induced bronchoconstriction. Plasma catecholamines did not change significantly. In the second protocol, continuous infusion of PGE1 produced a time-dependent reversal of H-induced bronchoconstriction (percentage of BCA increased to 80.0+/-9.0% 60 min after the start of PGE1 infusion), whereas saline infusion did not reverse the bronchoconstriction. Plasma catecholamines did not change significantly in either group.

CONCLUSIONS

Both intravenous bolus and continuous intravenous infusion of PGE1 reversed the H-induced bronchoconstriction. PGE1 may be used safely for patients with the hyperreactive airway and might be useful as a therapeutic agent for these patients.

Inhibitory effect of clonidine on ketamine-induced norepinephrine release from the medial prefrontal cortex in rats

We have investigated the effect of clonidine on ketamine-induced norepinephrine release from the medial prefrontal cortex in rats using microdialysis. Twenty-one male Wistar rats weighing 200-300 g were allocated randomly to one of four groups: i.p. injection of ketamine 100 mg kg-1 with clonidine 0 (saline: group C0, n = 6), 3 (group C3, n = 5), 30 (group C30, n = 5) and 300 micrograms kg-1 (group C300, n = 5). As reported previously, ketamine increases norepinephrine release. In groups C0 and C3, marked increases in norepinephrine release were observed with maximum values of mean 483 (SEM 55)% and 412 (53)% compared with basal values, respectively. Although significant increases in norepinephrine release were also observed (276 (43)%) in group C30, they were significantly lower than those in groups C0 and C3 (P < 0.01 and P < 0.05, respectively). In group C300, there was a significant reduction in norepinephrine release (62 (13)%) compared with basal and the three other groups (P < 0.01). This inhibitory effect of clonidine on norepinephrine may be related to reduction in undesirable emergence reactions after ketamine anaesthesia.

Expression of genes for proinflammatory cytokines in alveolar macrophages during propofol and isoflurane anesthesia

Anesthesia and surgery induce macrophage aggregation and neutrophil influx, responses that characterize an inflammatory reaction in the distal airway. We thus evaluated the time-dependent expression of genes for proinflammatory cytokines during propofol and isoflurane anesthesia. We studied patients anesthetized with propofol (n = 20) or isoflurane (n = 20). Alveolar macrophages were harvested by bronchoalveolar lavage immediately, 2, 4, and 6 h after induction of anesthesia, and at the end of surgery. RNA was extracted from harvested cells and cDNA was synthesized by reverse transcription. Expression of interleukin-1beta (IL-1beta), IL-6, IL-8, interferon gamma, and tumor necrosis factor-alpha was measured by semiquantitative polymerase chain reaction using beta-actin as an internal standard. We observed two 10-fold increases in gene expression of all proinflammatory cytokines except IL-6. The increases in IL-8 and interferon gamma were 1.5-3 times greater during isoflurane than propofol anesthesia. Expression of the genes for IL-1beta and tumor necrosis factor-alpha was similar with each anesthetic. Our data thus indicate that the pulmonary inflammatory response accompanying anesthesia and surgery is accompanied by the expression of proinflammatory cytokines, and that this expression was in some cases greater during isoflurane than propofol anesthesia.

IMPLICATIONS

Gene expression of proinflammatory cytokines in alveolar macrophages increased significantly over time. The increases were greater during isoflurane than propofol anesthesia, suggesting that inflammatory responses at transcriptional levels in alveolar macrophages are modulated by the type and duration of anesthesia.

The effects of nitrous oxide and ketamine on the bispectral index and 95% spectral edge frequency during propofol-fentanyl anaesthesia

In this study, we have sought to establish whether N2O and ketamine alter the bispectral index during propofol-fentanyl anaesthesia. Fourteen surgical patients were randomly assigned to one of two groups: the N2O group (n = 7) and the ketamine group (n = 7). In both groups, anaesthesia was induced with propofol 1.5-2 mg kg-1 and fentanyl 2 micrograms kg-1 and maintained with propofol 5-7 mg kg-1 hr-1 to target the bispectral index between 40 and 50. After the bispectral index value had stabilized the propofol infusion rate was fixed. In the N2O group, the following concentrations of N2O were subsequently inhaled at 20-min intervals; 20, 40, 60 and 70%, and then N2O was terminated. In the ketamine group, ketamine (0.4 mg kg-1 + 1.0 mg kg-1h-1) was given. The bispectral index and 95% spectral edge frequency were recorded 20 min after each change in concentration of N2O or ketamine infusion. The bispectral index and 95% spectral edge frequency did not change significantly in the N2O group, but increased significantly from 44.1 +/- 0.7 and 16.0 +/- 0.5 to 58.6 +/- 1.4 and 19.5 +/- 0.3 (P < 0.01), respectively, in the ketamine group. Additional N2O or ketamine did not decrease the bispectral index and 95% spectral edge frequency values. The depth of sedation should be assessed carefully using a bispectral index monitor when these anaesthetic agents are used together.

