Analysis of serum cytokine levels in primary biliary cirrhosis patients and healthy adults

By using commercially available ELISA kits, serum IL-6 and TNF-alpha levels in healthy adults, and the levels of various cytokines in patients with primary biliary cirrhosis or chronic viral liver diseases, were investigated. IL-6 levels of healthy subjects were distributed in a wide range, and the distribution pattern was similar to those of the patients. TNF-alpha levels tended to be low in females in their 30s, but there were no abnormalities in the patients. Characteristic findings, in the primary biliary cirrhosis patients, were an increase of IFN-gamma and IL-2 levels, and a decrease of GM-CSF levels (P < 0.05). IL-8 levels were higher in the patients than in the healthy subjects (P < 0.05), and the increase was remarkable in chronic viral liver disease patients. We believe that measurement of serum cytokine levels as a clinical immunological test is highly useful. Further development of simpler, more rapid, and more sensitive analysis methods is desired.

Interaction of intrathecally infused morphine and lidocaine in rats (part I): synergistic antinociceptive effects

BACKGROUND

Synergistic antinociception of opioids and local anesthetics has been established in bolus injections but not in long-term use. The somatic and visceral antinociceptive effects of intrathecally infused morphine or lidocaine were characterized, and the nature of the interaction of those agents in rats was evaluated.

METHODS

Intrathecal catheters were implanted in rats. Morphine (0.3 to 10 microg x kg(-1) x h(-1)), lidocaine (30-1,000 microg x kg(-1) x h(-1)), a combination of those, or saline was infused intrathecally at a constant rate of 1 microl/h for 6 days. The tail flick and colorectal distension tests were used to measure the somatic and visceral antinociceptive effects, respectively. Nociceptive tests and motor function tests were repeated on days 1, 2, 3, 4, and 6. Isobolographic analysis was performed on the results of the tail flick test to determine the magnitude of the interaction.

RESULTS

Intrathecally infused morphine produced dose-dependent antinociceptive effects in both the tail flick and the colorectal distension tests. Morphine showed a lower peak percentage maximum possible effect (%MPE) in the colorectal distension test than in the tail flick test. Intrathecal lidocaine also produced dose-dependent antinociceptive effects. Lidocaine infusion at 1,000 microg x kg(-1) x h(-1) caused motor impairment. Coinfusion of morphine 0.3 microg x kg(-1) x h(-1) and lidocaine 200 microg x kg(-1) x h(-1), which had no effects by themselves, significantly increased the percentage maximum possible effects (P < 0.01). Coinfused lidocaine potentiated the duration and the magnitude of morphine antinociception. Isobolographic analysis of the tail flick test on day 1 showed a synergistic interaction between morphine and lidocaine.

CONCLUSIONS

Morphine and lidocaine intrathecally coadministered synergistically potentiated the antinociceptive effects of each other. That coinfusion dramatically potentiated visceral antinociception, whereas the infusion of morphine alone showed little visceral antinociception.

Interaction of intrathecally infused morphine and lidocaine in rats (part II): effects on the development of tolerance to morphine

BACKGROUND

There has been little information regarding the effects of local anesthetics on tolerance to opioids, although chronic use of combination of opioids and local anesthetics is popular for pain control. This study was designed to examine the effects of lidocaine on morphine tolerance to somatic and visceral antinociception.

METHODS

Rats received a continuous intrathecal infusion of morphine (0.3-10 microg x kg(-1) x h(-1)), lidocaine (30-1000 microg x kg(-1). h(-1)), a combination of those, or saline. After 6- day infusion, intrathecal morphine challenge test (5 microg/10 microl) was performed, and time-response curve was constructed to assess the magnitude of tolerance. The tail flick (TF) test and colorectal distension (CD) test were used to measure somatic and visceral antinociceptive effects, respectively.

RESULTS

Antinociceptive effects in the TF and CD tests caused by morphine challenge were reduced (P < 0.01) in the morphine infused groups. The magnitude of the tolerance was inversely associated with the amount of morphine infused. Lidocaine infusion induced no different change in the morphine challenge test from that seen in the saline infusion group. Development of tolerance was greater in morphine 3 microg x kg(-1) h(-1) than in morphine 0.75 microg x kg(-1) x h(-1) + lidocaine 150 microg x kg(-1) x h(-1) despite their similar antinociceptive effects during intrathecal infusion. The infusion of a low dose of morphine (0.3 microg kg(-1) x h(-1)) did not reduce the antinociceptive effects in the challenge test.

CONCLUSION

Lidocaine in combination with morphine does not reduce tolerance to morphine nor develop cross-tolerance. The intrathecal infusion of morphine induced tolerance to somatic and visceral antinociception in a dose-dependent fashion.

Characteristics of tolerance to somatic and visceral antinociception after continuous epidural infusion of morphine in rats

A continuous epidural infusion of morphine may cause a complicated tolerance to develop, depending on the spinal and supraspinal sites. We designed this study to clarify the characteristics of the tolerance to somatic and visceral antinociception after epidural morphine infusion. Rats received epidural infusion of morphine at the rates of 50 or 100 microg kg(-1) h(-1), or isotonic sodium chloride solution for 7 days. The tail-flick (TF) test and colorectal distension (CD) test were used to measure the somatic and visceral antinociceptive effects, respectively. Nociceptive tests were performed on Days 1, 2, 3, 4, and 7. After 7 days, time-response curves after epidural morphine (10 microg) or intraperitoneal morphine (3 mg) challenge tests were conducted to assess the magnitude of tolerance. Epidurally infused morphine significantly increased percent maximal possible effects (%MPEs) (P < 0.05) in both the TF and CD tests, depending on the concentration of morphine. In the epidural morphine challenge test, increases in %MPEs were significantly attenuated (P < 0.05) in the morphine-infused group compared with the isotonic sodium chloride solution-infused group. The increases in %MPEs in the intraperitoneal challenge test were also attenuated in the morphine-infused group. We conclude that morphine tolerance to both somatic and visceral antinociception develops rapidly during epidural infusion and is based on the development of tolerance at the systemic, as well as the epidural, level.

IMPLICATIONS

A continuous epidural infusion of morphine rapidly induces tolerance to visceral and somatic antinociception in rats. This development is based on the development of tolerance at the systemic, as well as the epidural, level.

