[Effects of sevoflurane and isoflurane on intraocular pressure in adult patients]

We investigated effects of two anesthetic agents, sevoflurane and isoflurane, on intraocular pressure (IOP). Forty adult patients were allocated randomly to two groups; Group S (sevoflurane) or Group I (isoflurane). All patients were given a bolus of thiamylal (4-5 mg.kg-1) and vecuronium (0.1-0.2 mg.kg-1) and maintained with 1-3% sevoflurane or isoflurane supplemented with nitrous oxide. Ventilation was controlled and ETCO2 was monitored. IOP, blood pressure and heart rate were measured before induction of anesthesia (control) and at the 7 points of 5, 10, 15, 30, 45, 60 and 120 minutes after intubation. In Group S, IOP was reduced significantly until 30 min compared with control IOP and the maximum decrease was 40% at 10 min. In Group I, IOP was consistently lower than control and the maximum decrease was 40% at the same time as in Group S. But there were no significant differences between the two groups at each point. It seems that the remarkable reductions of IOP after inductions are mainly caused by induction agents. In both groups, hemodynamic parameters showed no remarkable changes during maintenance. These results suggest that both sevoflurane and isoflurane are useful anesthetics for elderly patients receiving ophthalmic surgeries.

[Annual changes of bacteria isolated from urinary tract infections and their susceptibility to new quinolone agents]

Statistical analyses were conducted on bacterial strains isolated from the urine of patients with urinary tract infections (UTI) in the Department of Urology at Aichi Medical University from January 1988 through December 1991. The drug sensitivity of the bacterial strains isolated from patients with complicated UTI between 1988 and 1991 was analyzed and compared. Among the outpatients with uncomplicated UTI, a total of 352 strains were isolated. E. coli was isolated the most frequently (90.1%). Among the outpatients with complicated UTI, a total of 829 strains were isolated. Enterococcus sp. was isolated the most frequently (21.2%). P. aeruginosa and S. aureus showed a tendency to increase. Among the inpatients with complicated UTI, a total of 671 strains were isolated. Enterococcus sp. was isolated the most frequently (22.5%). P. aeruginosa and S. aureus showed a tendency to increase, while E. coli and Enterobacter sp. showed a tendency to decrease. E. coli was highly sensitive to all drugs except ampicillin (ABPC). Proteus sp. and Klebsiella sp. were highly sensitive to norfloxacin (NFLX). P. aeruginosa was highly sensitive to gentamicin (GM). The frequency of NFLX-sensitive P. aeruginosa significantly dropped from 84.6% to 40.9% among the outpatients (P < 0.01), and from 75.0% to 44.4% among inpatients (P < 0.05). S. aureus was highly sensitive only to minocycline (MINO). The frequency of NFLX-sensitive S. aureus significantly dropped from 66.6% to 23.3% among inpatients (P < 0.05). Enterococcus sp. was highly sensitive to ABPC and MINO. Of the new quinolones, tosufloxacin (TFLX) had the strongest antimicrobial activity followed by (ciprofloxacin) CPFX on all the bacterial strains tested.

[Coagulation changes during liver resection]

Thrombin-antithrombin III complex (TAT) and plasminogen activator inhibitor (PAI) were measured during liver resection surgery in 8 patients. TAT and PAI activities of patients under liver resection were compared with those of 11 patients under resection of esophageal carcinoma. TAT activity increased during liver resection (P < 0.001) and reached 14 times (P < 0.001) of its control value in the recovery room. PAI activity was very stable during operation, but increased to twice (P < 0.01) of its control value in the recovery room. TAT activity of patients after liver surgery in the recovery room was (P < 0.05) more than twice of that of patients after esophageal surgery. We conclude that hypercoagulable state occurred during liver resection to a greater degree compared with that observed with esophageal surgery, and that its cause might be liver resection itself.