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.

Effects of sedatives on noradrenaline release from the medial prefrontal cortex in rats

RATIONALE

N-Methyl-d-aspartate (NMDA) receptor antagonism and GABA(A) receptor activation are believed to be critical targets for general anesthetic action. However, as NMDA antagonism of intravenous anesthetic agents causes post-anesthetic emergence reactions such as hallucination and agitation, while the GABA(A)-mimetic intravenous anesthetic agents do not, these two classes of intravenous anesthetic agents produce differential clinical profiles.

OBJECTIVE

We have investigated the differential effects of the GABA(A) agonists propofol and midazolam and the NMDA antagonist ketamine on noradrenaline release from the medial prefrontal cortex of the rat using microdialysis, as noradrenergic neurons have a role to play in anesthesia and are known to be important in the control of sleep, attention and learning.

METHODS

Twenty-one male Wistar rats (200-270 g) were randomly allocated into three groups: ketamine 100 mg x kg(-1) (n = 6), propofol 60 mg x kg(-1) (n = 8) and midazolam 5 mg x kg(-1) (n = 7) IP. A unilateral guide cannula was implanted stereotaxically into the medial prefrontal cortex under pentobarbital anesthesia (50 mg x kg(-1) IP). Forty-eight hours later, a dialysis probe was inserted through the guide cannula, and perfused with an artificial cerebrospinal fluid solution containing 1 mM pargyline. Following an equilibration period, samples of dialysate were collected every 10 min. Noradrenaline content was measured by high-performance liquid chromatography using an electrochemical detector.

RESULTS

Anesthesia times, defined as the duration between the loss of righting reflex and recovery, were 24.7+/-5.6 (SEM), 20.5+/-1.9 and 25.2+/-1.5 min for propofol, midazolam and ketamine, respectively (no significant between-group differences). Both GABA(A )agonists, propofol and midazolam, significantly decreased noradrenaline release (75% and 71% of basal release, respectively). The NMDA antagonist ketamine markedly increased noradrenaline release (413% of basal).

CONCLUSION

These data suggest that different clinical profiles observed with these two classes of sedatives may result from changes in noradrenaline release from the medial prefrontal cortex.

Physostigmine antagonizes ketamine-induced noradrenaline release from the medial prefrontal cortex in rats

Physostigmine is known to antagonize ketamine anesthesia. In this study, effects of physostigmine (0.1 mg kg(-1) i.p.) on ketamine (100 mg kg(-1) i.p.)-induced anesthesia time and noradrenaline release from the medial prefrontal cortex in rats were examined. Ketamine produced anesthesia for 27+/-1 min and increased noradrenaline release to 405% of the basal. Physostigmine significantly reduced anesthesia time to 23+/-1 min (p<0.05), and noradrenaline to 248% (p<0.05). Therefore, noradrenaline release may play an important role in ketamine anesthesia.

Movement response to skin incision: analgesia vs. bispectral index and 95% spectral edge frequency

We studied the movement response to skin incision in 68 adult (males/females) ASA I-II patients receiving propofol +/- fentanyl intravenous anaesthesia using the bispectral index and 95% spectral edge frequency monitoring with an A-1050 EEG monitor. Following Ethics Committee approval, patients were randomly assigned to one of the following four treatments: Group P (n = 17): propofol infusion, 1 mg kg-1 min-1 intravenous for 2 min, followed by propofol infusion, 200 micrograms kg-1 min-1, until skin incision; Group PF1 (n = 17): fentanyl bolus, 1 microgram kg-1 intravenous + propofol infusion as in Group P; Group PF2 (n = 17): fentanyl bolus, 2 micrograms kg-1 intravenous + propofol infusion as in Group P; and Group PF3 (n = 17): fentanyl bolus, 3 micrograms kg-1 intravenous + propofol infusion as in Group P. The bispectral index and 95% spectral edge frequency were monitored continuously and recorded prior to induction of anaesthesia (base-line) and at skin incision. Twelve, 10, 4 and 4 patients responded to skin incision in Groups P, PF1, PF2 and PF3, respectively (P and PF1 vs. PF2 or PF3; P = 0.0001, and 0.006). The bispectral index and 95% spectral edge frequency were significantly lower at skin incision compared with the base-line values in all the four treatment groups. However, only bispectral index values were significantly lower in the nonmovement as compared with the movement (M) category (32.6 +/- 8.9 vs. 37.4 +/- 10.3; P = 0.04). Though deeper levels of hypnosis to lower bispectral index and 95% spectral edge frequency values may be effective in preventing the movement response to skin incision, provision of adequate analgesia rather than lower bispectral index and 95% spectral edge frequency (clinical maintenance) values may be more reliable for preventing the response to skin incision as bispectral index and 95% spectral edge frequency measure the hypnotic component of the anaesthetic effect. Lower bispectral index values may be more discriminatory as compared with 95% spectral edge frequency values for preventing the movement response to skin-incision.