Quantitative and selective assessment of sensory block during lumbar epidural anaesthesia with 1% or 2% lidocaine

We have examined sensory block during lumbar epidural anaesthesia using a cutaneous current perception threshold (CPT) sensory testing device in 20 patients who received 10 ml of either 1% or 2% lidocaine (lignocaine). CPT at 2000, 250 and 5 Hz stimulation at the trigeminal (V), ninth thoracic (T9) and second lumbar (L2) dermatomes, and dermatomal levels of block to light touch, temperature and pinprick discrimination were measured before and every 5 min until 60 min after epidural lidocaine. There were significant differences between 1% and 2% epidural lidocaine in all CPT at T9 and L2, in addition to maximal cephalad spread of the three sensory modalities. After 2% lidocaine, all CPT increased significantly at T9 and L2. In contrast, only at 250 and 5 Hz for L2 did epidural block with 1% lidocaine produce significant increases in CPT. Maximal level of loss of touch sensation after 1% lidocaine was significantly lower than that of cold and pinprick sensations. We conclude that the dose of lidocaine affected intensity of sensory block during lumbar epidural anaesthesia. In addition, differential neural block resulting from epidural anaesthesia appeared to be associated with a differential effect on nerve fibres of different sizes.

The advantages of the lateral decubitus position after spinal anesthesia with hyperbaric tetracaine

We investigated the effects of lateral decubitus positioning after spinal anesthesia with hyperbaric tetracaine on the spread of sensory blockade and hemodynamic variables. One hundred ASA physical status I or II patients scheduled for elective surgery to the lower limb received spinal anesthesia at a rate of approximately 0.1 mL/s using 0.5% tetracaine in 7.5% glucose with 0.125% phenylephrine in the lateral decubitus position with the operated side dependent. They were randomly divided into three groups: patients in Group I were placed supine immediately after spinal injection; those in Group II remained in the lateral position for 10 min before being turned supine; those in Group III were kept in the lateral position for 20 min then turned supine. Neural block was assessed by cold, pinprick, and touch sensation, and a modified Bromage scale. Hemodynamic variables included blood pressure, heart rate, and the use of ephedrine for the treatment of hypotension. The median (10th, 90th percentiles) peak dermatomal level to pinprick on the dependent side in Group III was T8 (T11, T5), which was significantly lower than that in Groups I and II, which extended to T4 (T9, T3) and T5 (T10, T2), respectively (P < 0.05). The difference in the maximal cephalad spread of sensory blockade between both sides in Group III was only one dermatome but was statistically significant (P < 0.05); in contrast, there was no significant difference in the maximal sensory level between both sides in Groups I and II. The use of ephedrine for the treatment of hypotension was significantly less frequent in Group III than the other groups. We conclude that keeping a patient in the lateral decubitus position for 20 min after hyperbaric tetracaine spinal anesthesia maintains preferential anesthetic distribution to the dependent side. Despite small differences between the two sides, the restricted spread of blockade and less hemodynamic variability may be clinically advantageous.

IMPLICATIONS

The effects of posture on the spread of hyperbaric spinal anesthesia have not been adequately investigated. The results of the present study suggest an advantage of prolonged lateral decubitus positioning after intrathecal hyperbaric tetracaine.

Translocation (10;12)(q24;q15) in a T-cell lymphoblastic lymphoma with myeloid hyperplasia

We present a case of childhood T-cell lymphoblastic lymphoma (T-LBL) with a translocation (10;12)(q24;q15) as a main clonal abnormality, which to our knowledge is the first reported karyotype of this malignancy. The patient's peripheral blood and bone marrow showed marked leukocytosis mostly myeloid lineage cells, at diagnosis. The enlarged lymph node consisted of two different cell populations: CD2+/CD7+ prothymic lymphoblasts and a cluster of peroxidase-positive myeloid cells around vessels. This case might represent a rare but distinct clinical entity of LBL.

Antinociceptive effects of intrathecal L-type calcium channel blockers on visceral and somatic stimuli in the rat

L-type calcium channels can modulate neuronal transduction in the spinal cord. However, their role in noxious information processing in animals that are physiologically intact has not been elucidated. We evaluated the effects of L-type calcium channel blockers diltiazem and verapamil on somatic and visceral nociception at the level of the spinal cord. Intrathecal catheters were inserted at the L4-5 level in Sprague-Dawley rats. The tail flick (TF) test and colorectal distension (CD) test were used to assess somatic and visceral antinociceptive effects, respectively. Motor function was assessed by posture and muscle tone in the limbs. TF latency and CD threshold were measured before and for 180 min after the intrathecal administration of verapamil (50, 100, 300, and 500 microg), diltiazem (100, 300, 500, and 1000 microg), or isotonic sodium chloride solution. The percent maximal possible effect (%MPE) was calculated by transforming response threshold in TF and CD tests. Intrathecally administered diltiazem or verapamil increased both TF latency and CD threshold in a dose-dependent fashion. Isotonic sodium chloride solution, diltiazem 100 microg, and verapamil 50 microg did not increase %MPE in either test. Diltiazem 300 or 500 microg or verapamil 300 or 500 microg significantly (P < 0.05) increased %MPE, with the peak effects 5 min after administration and short-duration antinociception. %MPE was 100% until 15 min after the administration of diltiazem 1000 microg, and significant antinociception continued until 180 min in the TF test. Motor paralysis was observed after the administration of the larger dose of each drug. We demonstrated that intrathecally administered L-type calcium channel blockers diltiazem or verapamil produced both somatic and visceral antinociception and motor block dose-dependently.

IMPLICATIONS

We examined the effects of intrathecally administered L-type calcium channel blockers diltiazem and verapamil on somatic and visceral nociception in rats. L-type calcium channel blockers produced antinociceptive effects, suggesting a possible clinical application to control pain.

