[Damage of a laryngeal mask airway during anesthesia]

A 21-year-old man was scheduled for fixation of a fractured radius and ulna under general anesthesia using a laryngeal mask airway (LM). Anesthesia was induced with propofol 120 mg and fentanyl 0.1 mg. After administration of vecuronium 6 mg, we attempted insertion of the LM (# 5). The first trial was unsuccessful because the tube of the LM was bent in the pharynx. We attempted it again and the LM was successfully inserted. It was connected with the anesthetic circuit, and manual ventilation was started. However, the LM was suddenly broken at the basal part of the tube connector before the start of operation, and it became detached from the anesthetic circuit. Therefore, we removed the remaining LM from the mouth, and inserted a new LM (# 5). The peroperative course was uneventful. We conclude that inspection of a recycled LM is important before using it in order to prevent such an event as the present case.

Use of computed tomography for maxillary nerve block in the treatment of trigeminal neuralgia

BACKGROUND AND OBJECTIVES

Maxillary nerve block has traditionally been performed by using external anatomic landmarks. However, the classic approach to the nerve may be confounded because of anatomic variability. We describe a technique for the block using the suprazygomatic route guided by computed tomography (CT).

CASE REPORT

A 90-year-old woman had a 30-year history of episodic pain in her right maxillary region. We attempted to block the maxillary nerve with classic technique, but we could not identify the nerve by eliciting paresthesia. In addition, bleeding was noted after repeated attempts. To minimize complications and confirm the correct position of the needle tip, we planned the block with a suprazygomatic approach using CT guidance. The needle was inserted without paresthesia. The CT scan showed the needle tip was placed at the entrance of the pterygopalatine fossa and the distribution of contrast medium spread appropriately around the pterygopalatine fossa. After confirming the clinical effect and lack of complications of the block using the local anesthetic, 0.5 mL of 7% phenol was injected. This technique resulted in complete sensory loss in the area innervated by the maxillary nerve, and did so without complications.

CONCLUSIONS

A maxillary nerve block guided by a CT imaging is an alternative to classic techniques.

[Target-controlled propofol infusion for general anesthesia in three obese patients]

We report three cases in which the target-controlled propofol infusion technique was used in obese patients for general anesthesia. General anesthesia was induced by intravenous administration of fentanyl 150-300 micrograms and ketamine 50-80 mg and propofol 2 micrograms.ml-1 to achieve a target blood concentration by target-controlled infusion system. Anesthetic maintenance was achieved by ketamine 1 mg.kg-1.h-1 for 1 hour after the induction, propofol at target blood concentration of 2-3.5 micrograms.ml-1 and the intermittent epidural injection of 1.5% lidocaine through an epidural catheter. The surgical procedures were uneventful. The estimated blood concentrations of propofol at emergence from anesthesia calculated by ConGrace ranged from 1.49-1.69 micrograms.ml-1, and it took 230-300 seconds to emerge from anesthesia. The target-controlled propofol infusion technique appears useful to control the depth of anesthesia in obese patients.

Enhancement of Th2 response in IL-6-deficient mice immunized with myelin oligodendrocyte glycoprotein

To investigate the mechanism for the resistance of IL-6-deficient mice to experimental autoimmune encephalomyelitis (EAE), we examined the production of cytokines in lymph nodes (LNs) of wild-type and IL-6-deficient mice immunized with myelin oligodendrocyte glycoprotein (MOG) by reverse transcriptase-polymerase chain reaction analysis. Significant up-regulation of IL-4 production and down-regulation of IFN-gamma production were found in LNs from IL-6-deficient mice as compared to LNs from wild-type mice. Administration of IL-6, which caused typical EAE in IL-6-deficient mice immunized with MOG, reduced IL-4 production but did not restore IFN-gamma production in LNs of IL-6-deficient mice. These results implied that the resistance of IL-6-deficient mice to EAE might be mainly due to enhancement of Th2 response.

[The effects of intravenous anesthetics, propofol, fentanyl and ketamine on the excitability of spinal motoneuron in human: an F-wave study]

We have investigated the effects of various intravenous anesthetics, propofol, fentanyl and ketamine on the excitability of spinal motoneuron using an F-wave analysis in a total of 28 patients. All patients were divided randomly into three groups as follows; 2 mg.kg-1 intravenous bolus injection followed by 6 mg.kg-1.h-1 infusion of propofol (P group), 1 mg.kg-1 intravenous bolus injection followed by 1 mg.kg-1.h-1 infusion of ketamine (K group), and 5 micrograms.kg-1 injection of fentanyl (F group). The F-wave was determined after supramaximal electrostimulation of the median nerve in distal point. After establishing stable baseline values, intravenous injection of one of the three anesthetics was applied. The F-wave was recorded 3 minutes after the time of bolus administration. We found a significant (P = 0.018) reduction of the persistence from 77.5 +/- 15.2 to 40.9 +/- 16.8% in the propofol group. On the other hand, no significant changes in F-wave parameters were found in ketamine, or fentanyl group. These results suggested that motoneuron excitability in spinal cord could be inhibited by anesthetic dose of propofol, but not by ketamine or fentanyl.

Cremasteric reflex test as an objective indicator of spinal anaesthesia

We studied 100 men who were scheduled for urological surgery (Group 1) and another 50 men for orthopaedic surgery (Group 2). We attempted to anaesthetise both sides of the lower body in Group 1 and to anaesthetise one leg in Group 2 by injecting 0.3% hyperbaric dibucaine intrathecally. The presence or absence of the cremasteric reflex and loss of sensation to pinprick higher than the first lumbar dermatome were examined by two researchers who were blind to each other's results. In Group 1, both the reflex and the pinprick sensation were always absent bilaterally 5 min after intrathecal injection. In Group 2, in 23 of 50 patients the reflex had become absent bilaterally; in all these patients, bilateral sensory loss was detected. In the remaining 27 patients, both the reflex and the pinprick sensation were absent on the operation side, whereas both were present on the nonoperation side. Sensitivity, specificity and positive or negative predictive value for the cremasteric reflex were all 100%. Disappearance of the cremasteric reflex is a simple objective indicator of spinal anaesthesia at the first lumbar dermatome. This test may be useful in patients who cannot give reliable answers to conventional tests, such as the pinprick test.

Appropriate method of administration of propofol, fentanyl, and ketamine for patient-controlled sedation and analgesia during extracorporeal shock-wave lithotripsy

PURPOSE

The aim of this study was to identify the appropriate method for administering propofol, fentanyl, and ketamine (PFK) for patient-controlled sedation and analgesia (PCSA) during extracorporeal shock-wave lithotripsy (ESWL).