Quantitation of cerebral blood volume by 99mTc-DTPA-HSA SPECT

The characteristics of technetium-99m diethylenetriaminepentaacetic acid human serum albumin (99mTc-DTPA-HSA) as an agent for quantitation of cerebral blood volume (CBV) were examined. The radioactivity after decay correction as a percentage of the activity at 10 minutes was 84.3 +/- 1.3% at 120 minutes after the injection of 99mTc-DTPA-HSA. Radioactivity was found exclusively in plasma, with little in blood cells. The blood retention of 99mTc-DTPA-HSA is sufficient, and its use in the quantitation of CBV omits the need for centrifugation of the blood sample. CBV quantified using the tracer and a SPECT system with a single-head rotating gamma camera was 4.09 +/- 0.60 ml/100 g brain, similar to values reported previously. Two serial SPECT scans provided similar images, and the CBV values determined by the two scans were closely correlated (p < 0.001). The high reproducibility suggests that the method may be used to monitor the cerebrovascular response to drugs. It was concluded that 99mTc-DTPA-HSA has useful properties for quantitative CBV measurement and that quantitation of CBV by 99mTc-DTPA-HSA SPECT is feasible using a system with a single-head rotating gamma camera.

[A case of meningioma with non-accumulation of 99mTc-ECD and increased accumulation of 99mTc-HMPAO in the tumor]

99mTc-ECD SPECT and 99mTc-HMPAO SPECT with or without Matas test were performed in a 62-year-old woman with meningioma in the left anterior cranial fossa. After injection of 740 MBq 99mTc-ECD or HMPAO, 64 projection images were collected with a rotating Gamma camera. Matas test was carried out by compressing the left common carotid artery for about one minute immediately after RI injection. Although 99mTc-ECD SPECT showed non-accumulation in the tumor, 99mTc-HMPAO SPECT demonstrated increased accumulation in it. This area of increased accumulation disappeared on 99mTc-HMPAO SPECT with Matas test which causes decrease in blood flow of the tumor. These findings suggest 99mTc-ECD and 99mTc-HMPAO have a different mechanisms of accumulation in the meningioma.

[A comparison of the effects of omeprazole with those of ranitidine on intragastric pH and volume in patients for elective surgeries]

This study compared the effect of omeprazole with those of ranitidine on intragastric secretion during perioperative period. Thirty-one patients were randomly allocated to three groups. Each group received either omeprazole, ranitidine orally or one on the night before surgery. Intragastric pH and volume were measured after induction of anesthesia. Omeprazole group and ranitidine group had a higher mean pH than control group (P less than 0.01). None of the omeprazole group had an aspirate of pH lower than 2.5. One patient (10%) in the ranitidine group and five patients (50%) in the control group and five patients (50%) in the control group had aspirates of pH lower than 2.5. Mean gastric volume was not significantly different among these groups. A single dose of omeprazole 20 mg significantly decreased the number of patients at risk of aspiration pneumonitis.

[Three-dimensional display of 99mTc-MIBI myocardial scintigraphy]

One of 99mTc-hexakis, 99mTc-methoxyisobutyl isonitrile (MIBI), has been demonstrated to have a myocardial uptake proportional to regional coronary blood flow. In this study, 99mTc-MIBI myocardial scintigraphy were performed for 16 patients with ischemic heart disease. After injection of 740 MBq of 99mTc-MIBI, 64 projection images were collected during a 360-degree rotation. Three-dimensional (3D) display of the left ventricle was reconstructed with depth-shading method from 99mTc-MIBI SPECT images, which were reconstructed by filtered back projection method. In 9 of the patients, left ventricular cineangiography were performed as diagnostic gold standard. Four physicians blinded to patients' clinical informations interpreted 3D images and SPECT images on separate occasions. Diagnosis of hypoperfusion by 3D displays agreed with those of SPECT in 92.9% (104/112 segments), and disagreed in 7.1% (8 segments). Sensitivity and specificity of 3D images were 87.0 and 93.9%, which were not statistically different (p less than 0.05) from that of SPECT images (91.3, 97.0%). Receiver operating characteristic (ROC) analysis revealed nearly identical curves for the two. Although 3D display had nearly identical diagnostic ability with SPECT, observers reported that 3D images were easier to diagnose than SPECT images. An advantage of the 3D display is that the display gives a more realistic impression of the left ventricle to an observer than tomography or planar imaging. Another advantage is that 3D display can reduce the amount of data storage compared with that of SPECT. In conclusion, 3D images may be useful for diagnosis of hypoperfusion of left ventricle.

