Effects of amrinone on ischaemia-reperfusion injury in cirrhotic patients undergoing hepatectomy: a comparative study with prostaglandin E1

The effects of amrinone, a selective phosphodiesterase III inhibitor, on liver ischaemia reperfusion injury have not yet been clarified. Forty-five patients with hepatocellular carcinoma who underwent partial liver resection using Pringle's manoeuvre were studied. Patients were divided into three groups: those given amrinone, those given prostaglandin E1 (PGE1) and those not treated (controls). An indocyanine green (ICG) clearance test was performed before the operation and three times during surgery: just before induction of liver ischaemia, just after liver resection and 60 min after reperfusion. Blood lactate and base excess were measured at the same times. Systolic and diastolic arterial pressure, heart rate, cardiac index and oesophageal temperature were monitored. Aminotransferase levels were recorded the day before surgery, 1 h after operation and on the first and third postoperative days. These data were compared between groups. The ICG elimination rate, lactate and base excess in the amrinone group differed significantly from those in controls during the observation period (P = 0.03, P = 0.04 and P = 0.03, respectively). The differences between the PGE1 and control groups were not significant. There were no significant differences between the groups in perioperative vital signs, cardiac index or postoperative aminotransferase. Amrinone enhanced intraoperative ICG elimination in cirrhotic patients who underwent liver resection.

Procaspase 3/p21 complex formation to resist fas-mediated cell death is initiated as a result of the phosphorylation of p21 by protein kinase A

Caspase 3 is an essential factor for Fas-mediated cell death and exists endogenously in cells where its activation is suppressed by p21 and ILP. Inside the cell, procaspase 3 interacts with p21 on mitochondria. In the present study, we investigated the molecular basis for procaspase 3/p21 complex formation. During Fas-mediated cell death, mitochondria are damaged, accompanied by decreased mitochondrial membrane-potential and decreased intracellular ATP levels. This mitochondrial damage occurs before an estrangement of the procaspase 3/p21 complex, and we demonstrate that intracellular ATP-deprivation also initiates an estrangement of procaspase 3/p21 complex formation and accelerates Fas-mediated cell death. In addition, our current results revealed that the phosphorylated p21 by PKA interacts with procaspase 3. Here, we report that the mitochondrial role, especially for ATP synthesis, and PKA are necessary for the procaspase 3/p21 complex formation to resist Fas-mediated cell death.

Bcl-2 antiapoptotic protein mediates verotoxin II-induced cell death: possible association between bcl-2 and tissue failure by E. coli O157:H7

Verotoxin II (VTII: or Shiga-like toxin 2) is a key factor for Escherichia coli O157:H7-induced multiple tissue failure and contains a pentameric sequence (NWGRI) similar to the Bcl-2 homolog domain, BH1. In the current study, we demonstrate that VTII, but not VTI, interacts with Bcl-2 through each BH1 domain pentameric sequence (NWGRI) and that the VTII/Bcl-2 complex is necessary for cell-death induction in target cells. VTII translocates to mitochondria and induces cell death only when target cells are expressing Bcl-2. In addition, interruption of VTII-Bcl-2 complex formation by a pentameric BH1 synthetic peptide suppresses VTII-induced cell death. In the present article, we propose that Bcl-2 mediates VTII-induced target cell death by the interaction with each pentameric sequence of BH1 domain.

Survivin initiates cell cycle entry by the competitive interaction with Cdk4/p16(INK4a) and Cdk2/cyclin E complex activation

Survivin is observed uniquely in tumor cells and developmental cells, which undergo either inappropriate or programmed cell growth. In the current study, we investigated the influence of Survivin on cell cycle. Overexpression of Survivin resulted in accelerated S phase shift, resistance to G1 arrest, and activated Cdk2/Cyclin E complex leading Rb phosphorylation. In addition, nuclear translocation of Survivin followed by an interaction with Cdk4 was detected. Interestingly, Survivin nuclear translocation coincided with S phase shift, and prevention of nuclear transport suppressed Survivin nuclear translocation and S phase shift. Further, we also observed that Survivin competitively interacted with the Cdk4/p16(INK4a) complex in a cell free system and in vivo. These results suggest that Survivin initiates the cell cycle entry as a result of nuclear translocation followed by an interaction with Cdk4.

