Comparative carbon dioxide output through injured and noninjured peritoneum during laparoscopic procedures

Tension pneumoperitoneum may force gas into a small injured vessel if the opening is kept patent by surrounding tissues. However, the amount of carbon dioxide (CO2) that penetrates through injured or noninjured peritoneum has not been systematically determined. In 25 patients undergoing elective laparoscopic ultrasonography and cholecystectomy, CO2 output (VCO2) and O2 uptake (VO2) were measured at baseline and during anesthesia, pneumoperitoneum, laparoscopic surgical procedure (Surgery), and after hemostasis of the surgical field (Postsurgery). Before anesthesia, VCO2/BSA and VO2/BSA were 97.7 +/- 11.3 and 116.0 +/- 10.0 ml x min(-1) x m(-2), respectively. During anesthesia, they fell to 72.3 +/- 6.0 and 89.8 +/- 7.6 ml x min(-1) x m(-2), respectively (p < 0.05). VCO2/BSA increased to 96.0 +/- 11.1 at pneumoperitoneum (p < 0.05) and increased further to 126.1 +/- 11.0 ml x min(-1) x m(-2) at Surgery. It fell to 111.7 +/- 10.9 ml x min(-1) x m(-2) Postsurgery. VO2/BSA remained unchanged during pneumoperitoneum. Minute volume increased from 2.24 +/- 0.20 in anesthesia to 2.89 +/- 0.25, 4.01 +/- 0.32, and 3.46 +/- 0.28 L x min(-1) x m(-2) during pneumoperitoneum, Surgery, and Postsurgery, respectively, to maintain PaCO2. We conclude that the amount of CO2 absorbed following pneumoperitoneum prior to surgery is lower than that during Surgery or Postsurgery. The amount of CO2 absorbed through the surgical field was 2.3 times higher than that through the nonsurgical field while that from the peritoneum after hemostasis of surgical field was 1.6 times higher.

Propofol concentration required for endotracheal intubation with a laryngoscope or fiberscope and its interaction with fentanyl

The administration of fentanyl with propofol reduces the blood concentration of propofol required to achieve adequate anesthesia for tracheal intubation. However, different intubation procedures have variable intensities of noxious stimulation and may require different levels of anesthesia. The goal of this study was to determine the propofol blood concentration at which 50% of patients did not respond to stimulation (Cp50) for laryngoscopy, intubation with a laryngoscope, insertion of a slotted oral-pharyngeal airway (Ovassapian airway), and intubation with a fiberscope when administered in conjunction with fentanyl. Patients undergoing elective surgery were given varying amounts of propofol or propofol with fentanyl, and their responses to the four procedures listed above were assessed. These experiments demonstrated that the propofol concentration required for intubation with a laryngoscope was similar to that for intubation with a fiberscope, and that the required level was reduced by fentanyl. Hemodynamic responses to intubation were lower with a fiberscope than with a laryngoscope. We conclude that almost the same concentrations of propofol or fentanyl are necessary for suppressing both of the somatic responses to tracheal intubation with a fiberscope or a laryngoscope. Hemodynamic responses were attenuated more during intubation with a fiberscope.

IMPLICATIONS

The propofol blood concentrations at which 50% of patients did not respond to stimulation for laryngoscopy, tracheal intubation with a laryngoscope, and tracheal intubation with a fiberscope were 10.9, 19.6, and 19.9 microg/mL, respectively. These were reduced by fentanyl. Hemodynamic responses to intubation were less with a fiberscope than with a laryngoscope.

Reduction by fentanyl of the Cp50 values of propofol and hemodynamic responses to various noxious stimuli

BACKGROUND

Propofol and fentanyl infusion rates should be varied according to the patient's responsiveness to stimulation to maintain satisfactory anesthetic and operative conditions. However, somatic and autonomic responses to various noxious stimuli have not been investigated systematically for intravenous propofol and fentanyl anesthesia.