[Influence of calcium channel blockers and beta-blockers on pain relief with iontophoresis]

We studied usefulness of iontophoresis on pain relief using several Ca channel blockers, propranolol and guanethidine. Subjects were 18 healthy adult volunteers. We used 4% lidocaine with/without several drugs (2 mg of nicardipine, verapamil, diltiazem, propranolol and 10mg of guanethidine), and evaluated the pain relief effect with Nakahama's algesimeter. In all groups except for propranolol group, the pain recognition time was elongated significantly in comparison with control. In making comparison between each Ca channel blocker, we did not observe any significant differences, but, in propranolol group, elongation of pain threshold time was observed in some subjects. During these processes, systemic blood pressure and heart rate showed no remarkable changes. Our results suggest that it is possible to achieve more prolonged analgesic effect by the Ca channel blockers.

[Heat conservation during abdominal surgery]

Intraoperative hypothermia is a major problem in anesthetic management. We compared the heat conserving effect of a forced air warming system (Bair Hugger, Augustine Medical Inc.) with that of a warming blanket. Sixteen patients undergoing abdominal surgery were studied. Patients were anesthetized with nitrous oxide and oxygen combined with epidural anesthesia. Patients received tympanic, rectal, bladder and core temperature monitorings. Patients were divided randomly to Bair Hugger group (BH, n = 8) or warming blanket group (WB, n = 8). Temperature were measured every one hour over three hours. The BH group showed significantly higher temperatures than WB group. Bair Hugger system is an efficient way to maintain intraoperative body temperature.

A new method for monitoring the cerebrovascular response to acetazolamide using 99mTc-DTPA-HSA

We developed a new method for monitoring the cerebrovascular response to acetazolamide using technetium-99m diethylenetriaminepentaacetic acid human serum albumin (99mTc-DTPA-HSA). We infused 740 M Bq (20 mCi) of 99mTc-DTPA-HSA intravenously and carried out dynamic scanning of the anterior view of the head for 50 minutes. Ten minutes after the start of scanning, 1,000 mg of acetazolamide was injected intravenously. In three normal volunteers, the radioactivity in brain increased for an average of 8 minutes after the injection of acetazolamide and then remained relatively stable. The average of dilatation index [(peak count/the count just before acetazolamide injection-1)x 100] was 16.1. Our method enabled us to observe vasodilation caused by acetazolamide straight, and may be of value in assessing cerebral perfusion reserve easily and quantitatively.

Value of three-dimensional surface display of brain perfusion imaging. Comparison with tomographic imaging

The diagnostic ability of a three-dimensional surface display of I-123 IMP brain scintigrams and tomographic images was compared in 12 patients who underwent I-123 brain tomography for cerebral cortical hypoperfusion. Foci of decreased accumulation were independently diagnosed by four radiologists, first with transaxial images, second with three-dimensional images, and finally with both images subjectively compared for the purpose of diagnosing the existence, localization, and extent of lesions. Six different lesions (0 to 3 lesions/radiologist) were found only on the transaxial images, but 30 different lesions (1 to 14 lesions/radiologist) were found on the three-dimensional images. In 9 out of 12 cases, the three-dimensional images were regarded as superior for evaluating the extension of the lesion and for lesion existence and lesion localization in 5 out of 12 (P less than 0.05). In conclusion, a three-dimensional display of an I-123 IMP brain tomogram is superior to tomographic images in diagnosing the extent of cerebral cortical hypoperfusion. However, the display is not superior to tomographic images for diagnosing the existence and localization of hypoperfusion.