Detection of nivalenol genotoxicity in cultured cells and multiple mouse organs by the alkaline single-cell gel electrophoresis assay

We tested the genotoxicity of nivalenol (NIV), a potent toxic trichothecene from Fusarium nivale, in cultured CHO cells and in several mouse organs and tissues (liver, kidney, thymus, bone marrow and mucosa of stomach, jejunum, and colon) using the alkaline single-cell gel electrophoresis (SCG, or Comet) assay. NIV at 50 and 100 micrograms/ml damaged the nuclear DNA of CHO cells in the absence of S9 mix, showing that NIV was a direct mutagen. In an in vivo study, mice were sacrificed 2, 4, and 8 h after either oral (20 mg/kg) or intraperitoneal (3.7 mg/kg) administration of NIV. DNA damage was measured by the SCG assay as modified by us. After oral dosing, DNA damage appeared in the kidney and bone marrow at 2 h (returning to almost control level within the following 2 h), and in the stomach, jejunum, and colon at 2, 4, and 8 h, respectively. Liver and thymus DNA were not damaged. After intraperitoneal injection, no DNA damage appeared in any of the organs or tissues tested except for the colon, where extensive DNA damage was observed, as in the oral study, at 8 h. For histopathological examination, mice were sacrificed 2, 4, and 8 h after oral (20 mg/kg) administration of NIV. No necrotic changes were detected in any of the organs where NIV yielded statistically significant DNA damage. To measure the effect of NIV on transport activity in mice, 10 ml/kg (same volume as NIV treatments) of 1% brilliant blue FCF (BB) was administered orally. Thirty minutes later, the BB reached the colon, and simultaneous oral administration of NIV (20 mg/kg, dissolved in 10 ml BB solution) did not affect the dye transport rate. Thus, the strong yet delayed damage to colon DNA may follow from a systemic absorption rather than a topical effect. As a direct mutagen, NIV showed organ specific genotoxicity in mice in time and intensity.

Detection of pyrimethamine-induced DNA damage in mouse embryo and maternal organs by the modified alkaline single cell gel electrophoresis assay

We studied the embryonic and maternal genotoxicity of pyrimethamine (PYR), a potent teratogen and folate antagonist, using alkaline single cell gel electrophoresis (SCG, or Comet) assay as modified by us (we used isolated nuclei instead of isolated cells). ICR mice were treated on the 13th day of pregnancy with a single oral dose of 50 mg PYR/kg. Six maternal organs (liver, kidney, lung, brain, spleen, bone marrow), maternal and fetal placentas, and two embryos were taken 6 and 16 h after treatment; the embryos were divided into head and body portions. Each sample was minced, homogenized gently, and centrifuged. The nuclei from the precipitates were used. PYR induced DNA damage in all maternal organs except spleen and bone marrow 6 h after administration. The DNA damage in all the affected organs was less at 16 h than at 6 h, and that of the kidney and brain returned to control level at 16 h. PYR also induced DNA damage in maternal and fetal placentas and embryos that was detected at 6 and 16 h, with greater damage at 6 h. Co-treatment of folinic acid calcium salt (FNA, 10 mg/kg ip), a reduced active folate form, prevented the PYR-induced DNA damage in all target tissues examined 6 h after treatment. These data indicate that the observed embryonic and maternal DNA damage caused by PYR may be related to folate deficiency, and that the modified alkaline SCG assay can be used to predict fetal/embryonic genotoxicity in vivo, in addition to the organ-specific maternal genotoxicity.

[Quantitative assessment of differential nerve block during lumbar epidural anesthesia]

The study was performed to evaluate differential neural blockade during lumbar epidural anesthesia with a cutaneous current perception threshold (CPT) sensory testing device. Fourteen patients undergoing elective gynecological surgery received 10 ml of 2% lidocaine through an epidural catheter inserted at the L 1/2 interspace. CPTs at 2000, 250, and 5 Hz stimulation and sensation to light touch, temperature, and pinprick at ipsilateral dermatomes V, Th 9, and L 2 were measured before and every 5 min, until 60 min after the epidural lidocaine. The epidural block caused a significant increase in all CPTs at dermatome L 2 and in CPTs at 250 and 5 Hz at Th 9. Touch sensation at Th 9 was intact during the study period in 12 patients, most of whom lost sensation to the other stimulus: 12 patients did not respond to the cold stimulus and 10 patients to the pinprick. At L 2, sensory block to light touch, temperature, and pinprick was found in 11, 14, and 14 patients, respectively. There was no effect on any measurements made at V. In conclusion, epidural lidocaine results in a differential neural blockade as measured with CPT testing. Since the 2000-Hz stimulus detect abnormalities that correlate with large fiber functioning, it is suggested that loss of touch sensation is associated with effects of epidural lidocaine on large fibers.

Elevation of the serum Fas ligand in patients with hemophagocytic syndrome and Diamond-Blackfan anemia

Fas ligand (FasL) is a membrane protein that is expressed in activated T cells and natural killer cells. FasL binds to Fas on target cells and induces apoptosis. There exists a soluble form of FasL (sFasL), and sFasL also induces apoptosis of Fas-bearing cells. The serum sFasL concentrations were reported to be elevated in patients with large granular lymphocytic leukemia and natural killer cell lymphoma. In this study, we have measured serum sFasL concentrations in other hematological disorders, including severe aplastic anemia (SAA), hemophagocytic lymphohistiocytosis (HLH), and Diamond-Blackfan anemia (DBA). The serum sFasL concentration of age-matched healthy controls was 0.16 +/- 0.11 ng/mL (mean +/- SD, n = 22). The serum sFasL levels in the patients with HLH and DBA were 3.75 +/- 3.82 (n = 19; P < .0001, HLH v control) and 2.76 +/- 2.43 ng/mL (n = 6; P = .012, DBA v control), respectively. Serum interferon-gamma concentration was elevated in the patients with HLH (1.61 +/- 2.62 ng/mL) but not in those with DBA (below the detectable level). These results suggest that the Fas-FasL system plays a role, at least in part, in the pathophysiology of HLH and DBA.

[Circulatory collapse during laparoscopic cholecystectomy]

A 52 year-old female without any cardiac disease underwent laparoscopic cholecystectomy. Anesthesia was induced with thiamylal and maintained with nitrous oxide and isoflurane. Epidural anesthesia was also used during surgery. When the intraabdominal insufflation was performed in reverse-trendelenburg position 15 minutes after the start of incision, the heart rate suddenly decreased from 75 to 49 bmp with a fall in blood pressure. Her hemodynamic state recovered immediately after the release of intraabdominal pressure and the administration of ephedrine with a rapid infusion of Hespander. The circulatory collapse did not occur when the second insufflation was tried carefully. The circulatory collapse was probably due to the vagal reflex. The decrease in cardiac preload during the reverse trendelenburg position and the epidural administration of local anesthetics may have caused or worsened the circulatory collapse. In anesthetic managements of laparoscopic cholecystectomy using general anesthesia with epidural anesthesia, prophylactic hydrogenation and prevention of parasympathetic domination are important to minimize the vagal reflex.