METHODS

Twenty-one unpremedicated patients were randomly assigned to three groups that received different drug administration regimens. (group 1: low loading dose and high demand bolus, group 2: high loading dose and demand bolus, group 3: high loading dose and low demand bolus).

RESULTS

The patients in all groups were hemodynamically stable during ESWL. Oxygen desaturation was recognized in all groups, but was avoided by 2 l.min(-1) of oxygen supply via a nasal prong. The total administration dose of the drugs was significantly higher ( P < 0.05) in group 2 than in groups 1 and 3. The median level of sedation was the same, but the episodes of oversedation were not recognized in group 3 ( P < 0.05). A significant difference in the frequency of episodes of oversedation was found between groups 2 and 3 ( P < 0.05). The results were good or excellent for almost all patients, and were assessed as fair by only one patient in group 2.

CONCLUSION

We concluded that the method used for group 3 is the most appropriate for administering PFK for PCSA during ESWL.

[Use of intubating laryngeal mask airway for three patients with difficult intubation]

We used intubating laryngeal mask airway (ILM) for three patients with difficult intubation, and tracheal intubation was successfully performed through the ILM in all three cases. Difficult intubation in the first case was caused by direct invasion of malignant lymphoma into the right maxillary sinus leading to restricted mouth opening. Neck stiffness due to invasion of metastatic cancer into the cervical spine in the second case and facial trauma caused by traffic accident in the third case gave rise to the difficult intubation. Insertion of the ILM was successfully performed in all the patients following induction of general anesthesia, and the ventilation through the ILM was possible without any difficulties. Subsequently, all patients were intubated through the ILM successfully. We realized that the ILM is useful and should be prepared on the induction of anesthesia in patients suspected of difficult intubation.

[Two cases of extreme hemodilution caused by massive hemorrhage immediately after start of operation]

We describe two cases of extreme hemodilution due to large amounts of fluid infusion for unexpected massive hemorrhage. In both cases, unexpected hemorrhage with difficult hemostasis occurred within 60 min after the start of the operation. For lack of transfused blood, large amounts of fluid infusion using crystalloid and colloid solutions including 5% albumin, plasma expander and lactated Ringer's solution were administered to maintain circulatory blood volume. The hemoglobin concentration and hematocrit had been below 2.0 g.dl-1 and 10% for approximately one hour, respectively. The extreme hemodilution improved by the urgent blood transfusion. In one case, intraoperative autotransfusion with Cell-Saver was performed. In spite of intraoperative extreme hemodilution, their postoperative courses were uneventful. Intraoperative awareness was present in both cases.

[Anesthetic management of an emergency surgery for panperitonitis during an asthmatic attack]

We report anesthetic management of an emergency surgery for panperitonitis during an asthmatic attack in a patient with angina pectoris. A 71-year-old male patient, complaining of abdominal pain and dyspnea, was diagnosed as having panperitonitis and asthmatic attack by surgeons in the emergency room. General anesthesia was induced by intravenous injection of propofol (30 mg), ketamine (30 mg), fentanyl (200 micrograms), suxamethonium (60 mg) and diltiazem (5 mg) following cannulation of the left radial artery for continuous monitoring of direct arterial pressure. Anesthesia was maintained by continuous infusion of propofol (4-10 mg.kg-1.h-1) and ketamine (1 mg.kg-1.h-1) in combination with intermittent epidural injection of local anesthetics. Although sudden onset of increased peak airway pressure occurred 45 minutes after starting operation, 50 mg of propofol injection and 500 mg of aminophyline infusion could relieve this high airway pressure. Because increased peak airway pressure appeared frequently and this could not be relieved by bolus injection of propofol, we changed the intravenous anesthesia to nitrous oxide-oxygen-isoflurane (GOI). After this change, no asthmatic attack occurred during the operation. While the mechanical ventilation was required during the early postoperative period along with infusion of aminophyline and inhalation of beta-stimulants, the patient was weaned successfully from the mechanical ventilation 12 hours postoperatively. It was speculated that the intraoperative asthmatic attack might have been caused by light level of anesthesia with propofol and ketamine. We concluded that other analgesics, such as fentanyl or epidural local anesthetics, must have been supplemented at proper timing during the continuous infusion of propofol and ketamine during the surgery.

[Usefulness of laryngeal mask for difficult intubation in a child with congenital laryngeal webs]

We report a case of difficult intubation with congenital laryngeal web. An 11-year-old boy was scheduled for urinary surgery. After anesthetic induction, the anesthesiologist encountered resistance at the vocal cord preventing satisfactory intubation. A size 3 laryngeal mask was immediately inserted, and an adequate airway was obtained. We found a laryngeal web at the vocal cord by bronchoscope inserted thorough the laryngeal mask. The peroperative course was uneventful. Immediately after removal of the laryngeal mask, the patient developed airway obstruction due to sputum and/or laryngeal spasm. The obstruction was relieved through application of positive pressure ventilation and aspiration of the sputum.

[Anesthetic management of bilateral lung lavage for pulmonary alveolar proteinosis--comparison between sevoflurane and propofol]

A 55-year-old man with pulmonary alveolar proteinosis underwent lung lavage under general anesthesia using sevoflurane three years ago. Although transient hypoxia occurred postoperatively, there were no complications. Because of the recent deterioration of his symptoms, he was rescheduled for lung lavage. Anesthesia was induced with propofol 120 mg and fetanyl 0.2 mg. Vecuronium 7 mg was administered to facilitate tracheal intubation using a double-lumen tube. Anesthesia was maintained with propofol 4 mg.kg-1.h-1. Electrocardiogram, blood pressure, SPO2, EtCO2 and rectal temperature were monitored intraoperatively. We also checked PaO2 when necessary. Although transient hypoxia occurred after the procedure, it receded spontaneously. Since inhalation anesthetics inhibit hypoxic pulmonary vasoconstriction, intravenous anesthetics may be more useful for patients with severe pulmonary alveolar proteinosis.