On the circumstances of the publication of the 1855 edition of "Roshia Gyuto Zensho" (Russian Vaccination Book)

There is a report that the 1850 edition of "Roshia Gyuto Zensho" (Russian Vaccination Book) translated by Sajuro Baba and edited by Sen-an Riko is not extant and that the 1855 edition of the book is the first edition. The author found an important document entitled "Shichu-Torishimari Zokuruishu - Shoseki-no-bu" at the National Diet Library, which includes several official records describing the publication circumstances of "Roshia Gyuto-Zensho" issued in 1856. This document has scarcely been referred to by medical historians before. It reads as follows: "Ihachi Subaraya, the publisher, asked the magistrate of Edo to permit him to publish and sell two volumes of the translated vaccination book entitled "Roshia Gyuto Zensho" in 1856. The magistrate consulted the members of astronomy division of the Tokugawa Shogunate concerning its possible publication and gave finally a sanction to the publisher after careful consideration. There is a description in the records which shows that two volumes of the 1850 edition were submitted for check, indicating that the 1855 edition is the second and the 1850 edition is the first edition. Behind the situation regarding the granting of permission to the publisher by the Shougunate, there would have been the fact that Sajuro Baba, the translator of the book, was one of the founders of the division of astronomy of the Shogunate.

Is total body weight an appropriate predictor for propofol maintenance dose?

BACKGROUND

Infusion rate of propofol during anaesthesia is usually based on total body weight. In this study, we have determined the relationship between total body weight and plasma propofol levels when the infusion rate was based on total body weight.

METHODS

Sixty patients undergoing elective surgery were studied. Anaesthesia was induced with propofol 1 mg x kg(-1), ketamine 1 mg x kg(-1) and fentanyl 2 microg x kg(-1), and maintained with propofol 5 mg x kg(-1) x h(-1), ketamine 0.5-1 mg x kg(1) x h(-1) and fentanyl 5-15 microg x kg(-1). Propofol infusion rate did not change during anaesthesia, and infusion was terminated at the end of surgery. Immediately prior to termination of the propofol infusion, arterial blood (5 ml) was collected to measure plasma level of propofol by a high-performance liquid chromatography equipped with electrochemical detection.

RESULTS

There was a significant correlation between plasma propofol and total body weight (r=0.646, P<0.001). Plasma propofol concentration also correlated with infusion rate, corrected to lean body mass (r=0.527, P<0.001).

CONCLUSION

During a fixed infusion rate, plasma propofol concentration may be dependent on total body weight.

Relation between bispectral index and plasma catecholamines after oral diazepam premedication

The efficacy of anaesthetic premedication has been assessed using sedative scores or a visual analogue scale. However, in both it may be difficult to exclude evaluators' subjectivity or a placebo effect. Plasma concentration of catecholamines may also be useful for the assessment of patient anxiety. Recently bispectral electro-encephalographic analysis has been developed, and the bispectral index monitor has been reported to give measurements which correlate well with the depth of sedation. In the present study, we have examined the relation between bispectral index values and plasma catecholamine concentrations after oral diazepam premedication. Twenty-eight patients scheduled for elective surgery were randomly assigned to one of two groups: diazepam premedication group (group D(+), n = 14) and no premedication group (group D(-), n = 14). The patients were premedicated orally with diazepam 10 mg and roxatidine 75 mg in group D(+), and with roxatidine 75 mg only in group D(-) 90 min before arrival in the operating theatre. After patients arrived in the operating theatre, the bispectral index monitor was applied. Venous blood samples (6 mL) were collected in the case of patients in group D(+) for the measurement of plasma catecholamines levels using high-performance liquid chromatography. The bispectral index level (mean +/- SD) in group D(+): 93.5 +/- 773.5 was significantly lower than that in group D(-): 96.1 +/- 1.8 (P < 0.05). There was a significant correlation between bispectral index and plasma norepinephrine levels (r = 0.567, P < 0.05). The present study suggests that the bispectral index monitor may detect the effect of oral diazepam premedication.

