Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Topical and intermittent application of parathyroid hormone recovers alveolar bone loss in rat experimental periodontitis

BACKGROUND AND OBJECTIVE

Periodontitis is characterized by periodontal tissue inflammation and alveolar bone loss. The intermittent administration of parathyroid hormone (PTH), a major regulator of bone remodeling, has been demonstrated to stimulate osteoblastic activity. Although the systemic administration of PTH has been reported to protect against periodontitis-associated bone loss, the effect of the topical administration of PTH is unclear. In this study, the effect of intermittent administration of PTH on osteoblastic differentiation was examined in cultured calvaria cells and then the effect of topical and intermittent administration of PTH was determined by measuring the recovery of alveolar bone loss after inducing experimental periodontitis in rats.

MATERIAL AND METHODS

Alkaline phosphatase activity and bone nodule formation were measured in fetal rat calvaria cells. Experimental periodontitis was induced by placing nylon ligature around rat maxillary molars for 20 d. After ligature removal (day 0), PTH was topically injected into buccal gingiva three times a week for 10 wk. Micro-computed tomography analysis and histological examination were performed on days 35 and 70.

RESULTS

Intermittent exposure of PTH in calvaria cells increased alkaline phosphatase activity and bone nodule formation by 1.4- and 2.4-fold, respectively. Ligature procedures induced marked alveolar bone loss around the molars on day 0 and greater bone recovery was observed in the PTH-treated rats on day 70. An increase in osteoid formation on the surface of alveolar bone was detected in the PTH-treated rats.

CONCLUSION

Intermittent treatment with PTH stimulated osteoblastic differentiation in fetal rat calvaria cell cultures, and topical and intermittent administration of PTH recovered alveolar bone loss in rat experimental periodontitis.

Milk basic protein increases alveolar bone formation in rat experimental periodontitis

BACKGROUND AND OBJECTIVE

It is conceivable that the active components extracted from milk whey protein (i.e. milk basic protein, MBP) stimulate bone formation and suppress bone resorption. Periodontitis is characterized by excessive alveolar bone resorption. We examined whether milk basic protein could recover alveolar bone loss in rat experimental periodontitis.

MATERIAL AND METHODS

A nylon ligature was placed around the cervix of molars in 8-wk-old male Fischer rats for 20 d. Then, the ligature was removed and a powder diet containing 0.2 or 1.0% milk basic protein was provided daily for another 45-90 d. On days 45 and 90, the maxillae were extracted and analyzed using microcomputerized tomography (micro-CT), followed by histological analysis.

RESULTS

Micro-CT images showed that alveolar bone resorption was severely induced around the molar by the 20-d ligature procedure. Treatment with high-dose milk basic protein (1.0%) clearly recovered ligature-induced alveolar bone resorption on days 45 and 90, whereas low-dose milk basic protein (0.2%) did not show such a clear effect. Histological examination clarified that the osteoid thickness of alveolar bone was dose dependently increased by milk basic protein treatment for 90 d.

CONCLUSION

These findings suggest that a systemic administration of milk basic protein may be effective for the recovery of alveolar bone loss in periodontitis.

Propofol attenuates capacitative calcium entry in pulmonary artery smooth muscle cells

BACKGROUND

Depletion of intracellular Ca2+ stores results in capacitative Ca2+ entry (CCE) in pulmonary artery smooth muscle cells (PASMCs). The authors aimed to investigate the effects of propofol on CCE and to assess the extent to which protein kinase C (PKC) and tyrosine kinases mediate propofol-induced changes in CCE.

METHODS

Pulmonary artery smooth muscle cells were cultured from explants of canine intrapulmonary artery. Fura 2-loaded PASMCs were placed in a dish (37 degrees C) on an inverted fluorescence microscope. Intracellular Ca2+ concentration was measured using fura 2 in PASMCs using a dual-wavelength spectrofluorometer. Thapsigargin (1 microM), a sarcoplasmic reticulum Ca2+-adenosine triphosphatase inhibitor, was used to deplete intracellular Ca2+ stores after removing extracellular Ca2+. CCE was activated when extracellular Ca2+ (2.2 mM) was restored.

