Do changes in end-tidal PCO2 quantitatively reflect changes in cardiac output?

In anesthetized patients, acute decreases in cardiac output (CO) are often reflected as decreases in end-tidal CO2 tension (PETCO2), but the quantitative relationship between the changes in CO and the changes in PETCO2 is uncertain. We hypothesize that a quantitative relationship can be demonstrated if timing of the measurements in each episode of hemodynamic perturbation is standardized. In 24 patients undergoing abdominal aortic aneurysm surgery with constant ventilation, we prospectively performed 33 measurements of CO, PETCO2, and CO2 elimination (VECO2) within 10 min of hemodynamic changes. The percent decrease in PETCO2 directly correlated with the percent decrease in CO (slope = 0.33, r2 = 0.82). Also, the percent decrease in VECO2 correlated with the percent decrease in CO similarly (slope = 0.28, r2 = 0.84). The changes in PETCO2 and VECO2 following hemodynamic perturbation were parallel. This finding suggests that decreases in PETCO2 quantitatively reflect the decreases in CO2 elimination.

Characteristics of somatic mutation of the adenomatous polyposis coli gene in colorectal tumors

Mutation of the adenomatous polyposis coli (APC) gene was analyzed in 500 colorectal tumors from 70 familial adenomatous polyposis (FAP) and 102 non-FAP patients and in normal tissues from 119 FAP patients, using polymerase chain reaction-single-strand conformation polymorphism and direct sequencing methods. These tumors were histopathologically diagnosed. Sixty-eight germ line mutations (62% deletion, 9% insertion, and 29% single-base substitution) and 241 somatic mutations (56% deletion, 12% insertion, and 32% single-base substitution) were detected. All mutations formed stop codons resulting in truncated APC proteins, except for one germ line mutation. Differences were found between somatic and germ line mutations, including 3 new hot spots of mutation at codons 1378, 1450, and 1487-1490, which frequently occurred in somatic mutations but not in germ lines. The frequency of mutation in each histopathological type of FAP tumor was 53% in moderate adenoma, 64% in severe adenoma, 52% in intramucosal carcinoma, and 33% in invasive carcinoma, whereas the loss of heterozygosity including the APC gene increased with development to each histopathological type. A similar tendency was observed in non-FAP tumors. Additionally, we found 10 FAP tumors that had both somatic mutation and loss of heterozygosity. These tumors were assumed to have developed from moderate adenomas with germ line and somatic mutations, followed by deletion of the allele with germ line mutation. These results suggest that inactivation of the APC gene by two mutations is involved in the development of moderate adenoma, and loss of heterozygosity of the APC gene is associated with further development to carcinoma. It was also observed that the distribution of 75 somatic mutations from one FAP patient on the APC sequence was similar to the distribution of 159 somatic mutations from 83 patients with FAP and non-FAP, which suggests that the position of somatic mutation is mostly due to the APC sequence itself.

Management of anastomotic complications after sleeve lobectomy for lung cancer

One hundred twelve patients (102 male and 10 female) underwent sleeve lobectomy for lung cancer from January 1969 to December 1991. Bronchopleural fistula occurred in 6 (5.6%), bronchovascular fistula in 2 (1.8%), pulmonary arterial occlusion in 2 (1.9%), anastomotic stricture or stenosis in 7 (6.3%), and local recurrence in 7 patients (6.3%). Early repair of bronchopleural fistula combined with an omentopexy achieved permanent closure of the fistula. Two patients who underwent a completion pneumonectomy for a pulmonary arterial occlusion died of respiratory failure. Two patients experienced uncontrollable bleeding into the bronchial tree through a bronchovascular fistula and sudden death. Completion pneumonectomy is indicated for a stricture due to scar formation. If pneumonectomy is precluded by poor pulmonary reserve, endoscopic excision using biopsy forceps is an alternative. Endoscopic resection is the treatment of choice for suture granulomas. Complications associated with bronchial or vascular anastomoses are serious and frequently fatal.