Nitric oxide production of rat Leydig and Sertoli cells is stimulated by round spermatid factor(s)

In this study, we provide evidence of cell-to-cell interaction between rat germ cells and Leydig or Sertoli cells in relation to nitric oxide (NO) production and inducible nitric oxide synthase (iNOS) messenger RNA (mRNA) expression. As a result of being cultured in a round spermatid-conditioned medium (RSd-CM), NO production in both Leydig and Sertoli cells increased in proportion to the length of the culture period. iNOS mRNA expression in both types of cells also increased in a dose-dependent manner as a result of being cultured with RSd-CM. This increase was detected as early as 3 h and was maintained up to 24 h. In contrast, neither NO production nor iNOS mRNA increased in either type of cell following culture in a pachytene spermatocyte-conditioned medium (PS-CM). Our findings suggest that RSd may control NO production of Leydig and Sertoli cells. This cell-to-cell interaction may be an important mechanism of regulation of testicular function.

Effect of hypoxia on nitric oxide production and its synthase gene expression in rat smooth muscle cells

It has not been clarified yet as to whether hypoxia and inflammation affect NO synthesis. In this study, we investigated the transcription of inducible nitric oxide synthase (iNOS) mRNA and the production of nitric oxide (NO) in rat smooth muscle cells (SMCs) cultured under hypoxic conditions in the presence and absence of proinflammatory cytokine interferon-gamma (IFN-gamma) and lipopolysaccharide (LPS). We found that hypoxia inhibited the production of NO but did not affect the transcription of iNOS mRNA in rat SMCs treated with IFN-gamma, LPS, or both. These results indicate that O(2) is involved in the regulation of NO synthesis in inflammatory tissues.

Attenuation of second sound in superfluid 3He-A1

The attenuation of second sound (spin-entropy) wave in the superfluid A1 phase has been measured in magnetic fields up to 11 T and to sufficiently high frequency to observe the bulk attenuation proportional to the square of frequency. The measured attenuation coefficient is compared with the existing theories of hydrodynamics and dissipative coefficients. The resulting "excess" attenuation is discussed in terms of the temperature dependent spin diffusion coefficient in the superfluid.

Delapril versus manidipine in hypertensive therapy to halt the type-2-diabetes-mellitus-associated nephropathy

Thirty-nine hypertensive patients with type 2 diabetes mellitus were followed under long-term treatment (mean, 20.7 months) with manidipine hydrochloride, a Ca antagonist, or delapril hydrochloride, an ACE inhibitor, at nine institutions. Both the treatments showed similar antihypertensive effects, although slight but significantly larger decreases were observed in systolic and mean blood pressures at months 12 and 24 in the patients treated with manidipine (P < 0.02). The urinary albumin excretion index (AEI) tended to increase throughout the study in both treatment groups, but no significant difference in AEI was observed between the two treatment groups at any time point. Overt albuminuria developed in four patients on manidipine but did not appear in any of the patients on delapril. The risk of progression to overt albuminuria was significantly different between manidipine and delapril groups (P = 0.011). No increase in serum creatinine (Cr) was observed with delapril. The average excretion indexes of tubular markers such as beta2-microglobulin, alpha1-microglobulin, and NAG tended to be higher in the patients on manidipine than in those on delapril. Taken in sum, these findings suggest that the ACE inhibitor delapril is more beneficial than the Ca antagonist manidipine in the treatment of diabetic renal diseases via mechanisms other than the blood pressure regulation, partly through their different effects on tubular function. In conclusion, delapril was significantly more effective than manidipine in inhibiting progression to overt albuminuria in hypertensive type 2 diabetes mellitus patients.

Inhibition of apoptosis in cultured immature rat Leydig cells by human chorionic gonadotropin associated with Bcl-2 mRNA expression

Bcl-2 is the first identified negative regulator of apoptotic cell death. When the level of Bcl-2 mRNA in rat whole testes was examined in the present study, it gradually decreased in rats from 2.5 to 9 weeks old. We also examined the effect of human chorionic gonadotropin (hCG) on apoptosis and the level of Bcl-2 mRNA expression in immature Leydig cells in vitro. When the cells were cultured with serum free media (SFM), Bcl-2 mRNA levels gradually decreased. On the other hand, the level of Bcl-2 mRNA in cells treated with 50 ng/ml of hCG decreased at 6 h, but increased after 12 h. At 24 h, the level of Bcl-2 mRNA in the treated cells was almost the same as that of control cells (time = 0). At 12 h after the addition of various concentrations (from 0.1-1000 ng/ml) of hCG, Bcl-2 mRNA levels increased in a dose-dependent manner. An analysis of DNA fragmentation showed that treatment with hCG prevents the apoptosis of immature Leydig cells. Our findings suggest that Bcl-2 mRNA may be related to the programmed cell death of immature rat Leydig cells in vitro, which are inhibited by hCG.

The effect of apoptosis inhibitors on experimental autoimmune encephalomyelitis: apoptosis as a regulatory factor

The effect of apoptosis inhibitors on experimental autoimmune encephalomyelitis (EAE), a model for multiple sclerosis, was investigated by intraperitoneal or intracisternal administration of apoptosis inhibitors Ac-YVAD-cmk and zVAD-fmk. After onset of the disease, these agents had no suppressive effect on EAE and resulted in impaired recovery or earlier relapse. Histological examination revealed that administration of zVAD-fmk suppressed the apoptotic death of inflammatory cells in the central nervous system (CNS) of mice with EAE. The results indicated that the apoptotic elimination of infiltrated cells in the CNS might be one of the recovery mechanisms in EAE.

Structure-activity relationship in potentially anti-tumor promoting benzalacetone derivatives, as assayed by the epstein-barr virus early antigen activation

The in vitro anti-tumor promoting activities of antimutagenic benzalacetone (4-phenyl-3-buten-2-one), its monosubstituted derivatives and related compounds, cinnamaldehydes and cinnamic acids, were evaluated by determining the inhibitory effect on Epstein-Barr virus early antigen (EBV-EA) activation induced by 12-O-tetradecanoylphorbol-13-acetate (TPA) in Raji cells. In this short-term assay, benzalacetone, which is the basic structure of dehydrozingerone (one-half analog of curcumin) inhibited the EBV-EA activation; the IC(50) value, the molar ratio of benzalacetone to TPA needed for inhibiting 50% of positive cells activated with 32 pmol TPA, was 129. IC(50) values of 2- and 4-methoxybenzalacetones were about one-half of that of benzalacetone and the methoxy compounds were more effective than hydroxybenzalacetones. IC(50) values of chloro- and trifluoromethyl-benzalacetones were higher than that of benzalacetone, indicating that these compounds are weaker inhibitors. In addition, the position of a substituent on the benzene ring affected the inhibitory effect. In benzalacetone derivatives substituted by a hydroxy-, methoxy-, chloro- or trifluoromethyl group, the 2-substituted derivatives exhibited the strongest inhibitory effect, followed by the 3- and the 4-substituents. Cinnamic acid derivatives also decreased the inhibitory effects in the same order. In the side chain of benzalacetone, the terminal group adjacent to the carbon-carbon double bond also affected the inhibitory effect. The conversions of the methylketone to aldehyde and carboxyl groups, i.e., cinnamaldehyde and cinnamic acid, increased the inhibitory effect: the IC(50) values were about one-third of that of benzalacetone. beta-Methyl styrene, which in the side chain has no carbonyl group adjacent to the double bond, inhibited the EBV-EA activation at the concentration of about one-third of that of benzalacetone, indicating that the carbonyl group negatively affects the inhibitory effect. This agreed with the previous observation between isoeugenol and dehydrozingerone, 4-hydroxy-3-methoxy derivatives of beta-methyl styrene and benzalacetone, respectively. The mechanism of the EBV-EA activation inhibition was discussed by being compared with the inhibition of mutagenesis for which the unsaturated bonded-carbonyl system is necessary.