[Nurses' leadership in the perspective of postmodern ethics]

The administrative models arising from modernity are becoming increasingly obsolete in view of the needs of organizations, especially those which provide health care such as health institutions and their human capital. Since rationality is an essential element for the accomplishment of organizational objectives, modern ethics requires only that workers adjust to their prescribed functions and perform their tasks according to the rules. Post-modernity is characterized by saturation of information and consumption, pleasure of using goods and services, lack of values and meaning of life, reflecting a post-modern apathy. Without projects man's interior life has no substance. Health organizations are being strongly influenced by this context. Hence, ethics needs to be treated in a new way. Thus, the purpose of this paper is to approach nurse's leadership in light of post-modern ethics.

[Changes in professional practice of nurses at a teaching hospital in the inner Sao Paulo, as a result of the emergence of HIV/AIDS]

This investigation was conducted with the purpose of identifying the changes in the professional practice of nurses at a public teaching hospital as a result of the arrival of HIV/AIDS. Through interviews with 100 nurses it was found that 76 (76%) referred changes in their professional practice. Of these, 52 (68.4%) referred to the use of garments; 17 (22.3%) to continuing education; and 7 (9.2%) to nursing care. Of a total of 76 reasons presented by the nurses, 46 (60.5%) were related to fear of becoming infected; and 30 (39.5%) related to nursing care. The study revealed that the advent of HIV/AIDS has risen various changes in practical activities of nurses, especially in those related to garments, having as the main concern the fear of becoming infected. Continuing education programs that aim not only to identify the causes that determine low adherence to standard precaution measures and undesirable behavior as well as biosafety surveillance are needed.

Peri-operative blood lactate levels in recipients of living-related liver transplantation

BACKGROUND

The role of changes in peri-operative blood lactate levels in recipients of living-related liver transplants has not yet been clarified.

METHODS

Forty-three recipients were included in this study. Blood lactate, plasma total bilirubin, aminotransferase, body temperature, and gastric mucosal PCO2 levels were measured at six time points during surgery: just before the initiation of surgery, just after dissection of the hepatic vasculature, at the end of the anhepatic phase, and 30, 60, and 120 min after reperfusion. We calculated the rate of lactate accumulation during the pre-anhepatic and anhepatic phases and the elimination rate during reperfusion (neohepatic phase), and examined the correlation between these results and the clinical findings.

RESULTS

The rate of lactate elimination during the neohepatic phase was correlated with the ratio of graft weight to standard liver volume (P<0.0001). There was also a significant correlation between the rate of lactate accumulation during the pre-anhepatic phase and the preoperative total bilirubin levels (P=0.0008).

CONCLUSIONS

Each pre-anhepatic, anhepatic, and neohepatic phase had a characteristic blood lactate profile. The graft size strongly affected lactate levels during the early neohepatic phase.

Survivin promotes cell proliferation in human hepatocellular carcinoma

Survivin is a recently described inhibitor of apoptosis. Because suppression of apoptosis is important for carcinogenesis and tumor growth, we investigated the expression and function of survivin in human hepatocellular carcinomas (HCCs). We have shown that 4 HCC cell lines and 7 out of 8 human HCC tissues expressed survivin messenger RNA (mRNA), whereas expression of survivin mRNA was not detected in normal liver and nontumor areas of these tissues using the reverse transcription polymerase chain reaction. Survivin was detected primarily in the nucleus by immunofluorescence staining of HCC cells. In addition, 14 of 20 (70%) HCC tissues showed positive nuclear staining for survivin, whereas nontumor tissues showed little detectable staining by immunohistochemistry. Survivin expression strongly correlated with the proliferation index but not significantly with the apoptosis index in HCC tissues. Therefore, we performed cell cycle analysis after survivin transfection and showed that overexpression of survivin resulted in a decrease in the G(0)/G(1) phase and an increase in the S phase in all 4 HCC cell lines. Furthermore, we have found that survivin interacted with cyclin-dependent kinase 4 (Cdk4) and overexpression of survivin released p21(WAF1/Cip1) (p21) from Cdk4. From these results, we conclude that survivin promotes cell proliferation by interacting with Cdk4 and releasing p21 from Cdk4. This may play an important role in carcinogenesis and progression of human HCCs.