Microparticle resins as a potential nasal drug delivery system for insulin

The application of various resins for the nasal delivery of insulin was examined in rabbits. Intranasal administration of human insulin (28 U, 1 mg) mixed with fractionated sodium polystyrene sulfonate powder (an anionic resin with a particle size of 20-45 microns) caused a rapid increase of the plasma insulin level 413.0 +/- 71.7 microU/ml (mean +/- S.D.) after 15 min, while intranasal administration of insulin alone caused little increase. The blood glucose level decreased from 118.8 +/- 18.5 mg/dl to 65.8 +/- 13.8 mg/dl at 45 min after administration. These results were superior to those obtained with the unfractionated resin. Styrene-divinylbenzene copolymer (a nonionic resin; 20-45 microns fraction) showed similar enhancement of nasal insulin absorption. In contrast, polyacrylester (a nonionic resin; 20-45 microns fraction) and cholestyramine (a cationic resin) did not promote insulin absorption. These results suggest that some resins may be useful for nasal delivery of insulin.

Anaesthetic management of caesarean section in a patient with myelodysplastic syndrome

PURPOSE

This case report describes the anaesthetic management for Caesarean section in a patient with myelodysplastic syndrome.

CLINICAL FEATURES

A woman with myelodysplastic syndrome underwent Caesarean section on two occasions. The first Caesarean section was performed at age 20 yr using general anaesthesia with nitrous oxide-oxygen and fentanyl. In her second pregnancy at 25 yr, there was severe pancytopenia at 28-wk gestation with a leukocyte count 3.6 x 10(9).L-1, erythrocyte count 1.2 x 10(12).L-1, haemoglobin 50 g.L-1, haematocrit 14.7% and platelet count 51 x 10(9).L-1. Following leukocyte poor red cells and platelet transfusion, general anaesthesia was maintained with nitrous oxide-oxygen-sevoflurane and fentanyl. Both operations were uneventful and healthy infants were delivered.

CONCLUSION

It is important to have a team approach (anaesthetist, obstetrician and haematologist) for the perianaesthetic management of patients with myelodysplastic syndrome. An exact assessment of the haematological condition, the need for prophylactic treatment and anaesthetic management should be determined for each individual patient.

[Measurement of functional residual capacity by nitrogen washout during mechanical ventilation]

A medical gas analyzer AMIS 2000 SP, which is a mass spectrometer, incorporating a fractional residual capacity (FRC) measuring program based on a nitrogen washout method, has been introduced recently. The purpose of this study was to assess the reliability and the reproductivity of the FRC measuring system in a clinical situation. FRC was measured by this system connected to a ventilator (Bennet 7200ae). Our study examined; 1) the accuracy of the measurement using a syringe. 2) the difference in two consecutive measurements in the same subject during mechanical ventilation, and 3) the correlation between the measured and the predicted value calculated with Gorldman's formula in 18 subjects during ventilation. The first study has showed an excellent correlation (y = 0.953x + 0.092, r = 0.996, P < 0.001) or y = 0.909x + 0.132 (r = 0.999, P < 0.001) with a tidal volume of 400 ml or 500 ml, respectively) between the measured value and the syringe capacity. Reproductivity was proved by the linear regression (y = 0.977x + 0.024, r = 0.998, P < 0.001) between the two consecutive measurements. A good correlation was shown between the measured values and the predicted values (y = 0.656x - 0.415, r = 0.849, P < 0.0001). These results showed good reliability and reproductivity of our FRC measuring system. It is concluded that the FRC measurements using AMIS2000SP system can be used in clinical respiratory managements in ICU.

Flow cytometric analysis of IL-6 receptors on peripheral lymphocytes in patients with primary biliary cirrhosis

Interleukin-6 receptors (IL-6R) and interleukin-1 receptors (IL-1R) on lymphocyte surfaces were analyzed, using flow cytometry and dye-labeled IL-6 and IL-1 beta, to examine the clinical and immunological significance of these receptors. Incubation of peripheral blood mononuclear cells in the presence of mitogen resulted in a remarkable increase of lymphocytes expressing the IL-6 and IL-1 beta receptors on the cell surface. The increase in lymphocytes bearing these cytokine receptors may reflect an increase in stimulated lymphocytes. When peripheral blood from patients with primary biliary cirrhosis (PBC) was examined for these receptors, the percentage of IL-6R positive cells was significantly higher in the patients than in healthy controls (P < 0.01). The increase in IL-6R positive cells was only significant for the T lymphocyte fraction (P < 0.01). No significant change in IL-1R was observed. There was a significant positive correlation between the percentage of IL-6R positive T lymphocytes and the titer of antimitochondrial antibody in patients with PBC. These findings concerning IL-6R may be noteworthy elucidating autoimmune etiological features of PBC.

[Regional difference in the etiology of liver cirrhosis in Iwate]

To assess regional differences in the etiology of liver cirrhosis in Iwate, we analyzed 324 patients with liver cirrhosis treated at various hospitals. The etiology was HCV 44.8%, HBV 11.1%, HBV + HCV 4.6%, alcohol 27.5% (including heavy drinkers 17.9%), PBC 1.5% and non-B non-C 10.5% in Iwate. The incidence of alcoholic cirrhosis was higher than that in other prefectures, while that of HCV was lower. Especially in the northern area of Iwate, the rate of alcoholic cirrhosis was very high (39.1%--including heavy drinkers 21.8%) while viral cirrhosis was relatively low. Although the alcohol consumption volume in Iwate was not very high, marked alcohol consumption, especially shochu, was observed in the northern area of Iwate. The volume and kind of alcohol consumed in each area differed, and the etiology of liver cirrhosis differed regionally in Iwate. Thus, we should consider these districts and levels of alcohol consumption when treating patients with liver cirrhosis.