METHODS

Propofol and fentanyl were administered via computer-assisted continuous infusion to provide stable concentrations and to allow equilibration between plasma-blood and effect-site concentrations. The propofol concentrations needed to suppress eye opening to verbal command and motor responses after 50-Hz electric tetanic stimulation, laryngoscopy, tracheal intubation, and skin incision in 50% or 95% of patients (Cp50 and Cp95) were determined at fentanyl concentrations of 0.0, 1.0, 2.0, 3.0, and 4.0 ng/ml in 133 patients undergoing lower abdominal surgery. The ability of propofol with fentanyl to suppress hemodynamic reactions in response to various noxious stimuli also was evaluated by measuring arterial blood pressure and heart rate before and after stimulation.

RESULTS

The various Cp50 values for propofol alone (no fentanyl) for the various stimuli increased in the following order: Cp50loss of consciousness, 4.4 microg/ml (range, 3.8-5.0); Cp50tetanus, 9.3 microg/ml (range, 8.3-10.4); Cp50laryngoscopy, 9.8 microg/ml (range, 8.9-10.8); Cp50skin incision, 10.0 microg/ml (range, 8.1-12.2); and Cp50intubation, 17.4 microg/ml (range, 15.1-20.1; 95% confidence interval). The reduction of Cp50loss of consciousness, with fentanyl was minimal; 11% at 1 ng/ml of fentanyl and 17% at 3 ng/ml of fentanyl. A plasma fentanyl concentration of 1 ng/ml (3 ng/ml) resulted in a 31-34% (50-55%) reduction of the propofol Cp50s for tetanus, laryngoscopy, intubation, and skin incision. Propofol alone depresses prestimulation blood pressure but had no influence on the magnitude blood pressure or heart rate increase to stimulation. Propofol used with fentanyl attenuated the systolic blood pressure increases to various noxious stimuli in a dose-dependent fashion.

CONCLUSIONS

The authors successfully defined the propofol concentration required for various stimuli. Tracheal intubation was the strongest stimulus. The absence of somatic reactions for propofol does not guarantee hemodynamic stability without fentanyl. Propofol with fentanyl was able to suppress motor and hemodynamic reactions to various noxious stimuli.

The localization of plasminogen activator inhibitor-1 in glomerular subepithelial deposits in membranous nephropathy

In this study, the localization of plasminogen activator inhibitor-1 (PAI-1) and its association with glomerular subepithelial deposits of vitronectin (VN) in membranous nephropathy (MN) was evaluated. Renal biopsy tissue from 30 patients with MN along with specimens of normal kidney removed from six patients with renal tumors were examined for glomerular deposits of urokinase-type plasminogen activator, tissue-type plasminogen activator (t-PA), PAI-1, VN, and fibrinogen by using immunofluorescence and immunoelectron microscopic techniques. Deposits were characterized by pretreating the frozen sections with arginine, glycine, and t-PA to dissociate the VN-PAI-1 complexes, thus providing evidence of PAI-1 binding to VN. Glomeruli isolated from normal frozen kidney and from frozen kidney tissue with MN were subjected to immunoblot analysis. VN was found in the mesangial area and t-PA was observed along the capillary wall of normal glomeruli. Coarse granular deposits of VN, PAI-1, and t-PA were observed along the glomerular basement membrane in MN. Immunoelectron microscopy showed the presence of VN, PAI-1, and t-PA in the subepithelial immune deposits. Pretreating the samples with arginine decreased or abolished immunofluorescence staining for PAI-1 and t-PA, but not for VN. Pretreatment with t-PA decreased the immunofluorescence staining for PAI-1, but not for VN. Pretreatment with glycine decreased or abolished the staining for all three proteins. Immunoblot analysis revealed the presence of VN, PAI-1, t-PA, and t-PA-PAI-1 complex in glomeruli with MN as well as the presence of VN, but not of PAI-1, t-PA, or complex in the normal glomeruli. The findings from this study strongly suggest that PAI-1 was deposited in the glomeruli in MN as a result of binding to VN. Thus, VN-associated PAI-1 may injure the integrity of the fibrinolytic system in glomeruli affected by MN.