Effects of intraocular or systemic administration of neutralizing antibody against vascular endothelial growth factor on the murine experimental model of retinopathy

Vascular endothelial growth factor (VEGF), the strongest known angiogenic cytokine and also a potent enhancer of vascular permeability, is closely associated with diabetic ocular complications and other intraocular neovascular diseases. The therapeutic effect of VEGF-neutralizing antibody on oxygen-induced retinopathy in an experimental murine model of proliferative retinopathy was investigated. Intraocular and systemic injection of the antibody resulted in 46% and 18% reductions in the number of nuclei of newly formed vessels of this model, respectively. The results demonstrated that a neutralizing antibody against VEGF was highly effective in the treatment of intraocular neovascularization and suggested possible modes of therapy in human intraocular neovascular diseases, including diabetic proliferative retinopathy.

[Anesthetic management of a patient with West syndrome]

A 21-year-old female with West syndrome was scheduled for resection of hordeolum. She had an episode of convulsion at three months of age, and was diagnosed as having West syndrome at one year of age. She had epileptic seizures twice a week in spite of administration of phenytoin, clonazepam and sodium valproate. These drugs had been administered till the morning of the surgery. After premedication with atropine 0.25 mg, anesthesia was induced with propofol (12-->10-->8 mg.kg-1.h-1). The tracheal intubation was performed with vecuronium 0.1 mg.kg-1 and anesthesia was maintained with continuous infusion of propofol 6-8 mg.kg-1.h-1 and local infiltration with 1.0% lidocaine 5 ml. We administered phenytoin to prevent epileptic seizures during the surgery. No epileptic seizures occurred perioperatively. We conclude that propofol may be useful for a patient with West syndrome, and we should be careful not to lower the threshold for convulsion during the perioperative period.

The conserved tryptophan-arginine-tyrosine motif of a proteinaceous alpha-amylase inhibitor T-76 from Streptomyces nitrosporeus is important for inhibition of animal alpha-amylases but not for an alpha-amylase from Bacillus sp. no. 195

Site-directed mutagenesis of Trp-16, Arg-17, and Tyr-18, which were thought to form a putative active site in proteinaceous alpha-amylase inhibitor T-76 from Streptomyces nitrosporeus for inhibition, was performed. The mutation at the site (W16A, R17A, and Y18A) resulted in a marked decrease in inhibitory activity against all animal alpha-amylases tested. Only the alpha-amylase from Bacillus sp. no. 195 (BAA) remained sensitive to all the constructed mutant inhibitors. A competition between T-76 mutants and the wild-type for porcine pancreatic alpha-amylase (PPA) suggest that the loss of inhibitory activity against PPA in mutant inhibitors was due to the decrease in their binding ability for PPA. T-76 formed a complex with BAA as well as PPA at the stoichiometric ratio of 1:1. A competition between BAA and the PPA/T-76 complex suggests that PPA and BAA might bind to the same region or regions close to each other on the T-76 molecule. These results indicate that the conserved Trp-Arg-Tyr motif of T-76 is involved in the interaction between T-76 and PPA while other amino acid residues seem to be important for the T-76/BAA interaction. Since the BAA-type alpha-amylase is the actual target of the inhibitors from microbes in comparison with animal alpha-amylases, BAA might be a better material than PPA to elucidate the "true" function of proteinaceous alpha-amylase inhibitors.

The effects of combined sympathetic block and intravascular infusion of prostaglandin E1 on brachial arterial blood flow in dogs

We compared the effects of stellate ganglion block (SGB) with those of SGB combined with an intravascular infusion of prostaglandin E1 (PGE1) on brachial arterial blood flow (BABF) in 24 mongrel dogs. The experimental protocol was designed so that the dogs received one of the following: SGB with 0.5% mepivacaine 1.0 mL (n = 8); combined SGB and IV infusion of PGE1 at a rate of 150 ng x kg(-1) x min(-1) for 10 min (n = 8); or combined SGB and intraarterial (IA) infusion of PGE1 at a rate of 0.1 ng x kg(-1) x min(-1) for 10 min (n = 8). BABF increased significantly in all groups and reached a maximum of 67% 10 min after SGB, 124% with the combined SGB and IV infusion of PGE1, and 117% with the combined SGB and IA infusion of PGE1. We conclude that combined SGB and IV or IA infusion of PGE1 increases BABF significantly compared with SGB alone.

IMPLICATIONS

Combined stellate ganglion block and intraarterial or IV infusion of prostaglandin E1 increases brachial arterial blood flow significantly compared with stellate ganglion block alone.

A new biflavonoid from Calophyllum panciflorum with antitumor-promoting activity

A new biflavonoid named pancibiflavonol (1) was isolated from an EtOH extract of the stem bark of Calophyllum panciflorum, along with six known biflavonoids, and its structure was elucidated by spectroscopic methods. These biflavonoids all exhibited significant inhibitory activity against 12-O-tetradecanoylphorbol-13-acetate-induced Epstein-Barr virus early antigen activation in Raji cells.