Relaxant effect of propofol on the airway in dogs

Propofol has been suggested to produce airway relaxant effects in vivo, although the mechanism is unclear. We have evaluated the bronchodilating effect of propofol using a direct visualization method with a superfine fibreoptic bronchoscope. We studied 21 mongrel dogs anaesthetized with pentobarbital 30 mg kg-1 i.v. and pancuronium 0.2 mg kg-1 h-1. The animals were allocated randomly to one of three groups (n = 7 in each): propofol group, atropine-propofol group and histamine-propofol group. The trachea was intubated using a tracheal tube that had a second lumen for insertion of the bronchoscope to monitor continuously bronchial cross-sectional area (BCA). BCA was measured using the NIH Image program. In the propofol group, dogs were given the following doses of propofol at 10-min intervals: 0 (saline), 0.2, 2.0 and 20 mg kg-1 i.v. In the atropine-propofol group, saline, atropine 0.2 mg kg-1 and propofol 20 mg kg-1 were given at 10-min intervals. In the histamine-propofol group, bronchoconstriction was elicited with histamine 10 micrograms kg-1 and 500 micrograms kg-1 h-1 until the end of the experiment. Thirty minutes after the start of infusion of histamine, propofol (0, 0.2, 2.0 and 20 mg kg-1) was administered. Changes in BCA were expressed as percentage of basal area. Histamine decreased BCA by 39.2 (SEM 5.4%). Propofol increased significantly basal and histamine-decreased BCA in a dose-dependent manner by 18.4 (4.5%) and 15.8 (4.9%), respectively after 20 mg kg-1 i.v. However, propofol following atropine i.v. did not increase BCA (129.9 (8.2)% after atropine vs 125.7 (8.9)% after propofol). Therefore, the relaxant effect of propofol may be a result of reduction in vagal tone.

Allelic loss mapping and physical delineation of a region harboring a putative thymic lymphoma suppressor gene on mouse chromosome 12

Our previous allelic loss analysis of gamma-ray induced thymic lymphomas in F1 hybrid and backcross mice between BALB/c and MSM strains mapped the Tlsr4 region exhibiting a high frequency of allelic loss (62%) to a 2.9 cM interval between the markers D12Mit53 and D12Mit279 on mouse chromosome 12. To narrow further the interval harboring a putative tumor suppressor gene, a high-density scan has been carried out for informative 361 thymic lymphomas. Construction of a physical map of Tlsr4 with 3 YAC and 15 BAC clones and isolation of YAC- and BAC-derived polymorphic probes lead to fine allelic loss mapping. Three successive polymorphic sites within one BAC exhibit the retention of both alleles in seven, one and four lymphomas, suggesting that a common region of allelic loss for Tlsr4 exists within the BAC region. Pulsed-field gel electrophoresis of NotI digests of this and other clones determines that the commonly lost region is a 35 kb interval with a NotI site. NotI sites are frequently associated with coding regions, and our preliminary sequencing has identified ESTs in the region. Thus, the present study facilitates the identification of genes in the Tlsr4 region that would lead to isolation of a novel tumor suppressor gene.

Volatile anesthetics augment expression of proinflammatory cytokines in rat alveolar macrophages during mechanical ventilation

BACKGROUND

Previous studies indicate that anesthesia and surgery induce an inflammatory reaction in alveolar macro phages. However,they filed to independently evaluate the relative contributions of factors including mechanical ventilation, general anesthesia, and surgical stress. Therefore, the authors tested the hypothesis that inflammatory reactions at the cellular level in alveolar macrophages are induced within 2 h of inhalation of volatile anesthetics under mechanical ventilation.

METHODS

After administration of pentobarbital, rats were allocated to the nonventilated control or spontaneous or mechanical ventilation (n = 15/group) for 2 h at a fraction of inspired oxygen (FI(O2)) of 0.21. In a separate series of experiments, rats were mechanically ventilated without volatile anesthesia, or during exposure to halothane, enflurane, isoflurane, or sevoflurane (n = 15/group). Pulmonary lavage was performed, and RNA was extracted from harvested cells. The mRNA for the proinflammatory cytokines interleukin (IL)-1alpha, IL-1beta, IL-6, macrophage inflammatory protein-2 (MIP-2), interferon gamma (IFN-gamma), and tumor necrosis factor alpha (TNF-alpha) were measured by semiquantitative reverse transcription-polymerase chain reaction using beta-actin as an internal standard. Pulmonary lavage concentrations of these cytokines were measured by enzyme-linked immunoassay.

RESULTS

The lavage cell count and cytology were similar in each series of the experiment. Gene expression of MIP-2 and TNF-alpha was greater during mechanical than spontaneous ventilation and nonventilation control However, the concentrations of cytokines except MIP-2 and TNF-alpha were less than detection levels. During exposure to volatile anesthetics, gene expression for IL-1beta, MIP-2, IFN-gamma, and TNF-alpha all increased significantly compared with mechanical ventilation alone. Significant increases in lavage concentrations of MIP-2 and TNF-alpha were also observed.