Proliferation of macrophage-lineage cells in the bone marrow, severe thymic atrophy, and extramedullary hematopoiesis of possible donor origin in an autopsy case of post-transplantation graft-versus-host disease

A case of proliferation of CD68-positive macrophage-lineage cells in the bone marrow accompanied by severe thymic atrophy associated with graft-versus-host disease (GVHD) in a boy given allogeneic bone marrow transplantation (BMT) is reported. A 7-year-old boy was treated for posthepatitic severe aplastic anemia by BMT from his HLA-identical, mixed lymphocyte reaction-negative sister. After the transplantation his peripheral blood group converted to the donor type. However, the patient suffered from acute and chronic GVHD and slowly progressive anemia, and he died of multiple organ failure 21 months after BMT. At the autopsy diffuse and monotonous proliferation of CD68-positive macrophage-lineage cells was found to be replacing the blood-forming cells in the bone marrow. The thymus was almost empty of T lymphocytes, and remaining strands of extremely atrophic epithelial cells showed focal cystic change. Extramedullary hematopoiesis was found in the spleen. Analyses of microsatellite markers suggested the hematopoietic cells in the spleen to be of donor origin.

Gonadotropin therapy in males with hypogonadotropic hypogonadism: factors affecting induction of spermatogenesis after gonadotropin replacement

Sixteen patients with hypogonadotropic hypogonadism received gonadotropin replacement therapy. Two patients treated with HCG alone showed induction of spermatogenesis 2 and 12 months after the start of treatment. Three subjects receiving combination therapy showed sperm appearance 6-28 months after treatment. The patients showing sperm appearance, whose testicular volume was > or = 4 ml, showed a higher sperm count and impregnated their partners, although no relationship was found between pretreatment testicular volume and sperm appearance. The response to HCG test correlated with sperm appearance after gonadotropin therapy. Sperm appearance was not observed in any subject except for one who showed no response to luteinizing hormone-releasing hormone (LH-RH) test and none of the patients without response of FSH to LH-RH demonstrated any induction of spermatogenesis. In conclusion, the responses to LH-RH test and possibly to HCG test could predict the induction of spermatogenesis after gonadotropin replacement therapy, and a large testicular volume is associated with post-treatment fertility.

Carbon dioxide output in laparoscopic cholecystectomy

In pneumoperitoneum, carbon dioxide eliminated in expired gas (carbon dioxide output) contains both metabolic and absorbed carbon dioxide from the peritoneal cavity. When elimination of carbon dioxide is much higher than carbon dioxide output, storage of tissue carbon dioxide and arterial carbon dioxide concentrations change. Finally, the rate of carbon dioxide eliminated in expired gas is not a match for the real rate of metabolic production and absorbed carbon dioxide from the peritoneal cavity. During and after insufflation of carbon dioxide, changes in carbon dioxide output were elucidated under constant arterial carbon dioxide pressure (PaCO2), the same as the preinduction level. We studied patients undergoing elective laparoscopic cholecystectomy. Carbon dioxide output, oxygen uptake, respiratory exchange ratio (RER), expired minute ventilation (VE), deadspace to tidal volume ratio (VD/VT ratio) and arterial to end-tidal carbon dioxide partial pressure difference (PaCO2-PE'CO2) were determined before induction, and during anaesthesia, pneumoperitoneum and recovery. By controlling ventilatory frequency (f) every 1 min, PaCO2 was adjusted to concentrations before induction. Constant monitoring of end-tidal carbon dioxide partial pressure (PE'CO2) and intermittent measurement of (PaCO2-PE'CO2) (15-min intervals) were conducted to predict PaCO2). Carbon dioxide output and oxygen uptake decreased significantly from mean values of 83.5 (SEM 5.2), 101.6 (5.1) to 68.5 (4.2), 81.1 (4.6) ml min-1 m-2 (ATPS, P < 0.05) with sevoflurane anaesthesia, and RER did not change. During carbon dioxide pneumoperitoneum (intra-abdominal pressure 8 mm Hg), carbon dioxide output increased by 49% (102.4 (5.0) ml min-1 m-2) (P < 0.05) while oxygen uptake remained stable and RER increased from 0.84 (0.02) to 1.16 (0.03) (P < 0.05). It was necessary to increase VE during pneumoperitoneum by 1.54 times that during anaesthesia to maintain individual PaCO2 values constant. After removal of carbon dioxide from the abdominal cavity, the regression equation of excess carbon dioxide output/BSA best fitted a two-compartment model. The time constants of the rapid and slow compartments were 8.2 and 990 min, respectively. Excess carbon dioxide output/BSA was still 5.5 ml min-1 m-2, 30 min after pneumoperitoneum.