IL-6 plays a crucial role in the induction phase of myelin oligodendrocyte glucoprotein 35-55 induced experimental autoimmune encephalomyelitis

We investigated the role of IL-6 in myelin oligodendrocyte glycoprotein (MOG) peptide induced experimental autoimmune encephalomyelitis (EAE) using IL-6-deficient mice and found that IL-6-deficient mice were resistant to active induction of EAE, but that the treatment of those mice with IL-6 during the preclinical phase caused typical EAE. We also found that both wild-type and IL-6-deficient mice were resistant to passive transfer of EAE by lymphocytes from IL-6-deficient mice, but that passive transfer of lymphocytes from wild-type mice induced typical EAE in IL-6-deficient mice. Histological abnormalities of the central nervous system (CNS) in those IL-6-deficient mice with EAE were similar to those in wild-type mice with EAE. Reverse transcriptase-polymerase chain reaction (RT-PCR) analysis revealed no difference in the production of inflammatory cytokines such as IL-1beta, IL-2, TNF-alpha, and IFN-gamma in the CNS of IL-6-deficient mice with EAE as compared to the CNS of wild-type mice with EAE. These results indicated that IL-6 might be an important factor in the induction phase, but might have little influence on the effector phase of EAE. We further estimated the production of cytokines in MOG-stimulated lymph node (LN) cells by enzyme-linked immunosorbent assay. Increased IL-4 and IL-10 production and reduced IL-2 and IFN-gamma production were observed in LN cells from IL-6-deficient mice as compared to LN cells from wild-type mice. These results suggested that a shift of T cell responses from Thl to Th2 might explain the resistance of IL-6-deficient mice to EAE. Taken together, IL-6 may play a crucial role in the induction phase of EAE by modulating Th1/Th2 balance.

[A patient uninformed about his illness became aware of his lung cancer when an anesthesiologist visited him for pain control]

Much has been said about the importance of informed consent in Japan, but informing cancer to the patient has not been popular so far. We, as anesthesiologists, often treat pain in cancer patients, who occasionally, are not informed about the cancer. And we sometimes have patients with whom cautious consulting is necessary. This report presents our experience with a patient uninformed about the cancer but suspicious of his lung cancer. We met him as anesthesiologists, and this made the patient convinced that he had a cancer and was about to die soon.

[Anesthetic management of a patient with dilated cardiomyopathy under total intravenous anesthesia with propofol and ketamine combined with continuous epidural analgesia]

We report our experience with total intravenous anesthesia (TIVA) with propofol and ketamine combined with continuous epidural analgesia in a 72-year-old-male patient with dilated cardiomyopathy scheduled for a total prostatectomy. After premedication with atropine 0.5 mg and pethidine 35 mg, anesthesia was induced with ketamine 50 mg, fentanyl 0.1 mg and using a step down method of propofol (6-->4-->2 mg.kg-1.hr-1). After hemodynamic parameters had been stabilized, the trachea was intubated. Then, 1.5% lidocaine 6 ml was injected through an epidural catheter, placed at the L 1-2 intervertebral space. Anesthesia was maintained with continuous infusion of propofol 1 mg.kg-1.hr-1 and ketamine 1 mg.kg-1.hr-1, and continuous epidural analgesia with 1.5% lidocaine 2 ml.hr-1. Hemodynamics remained stable throughout the operative procedure. No postoperative complications occurred. TIVA with propofol and ketamine in combination with epidural analgesia is useful for patients with dilated cardiomyopathy in order to maintain stable hemodynamics during anesthesia.

[Reproductive and developmental toxicity study of gadobenate dimeglumine formulation (E7155) (3)--Study of embryo-fetal toxicity in rabbits by intravenous administration]

Gadobenate dimeglumine formulation (E7155) was daily administered by intravenous injection at 0.3, 0.9 or 2.0 mmol/kg/day to mated NZW female rabbits (20/group) to assess the effect on embryo-fetal development. Treatment with 2.0 mmol/kg/day caused initial, notable loss of body weight and reduction in food consumption. Slightly reduced body weight gain and food intake were recorded at 0.9 mmol/kg/day. There were no obvious adverse effects in dams given E7155 at 0.3 mmol/kg/day. There was a slightly higher incidence of early intrauterine deaths at 0.9 and 2.0 mmol/kg/day. Morphological examination of fetuses at 2.0 mmol/kg/day revealed small eye/microphthalmia and/or retinal irregularities in three fetuses from three separate litters. There was also an increase in the incidence of additional and/or fused sternebral centres and 20-thoracolumbar vertebrae at this dosage. From these results, the No Observed Adverse Effect Level (NOAEL) for general toxicity of dams and embryo-fetal development was 0.3 mmol/kg/day.

[Anesthetic management for transtracheal placement of a catheter for intracavity infusion of an antifungal drug in patients with pulmonary fungus ball of aspergillosis]

A catheter was inserted through the cricothyroid membrane under general anesthesia using a laryngeal mask airway in two patients with pulmonary fungus ball of aspergillosis to administer an antimycotic into the fungus ball. Anesthesia was induced with fentanyl and propofol in both patients. The laryngeal mask airway was inserted using intravenous injection of vecuronium. Anesthesia was maintained with continuous infusion of propofol. The catheter was inserted through the cricothyroid membrane and placed in the pulmonary fungus ball using bronchoscope. Perioperative and postoperative courses were uneventful in both patients. It was concluded that the laryngeal mask airway is useful for airway management when a catheter is inserted into a pulmonary fungus ball through the cricothyroid membrane.

[Anesthetic management for urgent endoscopy in a child with heterotopic liver transplant]

A 6-year-old boy with heterotopic liver transplant underwent urgent endoscopy under general anesthesia because of bloody stool. He was taking cyclosporin as an immunosuppressant. His hepatic function was normal and no side effects of cyclosporin were observed. Preoperative blood transfusion was performed because of severe anemia. Anesthesia was induced with midazolam 2 mg, ketamine 20 mg and fentanyl 0.05 mg, and maintained with addition of midazolam and ketamine. We did not use any inhalation anesthetics to avoid postoperative hepatic dysfunction. The endoscopy was successfully performed and the postoperative course was uneventful. We conclude that preanesthetic evaluation of immunosuppressant state and the hepatic function of transplanted liver is important for anesthetic management of a patient with heterotopic liver transplant.

Selective ablation of porcine and rabbit liver tissue using radiofrequency: preclinical study

Temperature changes and their distribution induced by 13.56-MHz radiofrequency (RF) heating of agar phantom and porcine and rabbit liver were investigated. It was possible to produce selective local heating of approximately 50 degrees C in the RF field of 2 x 2 x 2 cm(3) of the pig or rabbit liver. Coagulation necrosis after heating became pronounced and the margin between the coagulated lesion and normal tissue became clearer with time. Within 1 week after RF heating at 50 degrees C for 20 min, the coagulated area was replaced selectively and totally by necrotic tissue.