CONCLUSIONS

Gene expression of proinflammatory cytokines increase after inhalation of volatile anesthetics under mechanical ventilation. These data indicate that inhalation of volatile anesthetics under mechanical ventilation induces an inflammatory response at the transcriptional level within 2 h.

The relaxant effect of propofol on guinea pig tracheal muscle is independent of airway epithelial function and beta-adrenoceptor activity

Airway epithelium and vascular endothelium modulate the tension of the underlying smooth muscle by releasing relaxing factors such as prostanoids and nitric oxide (NO). We investigated whether the relaxant effect of propofol on airway smooth muscle is dependent on airway epithelial function. Tracheal spirals of female guinea pigs were mounted in water-jacketed organ baths filled with Krebs-bicarbonate buffer aerated with 95% O2 and 5% CO2 at 37 degrees C. Changes in isometric tension of the specimens were measured with a force-displacement transducer and recorded with a polygraph. Propofol (10(-4) to 10(-3) M) inhibited carbachol (CCh)-, histamine (HA)-, or endothelin-1-induced contractions of the muscles in a dose-dependent manner. Neither mechanical removal of the epithelial layer, chemical inhibition of epithelial synthesis of prostanoids, nor NO affected the relaxant effect of propofol on CCh- or HA-induced tracheal contraction. Furthermore, the blockade of beta-adrenoceptors did not change the relaxant effect of propofol. These results indicate that the relaxant effect of propofol on the airway smooth muscle is independent of the epithelial function or beta-adrenoceptor activity. Propofol is an excellent anesthetic for patients with hyperreactive airways in which the epithelial layer is damaged.

IMPLICATIONS

Airway epithelium, as well as vascular endothelium, plays an important role in modulating the baseline tone and reactivity of underlying smooth muscle. We investigated, in vitro, whether the relaxant effect of propofol on airway smooth muscle is dependent on airway epithelial function. We suggest that propofol relaxes airway smooth muscle independently of the epithelial function.

Comparative therapeutic evaluation of intrathecal versus epidural methylprednisolone for long-term analgesia in patients with intractable postherpetic neuralgia

BACKGROUND AND OBJECTIVES The goal of this study was to evaluate the analgesic effects of intrathecal versus epidural methylprednisolone acetate (MPA) in patients with intractable postherpetic neuralgia (PHN).

METHODS

We studied 25 patients with a duration of PHN of more than 1 year. The patients were randomly allocated to one of two groups: an intrathecal group (n = 13) and an epidural group (n = 12). Sixty milligrams of MPA was administered either into the intrathecal or the epidural space four times at 1-week intervals depending on the treatment group. Continuous and lancinating pain and allodynia were evaluated by a physician unaware of group assignment with a 10-cm visual analogue scale before treatment, at the end of treatment, and 1 and 24 weeks after treatment. In addition, cerebrospinal fluid (CSF) was obtained for measurement of interleukin (IL)-1beta, -6, and -8 and tumor necrosis factor-alpha before and 1 week after treatment.

RESULTS

We found marked alleviation of continuous and lancinating pain and allodynia in the intrathecal group (P < .001). The improvements were much greater in the intrathecal group than in the epidural group at all time points after the end of treatment (P < .005). IL-8 in the CSF decreased significantly in the intrathecal group as compared to the epidural group at the l-week time point (P < .01), whereas the other cytokines were undetectable.

CONCLUSIONS

Our results suggest the effectiveness of intrathecal as compared to epidural MPA for relieving the pain and allodynia associated with PHN. Also, our findings, together with the decrease in IL-8, may indicate that intrathecal MPA improves analgesia by decreasing an ongoing inflammatory reaction in the CSF.

Relaxant effect of magnesium and zinc on histamine-induced bronchoconstriction in dogs

OBJECTIVE

Magnesium sulfate (MgSO4) has been reported to produce bronchodilation in asthmatic patients. In vitro studies have suggested that divalent cations inhibit L-type voltage-sensitive calcium ion (Ca2+) channels in cardiac and smooth muscles. In this study, we evaluated the in vitro and in vivo effects of magnesium ion (Mg2+) and zinc ion (Zn2+) on the airway contracted by histamine.

SETTING

A university research laboratory.

SUBJECTS

IN VITRO

Tracheal smooth muscle from guinea pigs.

IN VIVO

Mongrel dogs.

MEASUREMENTS AND MAIN RESULTS

IN VITRO STUDY

The tension of isolated guinea pig tracheal strips was measured isometrically with a force displacement transducer. The specimen was contracted with histamine (10 microM). Then, MgSO4 (n = 6), zinc sulfate (ZnSO4, n = 6), or sodium sulfate (Na2SO4, n = 6) was cumulatively added to the organ bath.