Basic study on the effect of nasally administered salmon calcitonin preparation on the nasal ciliary epithelium

Nasal administration of drugs is an administration method which is worthy of attention. In such therapy, local administration should not damage the nasal mucous membranes. In the present study, we conducted an investigation by the tissue culture test method of the functional and morphological effects of new nasal calcitonin preparation, which is being developed as a nasal spray agent for osteoporosis, on the nasal ciliary epithelium. The nasal septal mucous membranes of C3H-strain mice were used, and 5 types of nasal calcitonin preparations with a microcrystalline cellulose base and additives added were used. The various drugs were added to nasal mucous membrane slices in RPMI-1640 culture medium; ciliary activity before addition and 0.5, 2, and 4 hr after was electrophotometrically measured; and morphological observation was then carried out by SEM. In the various additive groups, virtually no effect on ciliary activity was observed, and the same results were obtained when 3 and 9 times the estimated clinical spray dosage was added. Moreover, in morphological observation by SEM, in the various additive groups, no morphological changes in samples of nasal ciliary specimens were observed after 4 hr of culturing at the maximum administered dosage (9 times the estimated clinical spray dosage). Based on these findings, it was concluded that the series of calcitonin preparations with various additives had no hazardous effect on the nasal ciliary epithelium.

Effects of desoxycorticosterone acetate (DOCA) plus saline drinking on gentamicin-mediated nephropathy in rats

Studies were performed to examine the effect of desoxycorticosterone acetate (DOCA) treatment plus isotonic saline drinking on gentamicin (GM)-mediated nephropathy in rats. GM, 40 mg/kg/day, was subcutaneously injected for 13 days following a 5-week treatment with water drinking or DOCA (10 mg/kg/week) plus saline drinking. Twenty-four hours after the last injection of GM, renal blood flow (RBF) and Cin decreased to approximately 69% and 52% of the control values in water-drinking GM-treated rats, respectively, but was well maintained in DOCA plus saline-drinking GM-treated animals. There was no significant difference in morphologic tubular injury or the renal cortical GM content between GM-treated groups. Saline drinking alone (1% saline, 5 weeks) lessened neither GM-induced reduction in GFR nor tubular damage. Body weight loss occurred following GM injection in the water-drinking group but not in the DOCA plus saline-drinking and saline-drinking-alone groups. DOCA plus saline drinking significantly suppressed the plasma renin activity (PRA) but saline drinking alone did not. A significant inverse correlation was found between PRA and Cin in water-drinking GM-treated and untreated rats. The data suggest that the beneficial effect of DOCA plus saline drinking is associated with renin-angiotensin suppression rather than with the renal GM content or well-maintained hydration.

Factors affecting severity of renal injury and recovery of function in acute renal failure

Severity of renal injury and recovery of function in acute renal failure (ARF) are strongly related not only to the magnitude and nature of ARF insult but also to numerous factors in the host which govern renal susceptibility to the insult and repair of renal lesion. Prior ARF affords resistance to a rechallenge with the same or different ARF insult. The mechanisms for this acquired resistance to ARF have not been well established, but suggested mechanisms include (a) increased resistance of regenerated tubular epithelial cells to a rechallenge, (b) glomerular refractoriness to vasoactive substances, (c) failure of damaged kidney to concentrate the toxic substance, (d) enhanced antioxidant enzyme activity in glomeruli, and (e) increased Na(+)-K(+)-ATPase activity in regenerated tubular epithelial cells. Controversy still exists regarding roles of these factors in the resistance to renal failure. Functional and morphologic recovery of postischemic kidney is enhanced by antecedent unilateral nephrectomy but delayed in the presence of the contralateral kidney. The mechanisms for the effect of uninephrectomy remain unsettled. Recent studies suggest contributions of changes in preglomerular vascular resistance; alterations in the environment which follow ischemia to all functioning excretory renal tissues; and altered production and release of vasoactive substances such as angiotensin, endothelin, thromboxane, and atrial natriuretic peptide.