[Differential lung ventilation using Fogarty catheter after accidental damage of bronchial blocker cuff]

We performed differential lung ventilation using a Fogarty catheter after accidental damage of a bronchial blocker. A 57-year-old-man underwent thoracoscopic surgery for right pneumothorax. Anesthesia was induced with fentanyl and midazolam, and maintained with propofol and continuous epidural block with 2% mepivacaine. We used a single lumen endotrachial tube with a bronchial blocker for differential lung ventilation. We inserted the tip of the bronchial blocker into the right bronchus under fiberoptic broncoscopy after the patient had been placed in the lateral position. Four milliliters of air were injected into the bronchial blocker cuff before inserting the thoracoscope and differential lung ventilation was started. The right lung expanded suddenly because of accidental damage of the cuff one hour after starting surgery. We inserted a Fogarty catheter (10 Fr.) into the right bronchus under fiberoptic broncoscopy. Its balloon was inflated for differential lung ventilation. The procedure was performed successfully and uneventfully. We conclude that Fogarty catheter is an effective replacement for a damaged bronchial blocker cuff during differential lung ventilation.

Troglitazone and pioglitazone attenuate agonist-dependent Ca2+ mobilization and cell proliferation in vascular smooth muscle cells

1. The effects of troglitazone and pioglitazone on agonist-induced Ca2+ mobilization and cell proliferation were studied using fluorescent Ca2+ indicator fura-2 AM and incorporation of [3H]-thymidine in rat aortic smooth muscle cells. The patch clamp techniques were also employed. 2. Vasopressin and platelet-derived growth factor-BB (PDGF) caused a transient elevation in [Ca2+]i by Ca2+ mobilization from intracellular stores, followed by a sustained rise due to Ca2+ entry. Nicardipine partly inhibited the sustained phase, but La3+ completely abolished it. 3. Troglitazone and pioglitazone did not significantly affect the transient rise elicited by these agonists, but preferentially inhibited the sustained phase of [Ca2+]i. 4. Under voltage clamp conditions, troglitazone and pioglitazone inhibited voltage-dependent L-type Ca2+ current (ICa.L). They also inhibited nonselective cation channels (Icat) elicited by vasopressin in a concentration-dependent manner. The half maximal inhibitory concentrations of troglitazone on ICa.L and Icat were 4.6 and 5.7 microM, respectively. On the other hand, nifedipine and nicardipine did not inhibit Icat. 5. Vasopressin and PDGF increased incorporation of [3H]-thymidine, and nifedipine and nicardipine partly suppressed it. However, the inhibitory effects of La3+ and exclusion of extracellular Ca2+ were more potent than the Ca2+ blocking agents. Troglitazone and pioglitazone also inhibited it concentration-dependently. 6. These results suggest that troglitazone and pioglitazone preferentially inhibited agonist (vasopressin and PDGF)-induced Ca2+ entry and proliferation in rat vascular smooth muscle cells, where the inhibitory effects of thiazolidinediones on ICa.L and Icat might be partly involved. Thus, thiazolidinediones may exert hypotensive and antiatherosclerotic effects.

[Total intravenous anesthesia with propofol, fentanyl and ketamine for carotid endarterectomy under somatosensory evoked potential monitoring--combination with intraoperative hypothermia]

We reported anesthetic management combined with hypothermia for carotid endarterectomy under somatosensory evoked potential monitoring. Anesthesia was induced by propofol, fentanyl and ketamine, and maintained by infusion of propofol and ketamine and intermittent injections of fentanyl. Perioperative hypothermia was induced by gradually reducing the temperature of a circulating water mattress underneath the body to 15 degrees C. Additionally, somatosensory evoked potential monitoring was performed and recordings were obtained immediately after induction of anesthesia, and before as well as during cross-clamping of the internal carotid artery. Rectal temperature was reduced to 33.7 degrees C when cross-clamping of carotid artery was carried out, but major changes between before and during the procedure was not observed. All procedures were done uneventfully and gradual rewarming was accomplished by electric blanket. No neurological deficits were observed following recovery from anesthesia. Total intravenous anesthesia with propofol, fentanyl and ketamine may be useful for carotid endarterectomy under hypothermia and somatosensory evoked potential monitoring. This method may provide neuronal protection against ischemia injuries induced by cross-clamping of the carotid artery.

Eicosapentaenoic acid inhibits vasopressin-activated Ca2+ influx and cell proliferation in rat aortic smooth muscle cell lines

The purpose of this study was to clarify how eicosapentaenoic acid (EPA), an omega-3 polyunsaturated fatty acid, modulates the vascular action of vasopressin in rat aortic smooth muscle cell lines. The effects of EPA on Ca2+ mobilization and DNA synthesis elicited by vasopressin were investigated and compared to those of Ca2+ channel blocking agents, by means of Ca2+ measurements and the incorporation of [3H]thymidine. Patch-clamp techniques were also employed. Vasopressin (100 nM) elicited an initial peak of intracellular Ca2+ ([Ca2+]i), followed by a sustained phase due to Ca2+ entry. Nifedipine or nicardipine (1 microM), a potent L-type Ca2+ channel blocker, partly inhibited the sustained phase, but La3+ completely abolished it. EPA (10 microM) also inhibited it even in the presence of nicardipine. Under voltage-clamp conditions with CsCl-internal solution, depolarizing pulses positive to -30 mV from a holding potential of -40 mV elicited a slow inward current. The inward current was blocked by La3+, nicardipine, and nifedipine (1 microM), suggesting that the inward current mainly consisted of the voltage-dependent L-type Ca2+ channel (ICa.L). EPA (1-30 microM) also inhibited ICa.L in a concentration-dependent manner. The inhibitory effect of EPA was observed at concentrations higher than 1 microM, and its half-maximal inhibitory concentration (IC50) was 7.6 microM. Vasopressin induced a long-lasting inward current at a holding potential of -40 mV. The vasopressin-induced current was considered as a non-selective cation current (Icat) with a reversal potential of approximately +0 mV. Both nifedipine and nicardipine (10 microM) failed to inhibit it significantly, but La3+ completely abolished Icat. EPA also inhibited vasopressin-induced Icat in a concentration-dependent manner; its IC50 value was 5.9 microM. Vasopressin (100 nM) stimulated [3H]thymidine incorporation. Exclusion of extracellular Ca2+ with EGTA or La3+ markedly inhibited it. EPA (3-30 microM) also inhibited the incorporation induced by vasopressin, while nifedipine and nicardipine (1 microM) only partly inhibited it. These results suggested that EPA, unlike nifedipine and nicardipine, inhibited vasopressin-induced Ca2+-entry and proliferation in rat vascular smooth muscle cells, where the inhibitory effects of EPA on Icat as well as ICa.L might be involved. Thus, EPA would exert hypotensive and antiatherosclerotic effects.