Coexistence of somatic and germ-line mutations of APC gene in desmoid tumors from patients with familial adenomatous polyposis

Desmoid tumors, which are locally invasive with recurrence but without metastasis, are frequently observed in patients with familial adenomatous polyposis after abdominal surgery or during pregnancy. This study analyzed mutation of the adenomatous polyposis coli gene in 8 desmoid tumors from 7 familial adenomatous polyposis patients using polymerase chain reaction-single-strand conformation polymorphism and the direct sequencing method. Seven somatic mutations, 1 somatic allele loss, and 6 germ-line mutations were detected. The majority of adenomatous polyposis coli gene mutations were deletions of 1 to 19 base pairs in exon 15, and all mutations led to the formation of stop codons. A somatic mutation with repetition of 82 base pairs from codon 1399 to 1426 was also observed in a desmoid, which was most likely caused by an error during replication or repair replication. No mutation was detected in exons 1 to 2 of H-ras, K-ras, and N-ras genes and in exons 5 to 8 of p53 gene, in these tumors. The simultaneous existence of somatic and germ-line alterations of adenomatous polyposis coli gene observed in all 8 tumors strongly suggests that inactivation of both alleles of adenomatous polyposis coli gene is involved in the development of desmoid tumors.

Three polypeptides with distinct biochemical properties are major alpha chain-size components of type IV collagen in bovine lens capsule

Studies of intact type IV collagen from deposits of cultured cells or from tissues in culture, or more recently, isolated from EHS tumor have suggested that type IV collagen molecule is composed of two procollagen-like polypeptides (M(r) = 185k and 170k). We show that the major components of intact type IV collagen in bovine lens capsule are three polypeptides, two with sizes (M(r) = 180k and 175k) comparable to those of the procollagen-like polypeptides and one with a smaller size (M(r) = 160k). Both CNBr peptide mapping and electrophoretic analysis by utilizing a gel containing urea showed that the 180k polypeptide and the 160k polypeptide are chemically and genetically very similar to each other, but that the 175k polypeptide is chemically distinct from the other two polypeptides. It is unlikely that the 160k polypeptide resulted from cleavage of the 180k polypeptide during experimental manipulation, since a change of the acidic pH of extraction buffer to neutral pH, storage of the acid extract in acid for a prolonged time or incubation of the acid extract at 80 degrees C after neutralization gave rise to essentially no change in relative amount or size of the three polypeptides.

Immunohistochemical study of thymic B cells in myasthenia gravis and ulcerative colitis

The phenotypes of B cells and dendritic cells in human thymus were examined immunohistochemically using various monoclonal antibodies. Normal thymus contained a few B lymphocytes recognized by CD19, CD20, CD22, L26 and LN-2, which were localized in the medulla. These B cells were negative for LN-1, L30 and CD11c (Leu M5). Activated B cells recognized by CD23 (B6) and L29 antibodies were not present in normal thymus. Dendritic cells stained by CD11c were weakly positive for L26 and CD20. There was no difference in the distribution of dendritic cells between normal thymus and thymus from the patients. In the thymus from patients with myasthenia gravis, numerous B cells were demonstrated in the medullary area and lymphoid follicles. Activated B cells were seen mainly in the germinal center of lymphoid follicles and were scarce in the medulla. Many B cells were also found in the medulla and lymphoid follicles of the thymus from patients with ulcerative colitis. However most of those B cells were not activated, even in the lymphoid follicles. These results suggest that thymic B cells may contribute to the induction of immune abnormalities in patients with myasthenia gravis and those with ulcerative colitis, however, the mechanisms by which thymic B cells participate in the pathogenesis of these two diseases would be different.

[An emergency operation for a Jehovah's Witness with ruptured thoracic saccular aneurysm]

A 49-year-old male "Jehovah's Witness" was transferred to our hospital with hypotension, abdominal pain, and abdominal distension, and a diagnosis of ruptured thoracic saccular aneurysm was made. He and his family insisted on having an emergency operation for his ruptured aneurysm without blood transfusion. After an intensive discussion among the patient, his family, surgeons, and the director of the hospital, we performed the operation without blood transfusion. The operation using cardiopulmonary bypass took about five hours under enflurane anesthesia, but he died of circulatory collapse fifteen hours after the end of operation. As there may be various opinions concerning how we should take care of Jehovah's Witness patients, we have to manage them case by case.