[Reconstruction with peroneal free flap after ablation of head and neck cancer]

One-stage reconstruction of head and neck defects following radical surgery was performed for two patients with the peroneal flaps which had the peroneal artery, vein and their branches as a pedicle. These flaps were viable without any post-operative complications. The advantages of these flaps are described as follows. (1) The subcutaneous fat is thin, and thus the flap is flexible and not bulky. (2) The diameters of the peroneal artery and vein are relatively large and the pedicle is long. (3) A pretty large size of the flap can be utilized. (4) A relatively long bone can be obtained together with skin at the same time, and the angle of the fibula can be easily changed. (5) Bleeding is little when the flap is taken out. (6) The resection of the tumor and the harvest of the flap can be done at the same time, due to different surgical areas. (7) The skin graft to the donor defect is not necessary, and the defect can be closed at one-stage. (8) The donor site does not stand out. Thus, this method is cosmetically excellent. This procedure has many advantages. Reconstruction with the peroneal flap offers a safe, reliable, and versatile method.

[The group study of diagnostic efficacy of cerebro-vascular disease by I-123 IMP SPECT images obtained with ring type SPECT scanner--the ROC analysis on the diagnosis of perfusion defect and redistribution]

We performed two image reading experiments in order to investigate the diagnostic capability of I-123 IMP SPECT obtained by the ring type SPECT scanner in cerebro-vascular disease. Fourteen physicians diagnosed SPECT images of 55 cases with reference to clinical neurological informations, first without brain XCT images and second with XCT images. Each physician detected perfusion defects and redistributions of I-123 IMP and assigned a confidence level of abnormality for these SPECT findings by means of five rating method. From results obtained by ROC analysis, we concluded as follows: (1) Generally, I-123 IMP SPECT is a stable diagnostic modality in the diagnosis of cerebro-vascular disease and the image reading of XCT had no effects on the diagnosis of SPECT on the whole of physician, (2) However, there were unnegligible differences among individuals in the detectability of findings and the effect of XCT image reading, (3) Detectability of redistribution of I-123 IMP was lower than that of perfusion defect and inter-observer variation in the diagnostic performance for redistribution was larger than that of perfusion defect. The results suggest that it is necessary to standardize diagnostic criteria among physicians for redistribution of I-123 IMP.

[Incidental renal cell carcinoma]

We reviewed the cases of incidental renal cell carcinoma that had been treated at the Kitasato University Hospital between July, 1971 and December, 1989. Forty one of the 170 (24.1%) cases were found without any direct signs of renal cell carcinoma. The patients were between 30 and 78 years old (mean 55.0 years) and consisted of 29 males and 12 females. Fifteen cases were detected at the general health check-up and the remaining 26 during the postoperative follow-up for other malignant tumors or other diseases. Twenty three cases were identified by ultrasonography followed by computed tomography (CT) and excretory pyelography in 4 cases each. Especially, the number of patients incidentally found by ultrasonography had increased in the recent 8 years. Urinalysis did not show any microhematuria in 31 of the 37 cases (83.7%), and no tumor mass could be detected by excretory pyelography in 3 cases. We believe that ultrasonography may be valuable as a screening modality for early detection of renal cell carcinoma and should be used as a screening method at the routine health check-up.

[An in vitro rapid evaluation of drug-induced ototoxicity and of reductive effect of calcium on aminoglycoside ototoxicity using organ culture]