[Caesarean section in a patient with a history of HELLP syndrome]

A 36-year-old woman underwent emergency caesarean section following the diagnosis of HELLP syndrome. Four years earlier, after having undergone the same procedure for HELLP syndrome, she had experienced hypovolemic shock, renal failure, and disseminated intravascular coagulopathy during the postoperative period. This time, the patient showed bleeding, elevation of liver enzymes (ALT, AST, LDH) and a reduction of antithrombin III activity in the 36th week of pregnancy. Anesthesia was induced by thiamylal 4 mg.kg-1 and suxamethonium 1 mg.kg-1 and after delivery maintained by oxygen-nitrous oxide-isoflurane, and all procedures were performed without any incident. No major complications such as intraperitoneal bleeding, renal failure, or disseminated intravascular coagulopathy occurred during the postoperative period. It is suggested that caesarean section should be carried out as soon as possible after the diagnosis of HELLP syndrome is confirmed.

Troglitazone inhibits voltage-dependent calcium currents in guinea pig cardiac myocytes

BACKGROUND

It has been suggested that intracellular Ca2+ overload in cardiac myocytes leads to the development of diabetic cardiomyopathy. Troglitazone, an insulin-sensitizing agent, is a promising therapeutic agent for diabetes and has been shown to prevent diabetes-induced myocardial changes. To elucidate the underlying mechanism of troglitazone action on cardiac myocytes, the effects of troglitazone on voltage-dependent Ca2+ currents were examined and compared with classic Ca2+ antagonists (verapamil and nifedipine).

METHODS AND RESULTS

Whole-cell voltage-clamp techniques were applied in single guinea pig atrial myocytes. Under control conditions with CsCl internal solution, the voltage-dependent Ca2+ currents consisted of both T-type (ICa,T) and L-type (ICa,L) Ca2+ currents. Troglitazone effectively reduced the amplitude of ICa,L in a concentration-dependent manner. Troglitazone also suppressed ICa,T, but the effect of troglitazone on ICa,T was less potent than that on ICa,L. The current-voltage relationships for ICa,L and the reversal potential for ICa,L were not altered by troglitazone. The half-maximal inhibitory concentration of troglitazone on ICa,L measured at a holding potential of -40 mV was 6.3 micromol/L, and 30 micromol/L troglitazone almost completely inhibited ICa,L. Troglitazone 10 micromol/L did not affect the time courses for inactivation of ICa,L and inhibited ICa,L mainly in a use-independent fashion, without shifting the voltage-dependency of inactivation. This effect was different from those of verapamil and nifedipine. Troglitazone also reduced isoproterenol- or cAMP-enhanced ICa,L.

CONCLUSIONS

These results demonstrate that troglitazone inhibits voltage-dependent Ca2+ currents (T-type and L-type) and then antagonizes the effects of isoproterenol in cardiac myocytes, thus possibly playing a role in preventing diabetes-induced intracellular Ca2+ overload and subsequent myocardial changes.

[A case of cardiac arrest after torsades de pointes due to prolonged QT interval syndrome possibly associated with subarachnoid hemorrhage]

An 58-year-old woman with prolonged QT interval syndrome possibly associated with subarachnoid hemorrhage underwent clipping for cerebral artery aneurysm. Anesthesia was induced with diazepam, fentanyl and vecuronium, and maintained with nitrous oxide (66%)-oxygen and sevoflurane (1%) with fentanyl. However, three hours after the start of operation, torsades de pointes suddenly appeared and cardiac arrest was followed. After cardiopulmonary resuscitation, sinus rhythm was restored. At that time, serum potassium was decreased to 2.7 mEq.l-1. Five days after the operation, she died despite cardiopulmonary resuscitation for frequent episodes of ventricular tachycardia including torsades de pointes. Ventricular tachycardia including torsades de pointes may have been caused by decreased serum potassium.

Propofol prevents delayed neuronal death following transient forebrain ischemia in gerbils

PURPOSE

This study was conducted to ascertain whether propofol may protect against delayed neuronal death in the hippocampal CA1 subfield in gerbils.

METHODS

Thirty-five gerbils were randomly assigned to five groups: Group I, the control group, a sham operation treated with physiological saline solution (PSS); Group II, ischemia/reperfusion treated with PSS; Group III, ischemia/reperfusion treated with 50 mg x kg(-1) propofol; Group IV, ischemia/reperfusion treated with 100 mg x kg(-1) propofol; Group V ischemia/reperfusion treated with 150 mg x kg(-1) propofol. Transient forebrain ischemia was induced by occluding the bilateral common carotid arteries for four minutes under N2O/O2/halothane anesthesia after administration of propofol or PSS. Five days later, histopathological changes in the hippocampal CA1 subfield were examined using a light microscope and degenerative ratio of the pyramidal cells were measured according to the following formula: (number of degenerative pyramidal cell/total number of pyramidal cells per 1 mm of hippocampal CA1 subfield) x 100.

RESULTS

In group II, the pyramidal cells were atrophic and pycnotic; vacuolation and structural disruption of the radial striated zone was observed. In the other four groups, these changes were not observed. The degenerative ratios of pyramidal cells were as follows; group I: 5.9 +/- 1.9%, group II: 94.6 +/- 2.5% (P < 0.01), group III: 10.7 +/- 1.7%, group IV: 9.7 +/- 1.8%, group V: 9.2 +/- 1.9%.

CONCLUSION

This study suggests that propofol may prevent delayed neuronal death in the hippocampal CA1 subfield after cerebral ischemia/reperfusion in gerbils.

Inhibitory effect of Epstein-Barr virus activation by Citrus fruits, a cancer chemopreventor

To search useful compounds in Citrus fruit for cancer chemoprevention, we carried out a primary screening of extracts of fruit peels and seeds from 78 species of the genus Citrus and those from two Fortunella and one Poncirus species, which were closely related to the genus Citrus. These Citrus extracts inhibited the Epstein-Barr virus early antigen (EBV-EA) activation induced by 12-O-tetradecanoylphorbol 13-acetate (TPA) as a useful screening method for anti-tumor promoters. Our results indicated that Citrus containing substances may be inhibit susceptibility factors involved in the events leading to the development of cancer.