Direct coupling of microcolumn liquid chromatography with in-tube solid-phase microextraction for the analysis of antidepressant drugs

The direct coupling of in-tube solid-phase microextraction (in-tube SPME) with microcolumn liquid chromatography (micro-LC) has been investigated for the analysis of antidepressants in human urine. The use of in-tube SPME has been clearly shown to be advantageous for the on-line coupling of the SPME method, as the sample pretreatment technique, with micro-LC as the separation technique. This is because much smaller amounts of the sample solutions, desorption solvents and the mobile phase are required compared with conventional SPME-LC systems. The parameters for preconcentration have been investigated for the extraction capillary with the newly developed 'wire-in-tube' configuration.

Survivin initiates procaspase 3/p21 complex formation as a result of interaction with Cdk4 to resist Fas-mediated cell death

Caspase 3 is an essential death factor for the Fas-mediated cell death, and its inactivation in cells is initiated by an interaction with p21 on mitochondria or with IAP family member ILP. Survivin is also a member of IAP family and is specifically expressed during embryogenesis and in tumor cells and suppresses cell death signaling. In our current study, we demonstrated that Survivin translocation into the nucleus is dependent on Fas stimulation and cell proliferation. Survivin also interacts with the cell cycle regulator Cdk4, leading to Cdk2/Cyclin E activation and Rb phosphorylation. As a result of Survivin/Cdk4 complex formation, p21 is released from its complex with Cdk4 and interacts with mitochondrial procaspase 3 to suppress Fas-mediated cell death. Here, we propose that Survivin supports procaspase 3/p21 complex formation as a result of interaction with Cdk4 resulting in suppression of cell death signaling.

[Myocardial ischemia score as a preoperative screening method for intraoperative myocardial ischemia]

Three hundred patients for abdominal surgery with risk factors of ischemic heart disease (IHD), such as hypertension, diabetes mellitus, hyperlipidemia, smoking, old age, obesity, familial history, electrocardiographic abnormality, other perivascular diseases and male, were included in this study. Patients older than forty years were included in the study. ST segment in lead II and V5 was recorded by ST trend monitor from the time of entering the operating room to the time of exit and intraoperative myocardial ischemia occurred in 58 patients (19.3%). Correlation coefficients between each risk factor of IHD and intraoperative myocardial ischemia were calculated by multiple regression analysis and myocardial ischemia score (MIS) was determined. Intraoperative myocardial ischemia increased in patients with more than 10 points of MIS by discriminant analysis and hitting ratio of MIS was 86.3%.

[The effect of prophylactic nicorandil infusion to reduce intraoperative myocardial ischemia during abdominal surgery in patients with risk factors of ischemic heart disease]

Three hundred patients who had undergone abdominal surgery with risk factors of ischemic heart disease (IHD), such as hypertension, diabetes mellitus, hyperlipidemia, smoking, advanced age, obesity, familial history, electrocardiographic abnormality, other perivascular disease, and male, were included in this study. Patients older than forty years were included in the study. They were divided into two groups for a randomized double blind trial: nicorandil was administered in one group (group N) and placebo in another (group C), and we investigated the effect of prophylactic nicorandil infusion to reduce intraoperative myocardial ischemia. ST segment in leads II and Vs was recorded by ST trend monitor from the time of patient's entering the operating room to the time to exit. Intraoperative myocardial ischemia occurred in 11 patients in group N and in 32 patients in group C (P < 0.0001). Prophylactic nicorandil infusion was effective to reduce intraoperative myocardial ischemia in patients with risk factors of IHD during abdominal surgery.

[Humanistic approach to nursing communication: the case of a hospitalized adolescent female]

Nursing is a profession committed to the promotion of human beings. It takes into consideration their freedom, uniqueness and dignity. Therefore, communication plays an important role within the nursing process and its results, and it is also a fundamental component of the treatment. However, in the context of Brazilian hospitals, communication between nurses and patients is limited to the performance of these professionals' technical role. The purpose of this study is to analyse the case of a hospitalized female adolescent, focusing on the communication that happens between her and the nursing professionals who provide her assistance. This analysis was based on Bales' categories. Through the technique of direct observation, the behavior resultant from the interaction between nurses and the adolescent was analysed on a total of 30 hours during five days. The observation showed 428 units of interaction which were classified, by qualified professionals, in positive, negative and neutral socio-emotional areas. Considering the high incidence of interactions in the neutral area (89.2%), authors recommend a humanistic correction in the communication during the nursing process. This change in communication can qualify patient's care as well as generate satisfaction at work through empathy and solidarity.