[A malpositioned CVP catheter]

A 2-year-old boy was scheduled for patch closures of ASD and VSD. After anesthesia induction, infection of a double lumen central venous catheter (5 Fr, Arrow) was tried into the superior vena cava through the right jugular vein by Seldinger's method. We confirmed the placement of the catheter by drawing a small amount of blood. After the operation, chest X-ray examination in ICU revealed the misplacement of the catheter into his right intrapleural space. The catheter was left overnight to be used as a drainage route of a possible bleeding. Next morning, no abnormal finding in his chest X-ray and stable circulatory and respiratory conditions were found and we proceeded to extubate his endotracheal tube and take away the catheter. Two hours after the removal of the catheter, the boy showed forced respiration. He became cyanotic rapidly and then he needed emergency intubation. Following chest X-ray examination and an aspiration of intrapleural space revealed a severe hemothorax of the right side, where catheter had been inserted. The boy recovered without any disorders. This case suggests the importance to confirm the placement of CVP catheter, and to prevent the possible complications due to the malpositioned catheter.

The addition of phenylephrine contributes to the development of transient neurologic symptoms after spinal anesthesia with 0.5% tetracaine

BACKGROUND

Recent reports indicate that transient neurologic symptoms commonly occur after single-injection spinal anesthesia with lidocaine. Information regarding tetracaine has been limited to a single case report. In addition, little is known about the cause of these symptoms or the cofactors that affect their occurrence. The present study sought to determine whether the presence of phenylephrine or the concentration of glucose in the anesthetic solution affects the incidence of transient neurologic symptoms after spinal anesthesia with 0.5% tetracaine.

METHODS

One-hundred sixty patients classified as American Society of Anesthesiologists physical status I or II who were scheduled for elective surgery on a lower limb or perineum were sequentially assigned to one of four equal groups to receive intrathecal 0.5% tetracaine in 7.5% or 0.75% glucose, with or without 0.125% phenylephrine. Patients were evaluated on postoperative day one for the presence of pain, dysesthesia, or both in the legs or buttocks by an investigator unaware of the drug given.

RESULTS

Symptoms were present in 10 patients (12.5%) receiving a spinal anesthetic containing phenylephrine, but in only one patient (1.3%) receiving spinal anesthesia without phenylephrine. There was no significant difference in the incidence of symptoms between groups receiving 7.5% glucose and those receiving 0.75% glucose (8.8% and 5% of patients, respectively).

CONCLUSIONS

These results suggest that adding phenylephrine to tetracaine for spinal anesthesia increases the potential for transient neurologic symptoms, but that the concentration of glucose does not affect their occurrence.

An effective intradermal hepatitis B vaccination

Small dose intradermal (i.d.) inoculation methods of hepatitis B vaccine have been reported to be effective and economical. We determined the best method to obtain high antibody levels within a short period of time and for the long-term maintenance of these levels. A total of 173 female students were randomly allocated to seven groups: six i.d. inoculation groups, to which 6-12 micrograms was administered in three or four divided doses (Groups A-F), and a control group (Group G) which received three 10 micrograms intramuscular (i.m.) inoculations. Serum hepatitis B antibody levels were quantified in weeks 4 and 8, and months 4, 7, and 12. Positivities in all groups were not significantly different at each measurement time. In month 4, geometric mean antibody levels in the three i.d. groups (10-12 micrograms in three divided doses; 79.1-107.0 IU l-1) were significantly higher than in Group G, which had received two of three i.m. injections (17.6 IU l-1; P < 0.01, P < 0.05). In the group which received four 2 micrograms i.d. inoculations, the level was higher than in Group G in month 7, but lower in month 12. It was concluded that three i.d. inoculations, each of 4 micrograms, may be used to obtain high antibody levels within a short period of time. However, it is recommended that a 10 micrograms i.m. injection in month 6 is applied as a booster. Consequently, we could not present an economic and effective low-dose intradermal inoculation method.

Regional cerebral glucose utilization is modulated by the dosage of apolipoprotein E type 4 allele and alpha1-antichymotrypsin type A allele in Alzheimer's disease

Twenty Alzheimer's disease (AD) patients with defined apolipoprotein E (APOE), alpha1-antichymotrypsin (ACT) and presenilin-1 (PS-1) intronic genotypes were examined to quantify the regional cerebral metabolic rate of glucose (rCMRglc) using positron emission tomography (PET) and 18F-2-fluoro-2-deoxy-D-glucose (FDG). The frontal rCMRglc was significantly increased in patients with the APOE epsilon4 allele in a dose-dependent fashion. In contrast, the temporo-parietal rCMRglc was significantly reduced in ACT type A allele (ACT*A) carriers compared with those in non-ACT*A carriers. The PS-1 type 1 intronic allele had no significant effects on rCMRglc in any cerebral region. These results suggest that both the APOE and ACT genes may play a distinct role in the progression of AD as monitored by imaging studies of cerebral glucose utilization.

Assembly and regulation of the CD40 receptor complex in human B cells

CD40 is a member of the tumor necrosis factor (TNF) receptor superfamily. Studies with human B cells show that the binding of CD154 (gp39, CD40L) to CD40 recruits TNF receptor- associated factor 2 (TRAF2) and TRAF3 to the receptor complex, induces the downregulation of the nonreceptor-associated TRAFs in the cell and induces an increased expression of Fas on the cell surface. Combined signaling through the interluekin 4 receptor and CD40 induces an increased expression of Fas with a commensurate increase in the level of TRAF2, but not TRAF3, that is recruited to the receptor complex. In contrast, engagement of the membrane immunoglobulin and CD40 limits Fas upregulation and reduces the recruitment of TRAF2, relative to TRAF3, to the CD40 receptor complex. These studies show that the TRAF composition of the CD40 receptor complex can be altered by signals that influence B cell differentiation.

Multiple Inoculation with Three Attenuated Viruses for the Control of Cucumber Virus Disease

Multiple inoculation of cucumber seedlings with attenuated isolates of cucumber mosaic virus (CMV), zucchini yellow mosaic virus (ZYMV), and watermelon mosaic virus 2 (WMV-2) somewhat reduced yield loss due to mixed infection by virulent strains of these viruses in field experiments under severe epidemic conditions in 1994 and 1995. In addition, this protective inoculation largely protected grafted cucumber plants from viral wilt syndrome. In greenhouse experiments, no significant differences were observed between single and multiple inoculations in the cross-protection effects of the attenuated viruses against their respective virulent strains. Triply inoculated plants developed synergistic yellow leaf mosaic symptoms and 15% fewer marketable fruits compared with healthy plants. Thus, multiple inoculation is appropriate for the summer-early autumn production, when economic losses due to the concurrent incidence of CMV, WMV-2, and ZYMV are significantly greater than the loss in yield due to the inoculation.