[A case of total intravenous anesthesia with propofol, fentanyl and ketamine for lateral segmentectomy of the liver under pringle maneuver]

We successfully anesthetized an 80-year-old female for Pringle maneuver which was applied at the time of liver transection and consisted of cross-clamping the hepatoduodenal ligament for 25 minutes and releasing the clamp for 2 minutes until the completion of the liver transection. Anesthesia chosen was total intravenous anesthesia with propofol, fentanyl and ketamine (PFK) in combination with epidural anesthesia. The plasma concentrations of propofol at pre-, intra-, and post-Pringle maneuver under the intravenous infusion of propofol at 3 mg.kg-1.h-1 were 0.84, 1.49, and 1.29 micrograms.ml-1, respectively. All operative procedures were done uneventfully and recovery from anesthesia was prompt after the end of propofol infusion. Transient increases in liver enzymes were seen during early postoperative period, but no signs of hepatic failure were observed. In this patient, PFK anesthesia was useful and safe for the liver transection with Pringle maneuver.

[The current state of leak in anesthetic machines detected by low flow leak tests]

To assess the current state of leak in anesthetic machines, we selected 66 units of anesthetic machines for inspection and repair from various medical institutions. Based on a newly designed inspection flow chart a low flow leak test for internal circuits of the anesthetic machines was performed. The conventional low flow leak test was also performed for smooth detection of leak for rational evaluation. Only 39% of the anesthetic machines met the standard of the low flow leak tests, and leak was detected in the remaining 61%. The average residual leak mounted to 0.97 l.min-1, with the maximum of 5.3 l.min-1. Canisters, corrugated tubes, and vaporizers were considered the primary causes of leak. After the inspection and repair, leak in 77.5% of the anesthetic machines either disappeared or decreased and the average residual leak dropped to 0.34 l.min-1. However, 47% of the anesthetic machines still failed to meet the standard of the low flow leak tests. To further improve the situation, more detailed inspection and repair are necessary especially for precise detection of the cause of leak in the internal circuit of anesthetic machines which often remains undetected.

[Leak test for the internal circuit of anesthesia machines]

In spite of detailed periodic inspection performed by specialized engineers, a great number of anesthesia machines fail to meet the standard of low flow leak test because of leak in the internal circuit. To find out the background and the solution to the problem, we sent questionnaire to 11 major manufacturers and/or dealers each responsible for periodic inspection of anesthetic machines. According to the responses to the questionnaire, the manufacturers and/or the dealers had various methods of internal circuit leak test without a unified standard in detail. The mismatch of the test methods with those anesthesia machines equipped with check valve mechanism has also led to poor evaluation of internal circuit leak. Leak test must be standardized for its appropriate application to work effectively for the problem of leak in the internal circuit of anesthesia machines.

Excision of spinal tumor in a patient with severe pulmonary dysfunction using combined spinal and epidural anesthesia with two epidural catheters

BACKGROUND AND OBJECTIVES

Combined spinal and epidural anesthesia (CSEA) has become common practice. We performed CSEA using two epidural catheters in a 69-year-old female with severe pulmonary dysfunction caused by a diaphragmatic hernia, who underwent surgical excision of a lumbar spinal tumor.

METHODS

Combined spinal and epidural anesthesia was performed using two epidural catheters to minimize postoperative pulmonary complications. One epidural catheter was inserted above the surgical region, at the T11-12 interspace, and another one below the surgical region, via the sacral hiatus. Spinal anesthesia was produced using the L5-S1 interspace and 3 mL 0.5% bupivacaine. Oxygen, 3 L/min, was administered through a face mask during surgery.

RESULTS

Fifteen minutes after spinal anesthesia, analgesic level was confirmed below T7 using the pinprick method. The patient complained of pain in the surgical region 10 minutes after the dura mater was opened. We injected 5 mL 2% mepivacaine through the upper epidural catheter to relieve the pain. We also injected 10 mL 2% mepivacaine through the lower catheter when she felt pain in the right leg. The perioperative course was uneventful. Oxygen saturation was maintained above 95%.

CONCLUSIONS

Combined spinal and epidural anesthesia using two epidural catheters was used successfully to excise a spinal tumor in a patient with severe pulmonary dysfunction.

Anti-tumor-promoting effects of 8-substituted 7-methoxycoumarins on Epstein-Barr virus activation assay

In a search for anti-tumor-promoting agents, we carried out a primary screening of twenty-nine 8-substituted and four 6-substituted derivatives of 7-methoxycoumarins isolated from plants of the Murraya and/or Citrus species (Rutaceae), examining their possible inhibitory effects on Epstein-Barr virus early antigen (EBV-EA) activation induced by 12-O-tetradecanoylphorbol-13-acetate (TPA) in Raji cells. This investigation indicated that the prenyl (3-methyl-2-butenyl) or 2-hydroxy-3-methylbutyl (or butenyl) unit as an isoprenoid moiety at C-8 on the 7-methoxycoumarin nucleus plays an important role in the anti-tumor-promoting activity. Some of the 8-substituted 7-methoxycoumarins isolated from Murraya species, murrangatin (7), minumicrolin (10) and chloticol (18), were found to significantly inhibit EBV-EA activation, and preserved the high viability of Raji cells, suggesting that 7, 10 and 18 might be valuable anti-tumor-promoting agents.

Klinefelter's syndrome in the male infertility clinic

The clinical features of patients with Klinefelter's syndrome attending a male infertility clinic have been investigated in order to consider their assisted reproduction treatment options. Over 12 years, a total of 148 patients with sterility due to azoospermia had Klinefelter's syndrome. Eight patients were shown by fluorescence in-situ hybridization (FISH) on metaphase spreads to be mosaic (46,XY/47,XXY), and 140 patients showed only 47,XXY. Small testes were observed in 95% of patients and gynaecomastia was seen in 12.4%. Half of the patients showed hypergonadotrophic hypogonadism, while others showed normogonadism (usually hypergonadotrophic). Spermatozoa were observed in semen from one patient with mosaicism and one without. Three-colour FISH revealed hyperploidy in 2.7% and 2.3% of these spermatozoa respectively. Multiple-site testicular biopsies in five recent patients were performed and yielded a specimen with round and elongated spermatids in one patient with 47,XXY karyotype. This sample was cryopreserved for future intracytoplasmic sperm injection. At follow-up, 46% of couples had chosen artificial insemination with donor sperm, and none had chosen adoption. Two patients developed testicular tumours, one a mature teratoma and the other a Leydig cell tumour. Two patients required androgen replacement therapy.