[A study of the dynamics of gallbladder contraction in irritable bowel syndrome]

We examined gallbladder motility function after intramuscular injection of caerulein (0.2 micrograms/kg) to the cases of irritable bowel syndrome (IBS) by using ultrasonography. We measured gallbladder area pre and after caerulein injection (0' 5' 10' 15' 20' 25' 30' 40' 50' 60') and calculated contraction rate of gallbladder in each time. We applied one way analysis of variance among the four groups [diarrhea group (N = 9), alternative group (N = 8), constipation group (N = 8), control group (N = 15)]. Gallbladder contraction rate was low in diarrhea group and high in constipation group (p less than 0.05). And then we classified gallbladder contraction pattern to three groups (hyperkinetic, intermediate, hypokinetic). These three groups correlated bowel habits and biliary knocked pain. Therefore, constipation group showed hyperkinetic tendency and diarrhea group showed hypokinetic tendency (chi 2 analysis: p = 0.004 CMH analysis: p = 0.001). And biliary knocked pain significantly appeared in constipation group and hyperkinetic type of gallbladder (chi 2 analysis: p = 0.026, CMH analysis: p = 0.019). Consequently, it was suggested that bowel habits concerned with abnormality of gallbladder motility function in IBS.

Residual effects of repeated administration of triazolam and nitrazepam in healthy volunteers

The residual effects of hypnotics were investigated with a long-acting (nitrazepam) and a short-acting (triazolam) benzodiazepine hypnotic in 8 male volunteers. Subjects received placebo, nitrazepam 5 mg, or triazolam 0.25 mg for 7 consecutive nights in a random-order, double-blind crossover design. Daytime sleepiness, psychomotor performance, EEG activity and standing steadiness were assessed in the morning after 1, 4, and 7 days of drug treatment. Plasma concentrations of nitrazepam and triazolam were also assayed. The concentration of nitrazepam increased gradually during the course of treatment and was associated with residual sedative effects on days 4 and 7. Nitrazepam produced no apparent psychomotor impairments in these studies. On the other hand, there was no evidence of drug accumulation after triazolam administration and triazolam showed no residual sedative effects or residual impairment of psychomotor performance during the experiment. Thus, short-acting hypnotics may have an advantage over long-acting hypnotics in terms of producing less residual sedative effects during chronic treatment.

[Clinical study on total intravenous anesthesia with droperidol, fentanyl and ketamine--11. Effect on epidural pressure]

We have developed a new method of total intravenous anesthesia using ketamine, fentanyl and droperidol (NLA-FK). There are many reports describing a significant increase in cerebrospinal fluid pressure (CSFP) during ketamine administration, but little is known about changes in CSFP during NLA-FK. As epidural pressure (EP) is considered as a good index for CSFP, we measured it in 12 patients under either NLA-FK or isoflurane anesthesia, who underwent gastrectomy. In the NLA-FK group the EP increased significantly by 26% at the induction of anesthesia as compared with the preinduction level, and it decreased to the preinduction level 30 minutes after the induction. Thereafter the pressure was not appreciably changed. In the isoflurane group EP significantly decreased by 16% at induction, but the pressure significantly increased by 29% 30 minutes after the induction as compared with the preinduction level. The change was similar to that of the NLA-FK group. Although the increase in the EP during the induction of NLA-FK is significant, it is considered to be within normal ranges. However, further detailed clinical study is needed to attenuate the significant increase in the EP during the induction of NLA-FK.

[Effect of induced hypotension with prostaglandin E1 or trimetaphan on endocrine functions in surgical patients]

Twenty patients who underwent surgery of hip joint under enflurane anesthesia were studied to evaluate the effect of induced hypotension with prostaglandin E1 or trimetaphan on endocrine functions. Ten patients were given prostaglandin E1 and the remaining ten patients were given trimetaphan intravenously to maintain systolic blood pressure at about 80 mmHg. There were no significant differences between the two groups concerning plasma level of ACTH, cortisol, TSH, T3, T4, epinephrine and dopamine. However a significant difference in plasma norepinephrine levels was observed between them. Plasma norepinephrine levels after start of hypotension increased by 50% in the prostaglandin E1 group, but decreased by 50% in the trimetaphan group, when compared with each pre-hypotensive level. The data obtained suggest that the prostaglandin E1 would not influence ACTH-cortisol and thyroid functions, but may have a tendency to increase plasma norepinephrine levels in hypertensive patients complicated with pheochromocytoma.