[Postoperative brain infarction in a patient with the previous asymptomatic brain infarction]

We report a case of a postoperative brain infarction, in which an asymptomatic preoperative brain infarction was also revealed postoperatively. A 63-year-old man with bladder carcinoma was scheduled for the cystoplasty. The patient had no prominent preoperative abnormality. Anesthesia was maintained with isoflurane in N2O/oxygen combined with a spinal block and a continuous epidural block. Anesthesia lasted uneventfully for 16.5 hours. However, emergence from anesthesia was delayed. On the first postoperative day, motor aphasia and right hemiparalysis was confirmed. The computed tomography (CT) of the brain demonstrated a low density area in the frontoparietal region. The magnetic resonance imaging (MRI) indicated the corresponding lesion as the CT had demonstrated, and an old brain infarction in the parietal region. This meant that the patient had a history of asymptomatic brain infarction (ABI). Patients with ABI are considered to be a high-risk group for a brain infarction. It is important to evaluate the risk factors of brain infarction preoperatively and to minimize those risks during the operation. Maintenance of the cerebral perfusion pressure is imperative.

In vitro effects of sho-saiko-to on production of granulocyte colony-stimulating factor by mononuclear cells from patients with chronic hepatitis C

During the past 2 years, drug-induced interstitial pneumonia was reported in 66 Japanese patients, mainly among chronic hepatitis C patients, undergoing treatment with the Japanese herbal medicine "Sho-saiko-to" (TJ-9). As interstitial pneumonia is also induced by granulocyte colony-stimulating factor (G-CSF), we examined the effects of TJ-9 on G-CSF production in peripheral blood mononuclear cells. In patients with hepatitis B or C, G-CSF production in the absence of any stimulation was significantly lower than healthy controls (p < 0.01). G-CSF production increased along with the increase of TJ-9 levels, and this could induce excessive production of G-CSF in hepatitis C patients, and this may be a cause of interstitial pneumonia.

[A patient with acromegalic heart disease--a case report]

A perioperative anesthetic management of a 69 year old woman with acromegaly whose clinical course was characterized by severe heart failure is described. The patient showed symptoms of massive cardiomegaly. Endocrine studies indicated that her pituitary tumor was active with hyperproduction of growth hormone. There was no demonstrable evidence for other known causes of heart disease. Following hormonal therapy using continuous subcutaneous infusion of somatostatin for about two months, there was improvement in daily activity and reduction in heart size. After the improvement of cardiac function, transsphenoidal hypophysectomy was performed under general anesthesia and its perioperative course was quite uneventful. We conclude that because cardiac involvement such as left ventricular dilatation in acromegaly might be reversible with proper treatment, any surgical procedure, as long as the case is elective, should be considered after hormone therapy.

Effects of the Japanese herbal medicine "Sho-saiko-to" (TJ-9) on in vitro interleukin-10 production by peripheral blood mononuclear cells of patients with chronic hepatitis C

"Sho-saiko-to" (TJ-9) consists of 7 herbal components. In Japan, it is widely prescribed to patients with chronic viral liver disease. TJ-9 is known to suppress liver cancer development and possess macrobiotic effects, but its mode of action is not fully understood. This study investigated the following: 1) cytokine production levels, mainly interleukin (IL)-10, in peripheral blood mononuclear cells of chronic active hepatitis B and C patients, and healthy volunteers; 2) effects of TJ-9 on these productions; and 3) effects of each of its herb components on cytokine production in cell fractions. Results showed that without stimulants, IL-10 production in mononuclear cells of hepatitis B and C patients was significantly lower than that of healthy subjects (P < .01). IL-10 production induced by either phytohemagglutinin (PHA) or pokeweed mitogen (PWM) in mononuclear cells of hepatitis C patients were significantly lower than in patients with hepatitis B (P < .01) and healthy subjects (P < .05). IL-10 production induced by anti-CD3 or lipopolysaccharide (LPS) was significantly lower than in healthy subjects (P < .05). The addition of TJ-9 to the cultures strongly induced IL-10, and this induction was mainly attributable to the effects of 2 components (scutellaria root and glycyrrhiza root) on the monocyte/macrophage fraction. The production of IL-4 and IL-5 in cultures with concanavalin A (conA) was significantly higher in patients with hepatitis C than in the healthy subjects (P < .01; P < .05), but the addition of TJ-9 suppressed these increases by 25% to 33% (P < .01). Therefore, TJ-9 could adjust the decreased IL-10 production and the increased IL-4 and IL-5 production of mononuclear cells from patients with hepatitis C. Moderate regulation of the cytokine production system in patients with hepatitis C by using TJ-9 may be useful in the prevention of disease progression.

[Anesthetic management using transesophageal echocardiography during removal of a cardiac myxoma]

Removal of a cardiac myxoma can be complicated by mitral stenosis, arterial embolism and so on, all of which may be life-threatening but difficult to diagnose. We describe the use of transesophageal echocardiography (TEE) for the anesthetic management of two patients undergoing removal of a large myxoma in the left atrium (LA). The first case is a 78-yr-old woman, who was suffering from cardiac cachexy with a large LA myxoma. The anesthetic management of her surgery required the prevention of a decrease in cardiac output caused by anesthetic agents, massive bleeding and surgical procedures. The second case is an asymptomatic 60-yr-old man with LA myxoma, which appeared adherent to the mitral orifice in diastole. The goal of the anesthetic management of him was to prevent the obstruction of transmitral blood flow caused by the decrease in preload on the heart. Throughout the surgeries, TEE monitoring was conducted and helped decide the doses and/or rate of inotropes and vasodilators as well as the transfusion of fluid and blood to obtain stable circulatory conditions. It was also found to be of considerable value in understanding the pathophysiology of the tumors in LA. In conclusion, TEE monitoring during the surgery can be of much use both in the diagnosis and the anesthetic management of a patient with a large LA myxoma.

Effects of the Japanese herbal medicine 'Sho-saiko-to' as a cytokine inducer

The herbal medicine, Sho-saiko-to (TJ-9), has been widely prescribed to chronic viral liver disease patients in Japan. This study examined the inductions of such sytokines as interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), and granulocyte-colony stimulating factor (G-CSF), on some fractions of peripheral blood mononuclear cells (PBMC) by TJ-9 and each of its seven components. IL-1β, TNF-α, and G-CSF were highly induced by scutellaria root and glycyrrhiza root on monocytes/macrophages. By repeating the same experiments using taxol (an LPS antagonist)-treated substances, authors confirmed that these inductions were not attributable to the presence of quite low LPS in TJ-9 solution, and the cytokine inductions are the specific effect of TJ-9. Because TJ-9's macrobiotic effect in liver cirrhosis patients has been proven statistically in an etiological study, TJ-9 could be a new important therapy in chronic liver diseases.