Effect of varicocele on fertility potential: comparison between impregnating and nonimpregnating groups

Sixty patients with varicocele, complaining of infertility, underwent a corrective operation. Eighteen (30%) of the 60 patients impregnated their mates (impregnating group). Sperm concentration significantly increased after the operation in the impregnating group (p < .05), but not in the patients who failed to impregnate their mates (nonimpregnating group). Sperm motility was not altered after the operation in these two groups. Sperm velocity significantly increased postoperatively in the impregnating group (p < .05), while linearity was not altered in either group. Sperm swelling significantly increased postoperatively in the impregnating group (p < .05), but not in the nonimpregnating group. Preoperative sperm parameters were not different between the two groups. Varicocele may disturb sperm function including sperm motion besides spermatogenesis and may impair the fertility potential. However, a prospective large-scale controlled study is required to obtain a definitive conclusion.

A case of decapitated spermatozoa in an infertile man

A case of headless or decapitated spermatozoa of an infertile man is reported. The 33-year-old patient showed almost normal spermiogram except for a high percentage (more than 90%) of headless spermatozoa. Both hypoosmotic swelling and zona-free hamster egg tests showed that most headless spermatozoa appeared to be normal in their function as tails. The ultrastructure of the ejaculated spermatozoa was observed using a surface replica method and by conventional ultrathin sectioning. The headless spermatozoa were almost normal in structure except for the absence of the head. Tailless heads were rarely observed. Varieties of ultrastructural abnormalities were observed in spermatozoa heads. Among them, abnormalities in the nuclear membrane covering the posterior pole of the nucleus were prominent. The implantation fossa and the basal plate were not formed. Instead, the nuclear membrane with numerous nuclear pores was found in this region. The decapitation seemed to take place between the region of the basal plate and the proximal centriole.

[Effect of experimental left varicocele on rat Leydig cell function]

In order to study endocrinological disorders in varicocele, serum hormone (LH, FSH and testosterone) levels, intratesticular temperature, and testicular histology were evaluated in the rats with experimental left varicocele. Testosterone production and its responsiveness to human chorionic gonadotropin (hCG) in isolated Leydig cells were also determined in the model. The varicocele was created by partial ligation of the left renal vein. The mean difference between intratesticular and intraperitoneal temperature and the levels of serum hormones were similar in varicocele-induced and sham-operated rats at either 2 or 4 weeks after surgery. Histological examination using the Johnsen score count method showed defective spermatogenesis at 2 and 4 weeks. In Leydig cell incubation, testosterone levels in the media without hCG were similar in the left testes of varicocele-induced rats (LV), the right testes of varicocele-induced rats (RV), and the testes of sham-operated rats (S) at 2 and 4 weeks. Although the presence of various concentrations of hCG made no difference in testosterone production between LV, RV, and S at 2 weeks, there were significantly decreased elevations in the production at 100 mIU/ml and 1,000 mIU/ml of hCG in LV and RV as compared with that of S at 4 weeks. The bindings of [125I] hCG to Leydig cells from LV and RV were significantly lower than S at 4 weeks. Furthermore, testosterone responsiveness to dibutyryl c-AMP in Leydig cells was similar between LV, RV, and S.(ABSTRACT TRUNCATED AT 250 WORDS)

Acrobeads test using monoclonal antibody-coated immunobeads: clinical application

Acrosome-reacted sperm was examined in infertile and fertile males using the Acrobeads test. The Acrobeads score was significantly higher in fertile males than in infertile males with normal or abnormal seminal findings (p < .005 and p < .001, respectively). The Acrobeads score was 2 or more in all the fertile males, but 62% of the infertile males with abnormal seminal findings (p < .02). Therefore, a disturbance in the acrosome reaction is suggested to be one of the causes of decreased fertility potential. A high correlation was found between Acrobeads score and sperm motility (r = .46, p < .001) or motile sperm concentration (r = .51, p < .0001). The Acrobeads test, the results of which reflect the acrosome condition of the sperm, is useful in the assessment of sperm function related to fertility.