Serodiagnosis of cancer using porcine carboxypeptidase A as an animal antigen recognized by human monoclonal antibody HB4C5

Protein from hog which is recognized by human monoclonal antibody (HB4C5), generated from a patient with large cell lung carcinoma, was identified as carboxypeptidase A by comparison of the protein with carboxypeptidase A in enzymatic activity, immunologic reactivity, and amino acid sequence. Carboxypeptidase A activity was also found in human cancer tissue, and purified antigen from cancer tissue recognized by the antibody HB4C5 was reacted with rabbit anti-carboxypeptidase A serum, indicating that carboxypeptidase A is an antigen of HB4C5. Since large amounts of carboxypeptidase A can be obtained from porcine sources, a simple method for its purification was established. The fraction which was most reactive with HB4C5 was obtained from acetone powder of porcine pancreas by successive applications of water extraction, ammonium sulfate precipitation, trypsin treatment, and Mono Q column chromatography. Its apparent molecular weight was 40,000, according to SDS polyacrylamide gel electrophoresis. When the reactivity of IgG in sera with the purified carboxypeptidase A was measured, the detection rates for lung, ovary, larynx, uterus, and liver cancer were more than 50%, while the rates for stomach and breast cancer were around 30%, and pancreatic cancer, benign diseases, and normal controls were minimally detected.

Ten-year statistics and observation of facial bone fracture

Six hundred and seventy-four cases of facial bone fracture in the past 10 years were studied with respect to age and sex, region, cause, classification, and treatment at our clinic. About half of the cases of the single fractures of nasal bones were caused by sports and fights. Of the other cases of facial bone fracture, about 40% were caused by traffic accidents. Reduction of facial bone fracture should be performed as soon as possible from a functional as well as cosmetic point of view. Hence precise diagnosis and refined techniques of repairing are mandatory to avoid postoperative complications.

The relationship between clinical signs and hypercoagulable state in toxemia of pregnancy

The hypercoagulable state in patients with toxemia of pregnancy was investigated in comparison with normal pregnant women using new coagulation parameters, mainly thrombin-antithrombin III (TAT) complexes, alpha 2-antiplasmin-plasmin complexes (PIP), and D-dimer FDP. When the patients were categorized by the classification of the WHO Study Group (1985), significant increases of TAT complexes and alpha 2-PIP complexes with decreases of the ATIII level were observed in the groups with preeclampsia and severe gestational hypertensive disease as compared to normal pregnant women. A significant increase of D-dimer FDP was observed in a group with severe gestational hypertensive disease. Additionally, the relationship between clinical signs and the hypercoagulable state in the patients was analyzed using canonical correlation analysis as a multivariate analysis. The clinical signs and coagulation parameters had a significantly high correlation of lambda 1 = 0.7219, p less than 0.01. The results showed that clinical signs were associated with simultaneous coagulation abnormalities. The indices obtained from the results of canonical correlation analysis, which were called the clinical index and the coagulation index, should be useful in evaluating the efficacy of anticoagulation therapy.

Otoplasty in microtia

Microtia patients encountered over 9 years from 1978 to 1986 were listed. The total number of patients for the period was 155, 113 males and 42 females. The microtia occurred on the right side in 93 cases, on the left in 50 cases and bilaterally in 12 cases. Surgery was performed in 115 cases during the period. We applied a modification of the Brent method and have to date obtained good results. This method has several advantages: 1) Use of 7th and 8th rib cartilage means a relatively small amount of material, minimal surgical invasion and short operation time; 2) A more naturalistic auricle with clear grooves and ridges; 3) Preschool start completion of auricle reconstruction is possible, which contributes to the peace of mind of patient and parents.