IN VIVO STUDY

The bronchial cross-sectional area of mongrel dogs was measured by a direct visualization method demonstrated previously. The dogs were randomly assigned to three groups: group Mg (n = 7), group Zn (n = 7), and group Na (n = 7). Bronchoconstriction was elicited with histamine (10 microg/kg plus 500 microg/kg/hr iv). Thirty minutes after the start of histamine infusion, 0 (saline), 1, 10, and 100 micromol/kg ZnSO4 or 1, 10, 100, and 1000 micromol/kg MgSO4 or Na2SO4 were administered intravenously in group Zn, Mg, or Na, respectively. The bronchial cross-sectional area was assessed before (basal) and 30 mins after the start of histamine infusion and 5 mins after each dose of ZnSO4, MgSO4, or Na2SO4. Arterial blood was also obtained to measure plasma levels of epinephrine and norepinephrine by gas chromatography-mass spectrometry. All data are expressed as mean +/- SEM. The doses of the divalent cations that reversed histamine-induced contraction by 50% were calculated by GraphPad Prism. MgSO4 and ZnSO4 (9.38+/-0.28 and 1.84+/-0.30 mM, respectively) relaxed histamine-contracted tracheal strip in a concentration-dependent manner, whereas Na2SO4 did not. Similarly, the in vivo study showed that MgSO4 and ZnSO4 dose-dependently reversed histamine-induced bronchoconstriction (potency, ZnSO4 > MgSO4), whereas Na2SO4 did not. In groups Mg and Zn, the plasma catecholamine levels also dose-dependently increased except when 1000 micromol/kg MgSO4 was administered.

CONCLUSION

Because the divalent cations tested produced a spasmolytic effect on the contracted airway, infusion of divalent cations might be effective against asthmatic attack. However, high concentrations of these cations produce significant toxicity, so dosage will be an important concern in development of these agents.

Esophageal mucoepidermoid carcinoma containing signet-ring cells: three case reports and a literature review

We report 3 cases of esophageal signet-ring cell carcinoma which were found in a set of 505 resected esophageal tumors. The incidence of esophageal signet-ring cell carcinoma was 0.6%. All of the signet-ring cell carcinomas were histologically mixed with squamous cell carcinoma (mucoepidermoid carcinoma). The signet-ring cells had intracellular mucin, which was positive for both periodic acid-Schiff (PAS) and alcian blue at pH 2.5. At the time of presentation, extensive extraesophageal tumor spread and local extension were found in all cases. All of the patients died within 2 years after the esophagectomy irrespective of whether they received chemotherapy or radiotherapy. Our results, and those previously reported, suggest that most esophageal carcinomas containing signet-ring cell carcinoma are aggressive neoplasms associated with a poor prognosis after esophagectomy.

No psychological emergence reactions in schizophrenic surgical patients immediately after propofol, fentanyl, and ketamine intravenous anesthesia

PURPOSE

We attempted to determine the frequency of adverse psychological events after total intravenous anesthesia with propofol-fentanyl-ketamine (PFK) in surgical schizophrenic patients.

METHODS

PFK was used in 25 schizophrenic patients undergoing various surgical procedures from 1995 to 1997. Adverse events occurring during and after anesthesia were recorded. Psychiatric follow-up was also done during the first 3 postoperative weeks at least.

RESULTS

One patient died postoperatively of airway obstruction from concomitant severe malignant thyroid disease, but in the remaining patients neither respiratory nor cardiovascular states during or after anesthesia became unstable. None of the patients developed adverse psychological emergence reactions immediately after anesthesia. Two patients undergoing major surgical procedures exhibited delirium in the early postoperative days despite taking their routine antipsychotic drugs postoperatively.

CONCLUSIONS

We suggest that PFK maintains stable respiratory and cardiovascular states, and causes no psychological emergence reactions in schizophrenic surgical patients. However, adverse psychological events may occur postoperatively, probably due to continued psychic stress. We therefore recommend appropriate perioperative management and further psychological studies for such patients.

Estimation of the initial distribution volume of glucose by an incremental plasma glucose level at 3 min after i.v. glucose in humans

AIMS

The initial distribution volume of glucose (IDVG) could be a clinically useful indicator of the central extracellular fluid (ECF) space volume, namely the interstitial fluid volume status of highly perfused organs. In this study, we determined the formula of IDVG using incremental plasma glucose levels after i.v. glucose.