[Clinical study on renal pelvic and ureteral tumors]

Thirty five patients with renal pelvic and ureteral tumors were treated at our hospital between 1979 and December 1992. Thirty patients were male and five were female. They ranged in age from 44 to 80 years old (average 67.4 years). The most frequent symptoms were hematuria that was found in 31 cases (24 gross hematuria and 7 microscopic hematuria). Histopathologically, there were 30 transitional cell carcinomas (TCC), 1 squamous cell carcinoma (SCC), 2 TCC > SCC and 1 papillary adenocarcinoma. As to staging, 1 was pTis, 5pTa, 11pT1, 3pT2, 11pT3 and 4pT4. As to grading, 9 were G1, 16 G2 and 9 G3. The incidence of cancerous vessel invasion was noted in 8 of the 29 patients. The 5-year survival rate (Kaplan-Meier's method) was 44.9% for all of the patients. The 5-year survival rate according to staging and according to grading were as follows: 76.7% for low stage (pTis, pTa, pT1, pT2), 24.9% for high stage (pT3, pT4), and 83.3% for G1, 59.9% for G2 and 0% for G3. The 5-year survival rate was 20.8% and 68.7% in the patients with and without vessel invasion, respectively. Grade, stage and cancerous vessel invasion was suggested to be associated with the prognosis in renal pelvic and ureteral tumors.

Establishment and characterization of a clear-cell sarcoma (malignant melanoma of soft parts) cell line

A clear cell sarcoma (CCS) cell line, designated as NCS-1, was established in monolayer culture from a xenograft line originating from a metastatic CCS. Marked karyotypic aberrations and tumorigenicity in nude mice revealed the malignant derivation of the NCS-1 cell line. These cells contained abundant glycogen and were amelanotic by light microscopy. By electron microscopy, however, melanosomes in various developmental stages were seen, and some of them were partially melanized. The electron microscopic dopa reaction revealed the presence of tyrosinase activity. Enzyme-linked immunoadsorbent assay revealed that NCS-1 cells expressed a 75-kDa glycoprotein which was identified as a marker of highly differentiated melanoma cells. From these results, NCS-1 cells were found to retain both cytochemical and morphological properties of CCS. Application of NCS-1 cells to a panel of monoclonal antibodies recognizing melanocytic differentiation antigens showed that they corresponded approximately to highly differentiated melanoma cells. In conclusion, the present study strongly supports the close relationship between CCS and malignant melanoma.

[Experience of a double Malecot polyurethane intraurethral catheter in patients with dysuria]

We reviewed our experience of using double Malecot polyurethane intraurethral catheters (IUC). Ten patients with dysuria were treated between April 1991 and April 1993. Seven patients with benign prostatic hypertrophy (BPH) were judged as in a high risk group for operation. The three other patients had neurogenic bladder (two had underactive bladder and 1 had overactive bladder). Under local anesthesia, 150 ml of 0.1% Povidone iodine solution was infused into the bladder through a Nelaton catheter. Under guidance by ultrasonography, an IUC was placed into the bladder neck and posterior urethra using the specially designed introduction set. An long-term follow up of the BPH patients, two IUCs were removed for operation and one was exchanged for an indwelling catheter because of deterioration in general condition. In the neurogenic bladder patients, all IUC were removed because of the increase of residual urine, formation of a pseudourethra, or dislocation into the bladder. Side effects were observed in 6 patients such as, urethral bleeding and stone formation in the stent. Erosion and bleeding tendency in the urethral mucosa were shown in the prolonged duration cases. We conclude that a urethral stent is an effective devise for a high risk patient with benign prostatic hypertrophy but we must keep each patient under strict observation for complications during IUC placement.

Correlation of seminal plasma transferrin concentration and hypoosmotic swelling of the sperm

To investigate whether there is a relationship between seminal plasma transferrin concentration and hypoosmotic swelling of the sperm, semen samples from 46 infertile patients were examined. Seminal plasma transferrin concentration in oligozoospermic subjects (sperm concentration < 20 x 10(6)/mL) was significantly lower than that in normozoospermic subjects (sperm concentration > or = 20 x 10(6)/mL) (p < .05). Patients with > or = 50% swollen sperm showed significantly higher transferrin concentration in seminal plasma than those with < 50% swollen sperm (p < .05), while in oligozoospermic patients no difference was observed between seminal plasma transferrin concentration and hypoosmotic swelling. No relationship between seminal plasma transferrin concentration and serum gonadotropin levels was demonstrated. The results indicate that transferrin synthesis is important to sperm membrane integrity and functional competence. However, subsequent fertility must be examined to determine whether seminal plasma transferrin levels are predictive of fertilizing capacity.