Algorithm for the treatment of acute psychotic episodes

Most acute psychotic episodes are regarded as indicators of schizophrenia. We developed an algorithm for the treatment of such episodes. In Japan, psychiatrists tend to prescribe two or more neuroleptics at once, but it is thought that using a single neuroleptic is better, and the algorithm we report is based on this view. Since there are few reports on how to choose and use a single neuroleptic in Japan, our method is simply an example, with insufficient scientific support. It will need to be revised in future.

[Latent factors aggravating airway allergic symptom in urban population: the involvement of urban living environments]

The involvement of urban living environments in IgE-increase (atopy) and ECP-increase (enhanced eosinophil activity), the inter-relationship of IgE-increase and ECP-increase, and their involvement in developing airway allergic symptoms were studied on a population of adult nonsmoking women, in order to elucidate the latent factors aggravating airway allergic symptoms in an urban population. In our earlier study on child asthma in 1994, we examined the relationship between living environments and mite proliferation in asthma and non-asthma groups and the involvement of mite proliferation in developing atopy in the non-asthma group. The asthma group consisted of 190 children under 12 years old who had been recently diagnosed as having bronchial asthma and under the care of Osaka Prefectural Habikino Hospital. The non-asthma group consisted of 78 children under 12 years old who had been under care at Osaka Prefectural Hospital but had no present history of allergic symptom. The adult woman group consisted of 423 non-smoking women who had been diagnosed as having no allergic disease by the medical examination done at Yao City, Osaka, each March from 1995 to 1997. Individual living environments such as housing and heating styles were surveyed by questionnaire. Also, the amount of mite allergen (Dp: Dermatophagoides pteronyssinus, Df: Dermatophagoides farinae) in room and bedding dust (only in the case of children) and the concentration of continine in urine were examined as objective indicators for the load of environmental allergen and the indoor air pollution by tobacco smoke, respectively. Atopy was diagnosed according to whether Dp-specific immunoglobulin E (Dp-IgE) was present/absent (positive/negative), and ECP-increase was defined as serum ECP concentration over 10 ng/ml. The results were as follows: 1. An environment of higher humidity (dampness) causing a room to become moldy appeared to enhance mite proliferation, while heating only with an electric heater or kotatsu appeared to suppress it. 2. Living environments were involved in the development of atopy in children and adult women through the effects on mite proliferation. In the case of children, heating with oil or gas heater appeared to have a positive effect while reinforced concrete housing a negative effect, probably by effects on the immune system. However, in the case of adult women, such modification was not observed. 3. Passive smoking in adult women was related to ECP-increase. 4. IgE-increase and ECP-increase appeared to be involved in each other. 5. Among airway allergic symptoms such as cough, sputum and wheeze, atopy was involved in wheeze, and ECP-increase in cough.

[Preventive measures against AIDS and other sexually transmitted diseases known by students in the health field]

This study was carried out in to identify the preventive measures against Aids and other Sexually Transmitted Diseases (STD) that undergraduate health students predominantly know and to identify if there is a significant difference among the measures mentioned, considering the sex of subjects studied. A questionnaire was answered by health undergraduate students randomly selected. The results show that most of the items mentioned as preventive for Aids and other STD are important measures for their prevention. However, when data are analysed considering the frequency, that is the number of students that mentioned correct measures, we can observe that it is less than it was expected, what is very worrying. Another point observed in the results is that, there was no statistical difference, according to the sex of subjects studied. Data analysis evidence that knowledge of most undergraduate students is not enough, reinforcing the need to implement continuous specific educational actions.

Algorithm for the treatment of schizophrenia in Japan

Evidence-based psychopharmacological algorithms for the treatment of patients with schizophrenia have been developed in many countries in the last decade. While it would be of interest to consider a common algorithm based on international consensus, algorithms and information on antipsychotics available in each country are limited. Inspired by the algorithm generated by the International Psychopharmacology Algorithm (IPA) Project, this algorithm for the treatment of schizophrenia has been developed by the Japan Psychophamacology Algorithm (JPA) Project. New antipsychotics, such as clozapine, olanzapine and quetiapine, are excluded from this algorithm, being currently unavailable in Japan. In the end there was no essential difference between the algorithms for the treatment of acute schizophrenic episodes. However, combined use of antipsychotics appears to be more common in Japan and the adjunctive use of L-DOPS or thyrotropin-releasing hormone is included in the JPA algorithm for the treatment of drug-refractory schizophrenia.