Infection with GB virus C (GBV-C) in patients with fulminant hepatitis

BACKGROUND/METHODS

There appear to be hepatitis viruses other than hepatitis A, B, C, D and E. One of these has been proposed with a designation of GB virus C. Sera from 44 patients with fulminant hepatitis were tested for RNA of GB virus C by reverse-transcription polymerase chain reaction with nested primers deduced from the putative non-structural 3 (helicase) region.

RESULTS

RNA of GB virus C was detected in three (20%) of 15 patients with hepatitis B virus infection and three (12%) of 25 patients without markers of hepatitis A-E virus infection. Overall, GB virus C RNA was detected in six (14%) of the 44 patients with fulminant hepatitis, at a frequency significantly higher (p < 0.001) than that in three (0.9%) of 326 blood donors matched for age with the patients.

CONCLUSIONS

These results indicate a role of GB virus C in inducing fulminant hepatitis either by itself or in concert with the other hepatitis viruses.

Comparison of glucose 7.5% and 0.75% with or without phenylephrine for tetracaine spinal anaesthesia

PURPOSE

To investigate whether a marginally hyperbaric tetracaine solution with or without phenylephrine could produce consistent blocks as compared with a conventionally hyperbaric tetracaine solution injected at L3-4 interspace with the patient in the lateral position.

METHODS

We studied 120 ASA I or II patients scheduled for elective surgery to the lower limb. Patients were randomly divided into four equal groups to receive spinal anaesthesia using tetracaine 0.5% in glucose 0.75% or 7.5%, with or without phenylephrine 0.125%. Neural block was assessed in a double-blind manner by cold, pinprick, and touch sensation, and a modified Bromage scale after the injection of the study drug.

RESULTS

The median (10th, 90th percentiles) peak dermatomal level to pinprick obtained by the solutions in glucose 0.75% was T10 (L1, T5), which was lower than that obtained by the solution in glucose 7.5% extending to T5 (T10, T3) and T5 (T10, T2) with or without phenylephrine, respectively (P < 0.0001). The addition of phenylephrine prolonged the time to two-segment regression but did not change the maximum extent of blocks.

CONCLUSIONS

A marginally hyperbaric tetracaine with or without phenylephrine produced consistent blocks with spread restricted to the lower thoracic segments when administered intrathecally at the L3-4 interspace with the patient in the lateral position.

Antinociceptive effects of ONO-9902, an enkephalinase inhibitor, after visceral stress condition in rats

PURPOSE

The present study was designed to examine the antinociceptive effects of orally administered ONO-9902, an enkephalinase inhibitor, on both somatic and visceral pain after visceral stress conditions.

METHODS

Twenty six male rats were examined. Tail-flick (TF) and colorectal distension (CD) tests were used to determine somatic and visceral antinociceptive effects, respectively. Measurements were performed in rats under immediate post-stress conditions (group ST; n = 14) and in rats nor under stress conditions (group NST; n = 12). In the stressed group, the same device, CD, for visceral antinociceptive effects was used for visceral stress and was applied with an intracolonic pressure of 60 mmHg for 20 min after drug administration. The TF latency and CD threshold were measured before and at 30, 40, 50, 60 and 90 min after administration of ONO-9902 300 mg.kg-1 or distilled water.

RESULTS

Orally administered ONO-9902 did not produce any changes in the % maximum possible effect (%MPE) in either TF or CD tests in the unstressed group. In the stressed group, %MPE in the CD test increased 18% and 31% at 30 and 40 min, respectively, after oral administration of ONO-9902 compared with the control group (P < 0.05). However, %MPE to TF test did not alter even after the CD-induced stress condition.

CONCLUSION

These results suggest that ONO-9902 may have analgesic effects on visceral pain but not on somatic pain under immediate post-stress conditions.

A new CYP2D6 allele with a nine base insertion in exon 9 in a Japanese population associated with poor metabolizer phenotype

The CYP2D6 gene of a Japanese sparteine poor metabolizer (PM, proband) showing a urinary sparteine metabolic ratio of 31.6 was analysed, and a heterozygous CYP2D6(D), a deletional type, was found by restriction fragment length polymorphism analysis with Xba I enzyme. The PM did not have any other previously described mutations in the CYP2D6 gene causing the loss of catalytic activity of the CYP2D6 enzyme. Thus, a possible new allele(s) responsible for the PM phenotype was analysed. The results indicated that the PM possessed a new 9-base insertion in exon 9, designated CYP2D6(J9). The CYP2D6(J9) and CYP2D6(D) alleles were clarified to be inherited from the mother [2D6(W)/2D6(J9)] and the father [2D6(W)/2D6(D)], respectively. The 9-base insertion caused a large increase in the apparent K(m) value for bufuralol 1'-hydroxylation as examined by expression of the enzyme protein in yeast. Four of 300 Japanese carried a heterozygous CYP2D6(J9) allele (0.7%, 4/600 chromosomes) as determined by a polymerase chain reaction analysis.

Sensitivity to dexamethasone and absence of bcl-2 protein in Burkitt's lymphoma cell line (Black93) derived from a patient with acute tumor lysis syndrome: comparative study with other BL and non-BL lines

An Epstein-Barr virus (EBV)-negative Burkitt's lymphoma (BL) cell line, designated Black93, was established in culture from a patient who developed acute tumor lysis syndrome (ATLS). Growth inhibition in vitro by dexamethasone (DXM) and the expression of bcl-2 protein (Bcl-2) were investigated in Black93 and 17 other cell lines derived from EBV-negative or -positive BL, pre-B acute lymphoblastic leukemia (ALL), follicular lymphoma (FL), and EBV-positive lymphoblastoid cell lines of normal B cell origin (B-LCL), assuming an inherent susceptibility of Black93 to cell death. The most marked growth inhibition by DXM was observed in Black93, two other BL, two pre-B-ALL and two FL lines. The other cell lines were less sensitive or were resistant. DNA extracted from the Black93 cells treated with DXM showed a ladder of oligo-nucleosomal DNA on electrophoresis. On testing of fixed smears by indirect immunofluorescence, bcl-2 protein (Bcl-2) was undetectable in Black93 and three BL lines but was detected in all the other cell lines at varying intensity. Western blot analysis showed mostly the same results. In the BL lines, the most DXM-sensitive cell lines lacked Bcl-2 expression, and the DXM-resistant cell lines always expressed Bcl-2. While none of the DXM-resistant cell lines lacked Bcl-2 expression, several pre-B or FL lines that expressed [correction of expessed] Bcl-2 were sensitive to DXM. Black93 is the first reported cell line established from a patient with ATLS. The positive sensitivity to DXM and the lack of Bcl-2 expression observed in Black93 are a major characteristic exhibited frequently by BL lines and, probably, by fresh BL cells. These properties may contribute to the precipitation of ATLS.