METHODS

One hundred and fifty patients admitted to the general intensive care unit of the University of Hirosaki hospital were entered into this prospective study which was conducted in two stages. In the first stage 300 data points from 100 patients were used to measure the IDVG (3 determinations for each patients). This utilized a one compartment model to describe the incremental plasma glucose decay curve following an intravenous bolus injection of glucose which, in turn, was used to derive the parameters of an equation for IDVG prediction following a single plasma sample. The second stage was a validation of the equation using a separate data set (150 points) from a further 50 patients.

RESULTS

A one phase exponential decay model was well-fitted for the IDVG-postadministration glucose level curve, and indicated that the incremental glucose level at 3 min after i.v. glucose was best-correlated to the IDVG compared with those at 1, 2, 4, 5 and 7 min postadministration. The formula of the IDVG was obtained from the curve: IDVG=24.44xe-0.0298xDeltaGL+2.70, where DeltaGL=incremental glucose level at 3 min after i.v. glucose. Another 150 samples showed that the measured-IDVG from a one compartment model and predicted-IDVG from the formula were 7.24+/-1. 63 and 7.27+/-1.52 l, respectively, and that there was a significant correlation between the two IDVGs (r=0.966, P<0.0001).

CONCLUSIONS

Using an incremental glucose level at 3 min after i.v. glucose, we have established the reliable formula for determination of the IDVG which could be a clinically useful indicator of the central ECF volume.

Renin-aldosterone in elderly patients with hyperkalaemia under anaesthesia

Elderly patients with hyperkalaemia often have low concentrations of plasma renin and aldosterone, perhaps secondary to reduced glomerular filtration and sympathetic insufficiency. The endocrine response to surgical stress and volume expansion during anaesthesia was studied in seven elderly patients with hyperkalaemia (mean age 87.7 +/- SD 5.3 years), 18 elderly patients without hyperkalaemia (86.5 +/- 5.5 years), and 18 younger patients (52.6 +/- 7.2 years) as controls. Base-line values, in hyperkalaemic elderly patients, for plasma renin activity and plasma aldosterone concentration were 0.8 +/- 0.3 ng mL-1 h-1 and 2.8 +/- 0.8 pg mL-1 respectively (significantly lower than in the younger patients), and 287 +/- 42 pg mL-1 for plasma atrial natriuretic peptide levels, which were significantly higher. The plasma renin activity and aldosterone concentrations in elderly patients with hyperkalaemia were at all times lower, but not significantly, than those of the elderly patients without hyperkalaemia. The atrial natriuretic peptide concentrations (351 +/- 48 pg mL-1) in the hyperkalaemic elderly were significantly higher 90 min after induction of anaesthesia than in the normokalaemic elderly (108 +/- 38 pg mL-1). Hormone concentrations in the hyperkalaemic patients did not change during anaesthesia, but plasma atrial natriuretic peptide concentrations increased significantly in the normokalaemic elderly, and plasma renin activity and aldosterone of the younger patients increased significantly during anaesthesia. These results indicate that plasma renin activity, and the concentrations of aldosterone and of atrial natriuretic peptide in elderly patients with hyperkalaemia are unresponsive to surgical stress and volume expansion.

Effects of ketamine and pentobarbital on noradrenaline release from the medial prefrontal cortex in rats

PURPOSE

To determine the effects of ketamine and pentobarbital on noradrenaline release from the medial prefrontal cortex.

METHODS

In 14 male Wistar rats, a microdialysis probe with a 2 mm long semipermeable membrane was implanted in the medial prefrontal cortex. The dialysis probe was perfused at a rate of 1 microl x min(-1) with an artificial cerebrospinal fluid solution. The rats were randomly allocated to two groups: ketamine (group K, n=7) and pentobarbital (group P, n=7). Each rat was subsequently given 0 (saline), 1, 10 and 100 mg x kg(-1) ketamine i.p. in group K, and 0 (saline), 0.5, 5 and 50 mg x kg(-1) pentobarbital i.p. in group P. Sixty minutes elapsed between administration. Noradrenaline concentration was measured by HPLC with an electrochemical detector at 20 min intervals. (detection limit: 250 fg x 20 microl(-1), coefficient variation of the assay: 4.9%). The data in the 20-40 min after each dose of ketamine or pentobarbital i.p. were used for the statistical analysis.

RESULTS

Noradrenaline release after 100 mg x kg(-1) ketamine increased by 7.7 +/- 2.0 (SEM) pg x collection(-1) compared with 2.7 +/- 0.7, 3.3 +/- 1.0 and 4.2 +/- 0.8 pg x collection(-1) after saline, 1 and 10 mg x kg(-1) ketamine, respectively (P < 0.05). Noradrenaline release did not change after pentobarbital.