Hypertrophic cranial pachymeningitis in a patient with aplastic anemia

We report on a 13-year old girl with severe aplastic anemia and hypertrophic cranial pachymeningitis. She was admitted to our hospital with severe headache and vomiting. A computerized tomographic (CT) scan of the brain on the third day of symptoms showed a hyperdense area in the tentorial region. Magnetic resonance imaging (MRI) showed iso-intensity in the same tentorial region in T1- and T2-weighted images, and gadolinium enhancement of this region suggested a thickened dura mater. Initially, a diagnosis of subdural or subarachnoid hemorrhage was made. Since her platelet count was low (3000/microl) making the patient a poor-risk candidate for surgery, and the area was limited to the dura mater, conservative therapy, including glycerol administration and platelet transfusion, was carried out. Despite clinical improvement 10 days after admission without specific therapy, the iso-intense region on the left side of the tentorial region remained unchanged on MRI. On the other hand, the iso-intense area on the right side of the tentorial region became hyperdense on T1-weighted MRI images and was also enhanced by gadolinium. Cerebrospinal fluid findings were normal except for slightly elevated protein at 62 mg/dl. A diagnosis of hypertrophic cranial pachymeningitis of the tentorial dura mater with hemorrhage on the right side was made. Although hypertrophic cranial pachymeningitis is a rare disease, it must be considered in the differential diagnosis of severe headache in a case of aplastic anemia.

Genetic and epidemiological research at the National Institute on Alcoholism, Kurihama National Hospital

The National Institute on Alcoholism, Kurihama National Hospital, Japan, was designated as a WHO Collaborating Center on Research and Training of alcohol-related problems in 1988. As part of the collaboration and contribution to the WHO, the institute has made significant efforts for the advancement of alcohol research. This article summarizes recent research activities at the institute, focusing on two areas of research: epidemiological and genetic studies.

[Effects of cardiac output on blood and tissue pH during general anesthesia with constant ventilation]

We investigated the effects of cardiac output on blood and tissue pH in 106 adult patients undergoing cardiac or non-cardiac surgery under general anesthesia. After anesthetic induction, the minute ventilation volume was kept constant at 10 ml.kg-1 x 10 cycles.min-1. A pulmonary artery catheter and a nasogastric tube incorporating a tonometer were inserted. During surgery, cardiac index (CI), pH, Pco2, BE, So2 and Hb of arterial and mixed venous blood as well as gastric intramucosal pH (pHi) were measured simultaneously. Oxygen uptake index (Vo2I) and blood CO2 contents were calculated. The measurements were repeated every 10 to 20 minutes during surgery or during the prebypass period. Two patients with preoperative cardiogenic shock were excluded from data analysis because of development of severe acidosis and 624 sets of data from 104 patients were analyzed. Arterial and mixed venous pH correlated negatively with CI. Blood Pco2 and base excess (BE) correlated positively and negatively, respectively, with CI. Blood lactate concentration measured 142 times in the last 30 patients correlated positively with CI. Vo2I correlated positively with CI and Paco2 correlated positively with Vo2I. Veno-arterial differences in Pco2 and Cco2 correlated negatively with CI. Due to the difference, Caco2 correlated positively with CI, while Cvco2 did not correlate with CI. pHi correlated negatively with CI but only marginally. By multiple regression analysis, pHi was not affected significantly by CI, while it showed positive correlation with pHa, Hb, Sao2 and negative correlation with blood temperature. When cardiac output increased, blood pH decreased due to increased Pco2 and decreased BE. An increase in Paco2 might result from both an increase in Vo2 or Vco2 and decreased ventilation-to-perfusion ratio. A decrease in BE might result from increased washout of acids (e.g. lactate) from the tissue to the central circulation. In contrast to blood pH, pHi or tissue pH was not affected significantly by cardiac output unless patients were in cardiogenic shock.

Solid phase micro extraction coupled with semi-microcolumn high performance liquid chromatography for the analysis of benzodiazepines in human urine

SPME/semi-microcolumn HPLC (SPME/LC) was investigated to analyze benzodiazepines in human urine samples. SPME conditions such as extraction time, extraction temperature, salt concentration and pH of matrix, flush volume and desorption time were optimized by extracting various drugs from a prepared water matrix. Combination of adding saturated salts to the matrix and controlling pH ranged from neutral to weakly alkaline conditions makes the increase of extraction efficiency. Under optimal condition SPME/LC is more sensitive than direct HPLC analysis without the SPME process. The limits of detection (LODs) was several ppb level and the relative standard deviation (RSD) was < 15% when human urine samples were analyzed by this analytical system. The system is very useful and is enough to assay benzodiazepines in a human urine sample without tedious and complex analytical procedures. In this paper the applicability of SPME/LC to the analysis of benzodiazepines in human urine samples was reported. In addition, the extension to the evaluation of SPME/LC/MS system was also described.