The ototoxicity of aminoglycoside and anticancer platinum drug was analysed using an organ culture system. The effect of calcium antagonism on aminoglycoside ototoxicity was investigated by the same system. The inner ears of mice, 16-day embryos, were cultured for 5 days with or without gentamicin (GM) or kanamycin (KM) or streptomycin (SM), or ribostamycin (RSM), including 1, 10, 100, or 1000 micrograms/ml respectively. The 21st gestational day-inner ear was cultured in vitro during 4 days with or without Cisplatin (CDDP) or platinum analog DWA2114R (DWA), including 0.1, 1, or 10 micrograms/ml, respectively. The 16th gestational day-inner ear was cultured in vitro for 5 days with 10 micrograms/ml KM, adding 5 mM Ca2+ or 10 mM Ca2+ to the culture medium. The damages of crista ampullaris and macula utriculi of cultured inner ear were estimated according to the ototoxicity score based on morphological changes by a light microscopic observation of serial sections of the materials. We defined four grades for the damages according to the following criteria; grade 1: damage of apical surface of the hair cells, grade 2: the existence of debris in the endolymph space, grade 3: disappearance of the hair cells, grade 4: degeneration of the supporting cells. Using this system following results were obtained: 1) the effect of aminoglycoside was dose dependent, 2) the order of ototoxicity was following; GM greater than KM greater than SM greater than RSM, 3) the drug concentration of 1000 micrograms/ml is sufficient to study its ototoxic potential in this system, 4) the effect of both CDDP and DWA was obvious at a concentration of 0.1 microgram/ml, 5) DWA showed almost the same ototoxicity as CDDP at the same concentration, 6) Adding 5 mM Ca2+ or 10 mM Ca2+ to the culture medium, the ototoxic damage induced by 10 micrograms/ml of KM was not noticed. A protective effect of Ca2+ against KM ototoxicity was observed in vitro. This organ culture and ototoxicity score system can serve as a useful and adequate model system for evaluating the ototoxicity.

[Primary carcinoid tumor of the testis with metastasis to the upper vertebrae. Report of a case]

A case of primary carcinoid tumor of the right testis with metastases to the cervical and thoracic vertebrae and epidural is reported. A 53-year-old man was first recognized as being with dysthesia of the left arm and shoulder in April 1986. In June, 1987, he was admitted to the Neurology service, complaining of sudden occurrence of abasia. Myelography and computerized tomography demonstrated an epidural mass and several high density areas in the vertebral bodies of Th1 and Th2. The patient underwent laminectomy from C7 to Th2. At operation, the neurosurgeons noticed a tumor mass in the right scrotum and requested our consultation. Thus right high orchiectomy was performed. Pathological examination including Grimerius' and Fontana-Masson's stain revealed carcinoid tumor of the right testis associated with metastases to the spinal column. Postoperatively, tumor maker studies revealed elevation of blood 5-hydroxytryptophan and marked increase of urinary 5-hydroxy-indoleacetic acid excretion. They showed remarkable decreases after a course of PVB chemotherapy. The patient has been under our observation as an out-patient for the past 27 months with metastases. This is the first case of primary carcinoid tumor of the testis with metastases so far reported in the domestic literature.

[A case of retrovesical embryonal cell carcinoma]

We report a case of an extragonadal germ cell tumor in the retrovesical region. The patient complained of a perineal and micturition pain. Urethrography, CT and MRI showed a retrovesical tumor protruding into the bladder. Alfa-fetoprotein was increased to 12,170 ng/ml. Bilateral testes did not contain any palpable mass by careful palpation. No tumor was detected by ultrasonography, either. Clinically, he was diagnosed as having a retrovesical extragonadal germ cell tumor associated with paraaortic lymph-nodes and bilateral pulmonary metastases. Although he was treated by combination chemotherapy (PVB and VAB-6 regimen) and irradiation, he died of carcinomatosis about 6 months after the admission. There was no evidence of tumor in bilateral testes on autopsy. This case was a second case of extragonadal germ cell tumor originating from the retrovesical lesion in the literature.

Crystal-storing histiocytosis and crystalline tissue deposition in multiple myeloma

Systemic distribution of crystal-storing histiocytes, increasing in number, and widespread crystalline tissue deposition were found in a 75-year-old man with a 5-year history of IgG-kappa-type multiple myeloma associated with corneal opacity and chronic renal failure. Characteristic crystalline inclusions were present not only in myeloma cells but also in cornea, epithelial cells of glomeruli, tubuli, Bowman's capsules, and choroid plexus. Histiocytes had particularly infiltrated the renal interstitium. These inclusions were positive by immunofluorescence for kappa light and gamma heavy chains. By electron microscopy, the inclusions were filled with fine crystalline hexagonal columns, each possessing a core structure. Of various factors generally considered responsible for renal failure in multiple myeloma, marked infiltration of histiocytes and the nephrotoxic effects of light chain appeared most relevant in the present case.