CONCLUSION

This study suggests the ketamine and pentobarbital have different effects on noradrenergic neurons in the medial prefrontal cortex. The stimulating effect of ketamine on noradrenaline release from the cortex might contribute to unique clinical features of ketamine anesthesia.

Middle latency auditory evoked potentials during total intravenous anesthesia with droperidol, ketamine and fentanyl

We investigated whether total intravenous anesthesia with ketamine, fentanyl and droperidol would affect middle latency auditory evoked potentials and explicit memory, and whether dreams during the anesthesia are related to plasma concentrations of fentanyl and the infusion technique. A total number of 40 patients were the subjects for this study. Twenty patients (group A) were maintained with intravenous ketamine 2 mg kg-1 hr-1 and fentanyl 5 micrograms kg-1 hr-1 for the first 60 min and 3 micrograms kg-1 hr-1 for the next 90 min, and droperidol 0.1 mg kg-1. The remaining 20 patients (group B) were maintained with intravenous ketamine 2 mg kg-1 hr-1, droperidol 0.1 mg kg-1 and fentanyl 50-100 micrograms in a bolus intermittently as needed by vital signs such as increases in heart rate and arterial blood pressure. Middle latency auditory evoked potentials, plasma fentanyl and ketamine levels were measured; explicit memory and dreams were also estimated. There were no patients who recollected explicit memories of intraoperative events in both groups. The middle latency auditory evoked potentials were not significantly changed during the anesthesia in both groups. We could find no significant differences in latencies and amplitudes of the middle latency auditory evoked potentials between the both groups. Plasma fentanyl levels of group B patients were significantly lower than those of group A patients and the incidence of the dreams was significantly higher in group B patients. We conclude that the anesthesia with ketamine, fentanyl and droperidol is not associated with the explicit memories, though the middle latency auditory evoked potentials were not significantly changed as compared with those in the waking state. In addition, dreams during the anesthesia may correlate with plasma fentanyl concentrations or the infusion technique.

New information about Seishu Hanaoka's family tree according to the burial records of Jizoji Temple

Since Shuzo Kure published his voluminous monograph entitled "Seishu Hanaoka and His Surgery" in 1923, the biography of Hanaoka has been widely studied and two monographs were published in 1964 and 1973 to describe in detail the life and activities of Hanaoka. In spite of these historical studies, for more than seventy years several important persons have been unclarified in the pedigree of the Hanaokas. Recently the author made a repeated survey of two volumes of the burial records of Jizoji temple of Naka town, Wakayama Prefecture. The temple had been the family temple of the Hanaokas during Seishu Hanaoka's lifetime. About one hundred and eight posthumous names, given names, and death dates of the Hanaokas were found in the records, which can be classified into several branches. The most important findings are: 1) the given and posthumous name and death date of Seishu's younger sister (Otane) was identified and another younger sister's posthumous name and death date were guessed with a strong probability; 2) Seishu's third son's death date was identified and the given and necromancy name and, death date of Seishu's third daughter were made clear. In addition, several important findings on Seishu's ancestors are presumed from this investigation of the burial records. These new findings are very useful to understand the background of Hanaoka's study on "Mafutsu-to" and his biography.

Response to surgical stress in elderly patients and Alzheimer's disease

PURPOSE

To determine the effect of surgical stress on plasma epinephrine, norepinephrine, ACTH and cortisol concentrations in patients aged 80-99 yr and in patients complicated with Alzheimer's disease.

METHODS

A prospective controlled study was undertaken in 55 undergoing surgical reduction of femur neck fracture in Hirosaki University hospital and Hakodate Watanabe hospital; 18 patients in 80-99 yr (Group 1) and 18 patients in 40-59 yr (Group 2) and 7 patients (Group A) with and 12 patients (Group B) without Alzheimer's dementia (AD) aged 60-79 yr.

RESULTS

The increase in plasma norepinephrine level (274%) of group 1 patients, 15 min after skin incision was higher than that in group 2 (191%) (P < 0.01). Mean plasma cortisol levels (40.4+/-4.7 and 44.1+/-5.2 microg x dl(-1)) of group 1, 15 min after skin incision and 60 min after the end of surgery were significantly higher than the 29.8+/-3.5 and 22.3+/-3.0 microg x dl(-1) of group 2 (P < 0.05). Plasma norepinephrine (1092.9+/-112.0 pg x ml(-1)) and cortisol concentrations (53.4+/-5.8 microg x dl(-1)) in group A were higher than in group B (772.6+/-82.4 pg x ml(-1) and 41.7+/-4.3 microg x dl(-1)) 15 min after skin incision (P < 0.05).

CONCLUSIONS

Plasma norepinephrine and cortisol responses to surgical stress are activated in elderly patients and in patients with Alzheimer's disease.