[Body temperature changes during combined inhalational and epidural anesthesia]

We investigated the effects of combined inhalational and lumbar epidural anesthesia on body temperature in 8 women for long-lasting lower abdominal surgery. Probes for forehead deep temperature and skin-surface temperatures were placed on the forehead, forearm, fingertip and toe tip on patients' arrival at the operating room. Tympanic membrane temperature was also measured. Lumbar epidural block was established with 2% lidocaine 10 ml. Twenty minutes later, general anesthesia was induced and maintained with nitrous oxide-oxygen-isoflurane. Epidural anesthesia was maintained with intermittent dose of 1% mepivacaine. Before the end of surgery, isoflurane concentration was increased from about 0.5% to 2% and was maintained at this level for 20 minutes, after which it was reduced. With the establishment of epidural blockade, toe tip temperature increased and fingertip temperature decreased, while core temperature remained unchanged. After induction of general anesthesia, fingertip temperature increased, while core temperature decreased. The core temperature drop during the anesthetic induction was significantly affected by the increase in toe tip temperature. Before the end of surgery, core temperature remained at a reduced but constant level, while fingertip temperature continued to decrease. With the application of 2% isoflurane, fingertip temperature increased, while core temperature decreased. The core temperature drop was significantly affected by the increase in fingertip temperature. After the reduction of isoflurane concentration, these temperature changes were reversed fully. At the end of surgery, fingertip temperature decreased, while core temperature increased. During mild hypothermia, isoflurane depressed thermoregulatory vasoconstriction dose-dependently until its concentration reached 0.6-0.7%. In conclusion, anesthetics-induced redistribution of body heat significantly affects the core temperature throughout anesthesia. Peripheral hypothermia results in core temperature drop when the redistribution is induced by anesthetics. Thermoregulatory vasoconstriction may not only suppress heat loss but also increase core temperature through centralization of body heat.

[Does mixed venous desaturation during a bed bath indicate cardiopulmonary decompensation in postoperative cardiac patients?]

The bed bath procedure consists of cleansing patients' body, passive position change, changing gown and making a bed. During the procedure, mixed venous desaturation was observed consistently in postoperative cardiac patients. We investigated the cause of the phenomenon in 22 patients undergoing cardiac surgery in their first postoperative day. The patients were breathing oxygen-enriched air via a Venturi mask. Cardiac index (CI), transluminal SvO2, arterial blood gas, Hb, DO2, VO2, FIO2, A-aDO2 and Qp/Qs were measured before and during the bed bath, while the patients were in the supine and left lateral position, respectively. Mean 8.5 +/- 1.5 minutes were required to complete the bed bath. During the bed bath, SvO2 decreased from 71 +/- 7% to 59 +/- 9% (P < 0.001), and returned to the baseline 6.5 +/- 7.4 minutes after the completion of the bed bath. VO2 increased markedly from 128 +/- 27 to 194 +/- 47 ml.min-1.m-2 (P < 0.001), while DO2 increased slightly from 480 +/- 91 to 513 +/- 110 ml.min-1.m-2 (P < 0.05). Among the determinants of DO2, CI increased slightly from 3.3 +/- 0.6 to 3.6 +/- 0.8 l.min-1.m-2, Hb remained unchanged and SaO2 decreased from 98.5 +/- 0.8 to 98.0 +/- 1.1%. FIO2 also decreased, while A-aDO2 and Qp/Qs remained unchanged. There was a negative correlation between VO2 change and SvO2 change, but no correlation between DO2 change and SvO2 change. There was a positive correlation between SaO2 change and SvO2 change, as well as between FIO2 change and SaO2 change. Therefore, the major cause of mixed venous desaturation was not the decreased DO2 or cardiopulmonary decompensation but the increased VO2 due to increased activity of the skeletal muscles. However, the decrease in SaO2 due to markedly increased O2 demand and the limited increase in CI might partially contribute to the marked decline in SvO2 through the limited increase in DO2.