[Effects of E2078, a new dynorphin derivative, on pituitary-adrenocortical functions in dogs]

E2078, a new analgesic is a dynorphin derivative. E2078 shows strong affinity to kappa receptors and is not rapidly cleaved by peptidases. This analgesic is also considered to be free of tolerance and dependence. In the present study, to determine the effect of E2078 on pituitary-adrenocortical function the author administered E2078 (0.001, 0.05, 0.1, 1.0, 10.0 mg.kg-1) by intramuscular injection to 38 adult mongrel dogs under enflurane anesthesia (1.0%) and then investigated the changes in the plasma concentrations of ACTH, cortisol, beta-endorphin, PRA, aldosterone and ADH. In the animal groups which received E2078 at dosages of 0.001, 0.05, 0.1, and 1.0 mg.kg-1, no significant differences in the plasma concentrations of each hormone were detected compared with the control group which received physiological saline by intramuscular injection. However, in the dog group which received E2078 at 10.0 mg.kg-1, the plasma concentrations of PRA and aldosterone were significantly elevated.

Psychogenic vomiting: the relation between patterns of vomiting and psychiatric diagnoses

Fifty nine patients admitted with a diagnosis of psychogenic vomiting were classified into five patterns of vomiting: continuous, habitual postprandial, irregular vomiting, nausea, and self induced. The psychiatric disorders related to the onset of vomiting were either a major depression or a conversion disorder. Continuous vomiting was usually due to a conversion disorder, while in many cases of habitual postprandial and irregular vomiting, major depression was observed. The patients' psychiatric disorders and vomiting patterns often changed during the clinical course. Assessing the psychiatric problems and vomiting patterns is important in the diagnosis and treatment of psychogenic vomiting.

Inflammatory bowel diseases and thymus disorder: reactivity of thymocytes with monoclonal antibodies

Thymectomy is one of the most effective means of treating myasthenia gravis (MG). Formation of lymphoid follicles in the thymus is seen at high rate in ulcerative colitis (UC) as well as MG. We examined the subsets of lymphocytes in the thymuses taken from patients with inflammatory bowel diseases (IBD), using OK series monoclonal antibodies. Decreases in OKT8 (CD8)-, 6(CD1)- and 10-positive cells and an increase of IA1-positive cells were observed in UC. In contrast, there were no significant changes in Crohn's disease (CD). Therefore, the thymocytes from UC appear to consist of comparatively matured cells under the influence of thymic hormone.

In vitro effect of thymic epithelial culture supernate on cyclic GMP levels in rabbit platelets

When supernatants of thymic epithelial cell cultures (STEC) or thymosin fraction 5 were incubated with washed platelets (37 degrees C for 30 min), the levels of platelet guanosine 3',5'-cyclic monophosphate (cyclic GMP) were increased in a dose-dependent manner. In contrast the supernatants from Chang, HeLa, or HCC-M cell cultures did not significantly affect the levels of intracellular cyclic GMP. The increment of intracellular cyclic GMP levels following treatment with STEC increased with longer incubation times until a plateau was reached at 30 min. This activity of STEC was found in fractions with a molecular weight below 10,000 daltons. Contents of guanine and guanosine in STEC were lower than those observed in other culture supernatants. STEC did not affect guanylate cyclase activity in platelets, but significantly inhibited cyclic GMP phosphodiesterase activities in platelet soluble and membrane fractions. Thymosin fraction 5 inhibited the phosphodiesterase activity of the soluble but not the membrane fraction.

[A case report of esophageal intramural pseudodiverticulosis]

A 76 year old man with esophageal intramural pseudodiverticulosis occurring in reflux esophagitis is presented. This unusual condition characterized by multiple small outpouchings in the esophageal wall and associated with a high incidence of benign esophageal stricture. Our case demonstrated typical radiological feature by barium swallow.

[Effect of combined administration of HBs antigen and anti-HBs antibody on induction of anti-HBs antibody production in vitro and in vivo]

It was considered that nonresponsiveness to hepatitis B surface antigen was in part due to a failure in the antigen recognition (i.e., antigens' phagocytosis, processing and presentation by accessory cells). In order to enhance the capture of antigens, we investigated the effect of simultaneous administration of HBs antigen and anti-HBs IgG on antibody responses in vitro and in vivo. As a result, in vitro sensitization of mononuclear cells from anti-HBs-positive subjects with HBs antigen and anti-HBs IgG induced significant amounts of anti-HBs IgG production in 5 of 6 cases, whereas sensitization with HBs antigen alone failed to induce the antibody production in most cases. In vivo administration of HBs vaccine and anti-HBs immunoglobulin to non-responders to the vaccine triggered active anti-HBs antibody responses in 3 of 7 cases in vivo and in 5 of 7 cases in vitro.