[Tau protein in cerebrospinal fluid--a potential marker of Alzheimer's disease]

Levels of the microtubule-associated protein tau in cerebrospinal fluid (CSF-tau) were measured in samples from 87 patients with Alzheimer's disease (AD), 114 patients with non-AD neurological diseases, and 22 normal control subjects, by sandwich enzyme-linked immunosorbent assay. The CSF-tau level was significantly higher in patients with AD than in patients with non-AD neurological diseases and in controls. High CSF-tau levels were found irrespective of age at onset, apolipoprotein E genotype, clinical stage, and ethnic group. Western blots of AD CSF proteins revealed two to three immunoreactive bands with apparent molecular mass between 50 and 65 kDa, which is consistent with phosphorylated CSF-tau. These results suggest that CSF-tau reflects progressive accumulation of tau due to the progressive death of neurons in the AD brain. Assay of CSF-tau may prove to be a reliable diagnostic test for AD.

Coexpression of cell-surface immunoglobulin (sIg), terminal deoxynucleotidyl transferase (TdT) and recombination activating gene 1 (RAG-1): two cases and derived cell lines

While it is generally agreed that in the lymphoid differentiation of B lineage cells there is no stage in which cell-surface immunoglobulin (sIg) and terminal deoxynucleotidyl transferase (TdT) are expressed simultaneously, a few B cell acute lymphoblastic leukemia (B-ALL) cases with this phenotype have been reported. Two such cases and the derived cell lines are reported here, in which the expression of recombination activating gene-1 (RAG-1) was also detected. One case was a CD19+ CD22+ HLA-DR+ sIg+ (gamma, kappa) B-ALL. The cell line (Bay9I) also expressed CD10. Karyotypic analysis revealed t(14;18)(q32;q21) and additional aberrations. In the other case, the fresh leukemia cells expressed CD19, CD24 and HLA-DR antigen. The derived cell line (Tree92) also expressed CD22 and sIg (mu, lambda). The karyotype of the Tree92 cells was t(8;14)(q24;q32) with additional aberrations. Tree92 is the first established cell line having both t(8;14)(q24;q32) and TdT. TdT was detected by Northern blotting as well as indirect immunofluorescence analysis. In addition, both Bay9I and Tree92 expressed RAG-1, as detected by Northern blot analysis. Cross-linking of sIg on Tree92 cells with anti-mu antibody led to significant down-regulation of RAG-1 expression. It seems that there is a sIg+ TdT+ RAG-1+ B lineage differentiation stage, and that signaling through sIg can modulate RAG-1 expression.

Antinociceptive effects of epidural and intravenous ketamine to somatic and visceral stimuli in rats

PURPOSE

To evaluate the antinociceptive effect of epidural and intravenous ketamine on somatic and visceral stimuli and to address the emergency reaction.

METHODS

Rats were randomly allocated into nine groups (n = 6); five groups with chronically implanted epidural catheters received saline or 0.5, 1, 2 and 4 mg. kg-1 ketamine epidurally, four groups received saline, or 1, 5 and 10 mg. kg-1 ketamine i.v. To assess somatic and visceral antinociceptive effects, tail flick (TF) test and colorectal distension (CD) test were carried out, respectively. Emergence reactions were graded. Maximal possible effects (% MPE) were calculated.

RESULTS

Epidural ketamine increased % MPE in both tests in a dose-dependent fashion for 30 min (vs saline group, P < 0.05). Epidural ketamine 0.5 mg. kg-1 produced an increase in % MPE in the CD test (P < 0.05) but failed in the TF test. Intravenous ketamine, 10 mg. kg-1, produced 100 +/- 0 (mean +/- SE) % MPE in the CD test but 36 +/- 15% MPE in the TF test. Dose response curves indicated greater visceral antinociception than somatic. All rats showed emergence reactions following intravenous ketamine 10 and 5 mg. kg-1.

CONCLUSION

Both epidural and intravenous ketamine produce greater antinociceptive effects to visceral than to somatic stimulation, and that epidural ketamine has a low incidence of emergence reactions.

Fulminant hepatic failure caused by ecarazine hydrochloride (a hydralazine derivative)

The cause of fulminant hepatic failure is reported to be unknown in more than half the cases in Japan. We recently reviewed 23 cases of fulminant hepatic failure that had been treated at our hospital. The cause of disease had been regarded as unknown before this study. It was found that seven of these patients had been under ecarazine hydrochloride therapy when they developed fulminant hepatic failure. We examined the reasons why fulminant hepatic failure in these seven patients had not been previously attributed to ecarazine, and found that it could be explained by the following factors: (1) the time from the start of ecarazine therapy to the onset of hepatic failure was long; (2) in all cases, hepatic failure developed more than 10 days after the clinical recognition of hepatitis; and (3) characteristic signs of drug-induced hepatic failure such as a skin rash and positive lymphocytes stimulation test with the drug were absent in all cases. Fulminant hepatic failure in these cases could be characterized by: (1) rapid decrease in serum alanine transaminase (ALT) level after discontinuation of ecarazine, (2) prolonged jaundice despite discontinuation of ecarazine, (3) high incidence of anti-nuclear antibody (ANA) (57%), and (4) histological findings of extensive hepatocellular necrosis ranging from bridging necrosis to massive necrosis. Of the seven patients, four died of fulminant hepatic failure. These four patients had received high doses of ecarazine hydrochloride for prolonged periods. Our data suggest that there may be many cases in which the cause of fulminant hepatic failure or acute hepatitis was not previously determined that can be attributed to long-term drug therapy for chronic diseases.