[Studies of transrectal prostatic ultrasonography on patients with male infertility]

The diagnostic significance of transrectal prostatic ultrasonography for chronic prostatitis and varicocele was evaluated in 380 male infertility patients. Of 20 patients with pyospermia, thought to be mainly caused by chronic prostatitis, 10.0 percent showed heterogeneous echo pattern of the prostate, while 25.0 percent showed capsular irregularity. Since 285 patients with non-infected semen showed similar sonographic findings, it is concluded that prostatic ultrasonography has little value in the diagnosis of chronic prostatitis in infertile patients. Enlarged periprostatic echo-free zone, thought to coincide with the dilatation of the Santrini's plexus, was found in 42.9 and 42.7 percent of patients with chronic prostatitis and varicocele, respectively, in contrast to 34.0 percent of patients without either diseases. Twelve percent of patients with varicocele showed highly enlarged echo-free zone, which was significantly more frequent compared to 5.0 percent in normal patients. Moreover, follow up of 4 patients with varicocele pre- and post-operatively found 2 of them to show a great improvement in the enlargement of the zone. These results suggest that varicocele may cause the dilation of the Santrini's plexus through a venous anastomosis in some patients and transrectal ultrasonography may be a useful tool in detecting small varicoceles in such patients.

Epidermal growth factor concentrations in seminal plasma from patients with hypogonadism--changes after hormone replacement

Epidermal growth factor (EGF) content in seminal plasma of 17 patients with androgen deficiency (12 Klinefelter's syndrome and 5 hypogonadotropic hypogonadism) was determined before and after hormone replacement. No significant increase of plasma testosterone level was demonstrated after testosterone administration in Klinefelter's syndrome, although the level in 4 of 5 patients with hypogonadotropic hypogonadism reached the normal range. In 16 patients, except 1 with hypogonadotropic hypogonadism with no increase of blood testosterone level, prostate volume increased after hormone therapy, and volumes after treatment were significantly larger than those before treatment. On the other hand, EGF concentration in seminal plasma remained at the pretreatment level in most patients. It is therefore concluded that although the prostate volume increases to almost normal after treatment, prostate function does not improve in most patients, indicating that in patients with hypogonadotropic hypogonadism fertility potential may remain low, even if they obtain normal seminal parameters after treatment.

[Strangulation of the penis by a metallic ring]

An 81-year-old male patient visited our hospital on November 13, 1992 for the treatment of penile edema that had been caused by a metallic ring which he placed for fun 4 days prior to the visit. He had placed the metallic ring on the base of the penis and subsequent penile edema made it impossible to remove the ring. He had no problem with urination. The ring was successfully removed with a metal-cutting tool. But 3 days later, infected penile ulceration occurred at the base of the penis and the necrotic tissue was resected. It took 25 days for the wound to heal. It is stressed that penile strangulation is a serious injury and prompt removal is necessary.

[Clinical studies on methicillin-resistant Staphylococcus aureus (MRSA) infections]

We experienced 20 cases of methicillin-resistant Staphylococcus aureus (MRSA) infection from April 1991 to September 1992. Of them, 9 showed substantial morbidity and their clinical courses are herein reported. The clinical presentations of these cases were wound infection and enterocolitis. Although in 8 cases MRSA was eradicated in 14 to 160 days by effective antibiotics administration, one had a fatal outcome. All strains isolated showed similar drug-sensitivity pattern suggesting hospital infection. Sensitivity to vancomycin and arbekacin, however, remained high and these drugs were effective clinically. It should be stressed that treatment strategy of MRSA infection should consist of isolation of patients with MRSA from other patients, use of disposable equipment and products, and serious and continuing concerns of medical personal on communicability of MRSA.