RESULTS

Thapsigargin caused a transient increase in intracellular Ca2+ concentration (182+/-11%). Restoring extracellular calcium (to induce CCE) resulted in a peak (246+/-12% of baseline) and a sustained (187+/-7% of baseline) increase in intracellular Ca2+ concentration. Propofol (1, 10, 100 microM) attenuated CCE in a dose-dependent manner (peak: 85+/-3, 70+/-4, 62+/-4%; sustained: 94+/-5, 80+/-5, 72+/-5% of control respectively). Tyrosine kinase inhibition (tyrphostin 23) attenuated CCE (peak: 67+/-4%; sustained: 74+/-5% of control), but the propofol-induced decrease in CCE was still apparent after tyrosine kinases inhibition. PKC activation (phorbol 12-myristate 13-acetate) attenuated CCE (peak: 48+/-1%; sustained: 53+/-3% of control), whereas PKC inhibition (bisindolylmaleimide) potentiated CCE (peak: 132+/-11%; sustained: 120+/-4% of control). Moreover, PKC inhibition abolished the propofol-induced attenuation of CCE.

CONCLUSION

Tyrosine kinases activate and PKC inhibits CCE in PASMCs. Propofol attenuates CCE primarily via a PKC-dependent pathway. CCE should be considered a possible cellular target for anesthetic agents that alter vascular smooth muscle tone.

Propofol attenuates acetylcholine-induced pulmonary vasorelaxation: role of nitric oxide and endothelium-derived hyperpolarizing factors

BACKGROUND

The mechanism by which propofol selectively attenuates the pulmonary vasodilator response to acetylcholine is unknown. The goals of this study were to identify the contributions of endogenous endothelial mediators (nitric oxide [NO], prostacyclin, and endothelium-derived hyperpolarizing factors [EDHFs]) to acetylcholine-induced pulmonary vasorelaxation, and to delineate the extent to which propofol attenuates responses to these endothelium-derived relaxing factors.

METHODS

Canine pulmonary arterial rings were suspended for isometric tension recording. The effects of propofol on the vasorelaxation responses to acetylcholine, bradykinin, and the guanylyl cyclase activator, SIN-1, were assessed in phenylephrine-precontracted rings. The contributions of NO, prostacyclin, and EDHFs to acetylcholine-induced vasorelaxation were assessed in control and propofol-treated rings by pretreating the rings with a NO synthase inhibitor (l-NAME), a cyclooxygenase inhibitor (indomethacin), and a cytochrome P450 inhibitor (clotrimazole or SKF 525A) alone and in combination.

RESULTS

Propofol caused a dose-dependent rightward shift in the acetylcholine dose-response relation, whereas it had no effect on the pulmonary vasorelaxant responses to bradykinin or SIN-1. Cyclooxygenase inhibition only attenuated acetylcholine-induced relaxation at high concentrations of the agonist. NO synthase inhibition and cytochrome P450 inhibition each attenuated the response to acetylcholine, and combined inhibition abolished the response. Propofol further attenuated acetylcholine-induced relaxation after NO synthase inhibition and after cytochrome P450 inhibition.

CONCLUSION

These results suggest that acetylcholine-induced pulmonary vasorelaxation is mediated by two components: NO and a cytochrome P450 metabolite likely to be an EDHF. Propofol selectively attenuates acetylcholine-induced relaxation by inhibiting both of these endothelium-derived mediators.

K(+) channel inhibition, calcium signaling, and vasomotor tone in canine pulmonary artery smooth muscle

We investigated the role of K(+) channels in the regulation of baseline intracellular free Ca(2+) concentration ([Ca(2+)](i)), alpha-adrenoreceptor-mediated Ca(2+) signaling, and capacitative Ca(2+) entry in pulmonary artery smooth muscle cells (PASMCs). Inhibition of voltage-gated K(+) channels with 4-aminopyridine (4-AP) increased the membrane potential and the resting [Ca(2+)](i) but attenuated the amplitude and frequency of the [Ca(2+)](i) oscillations induced by the alpha-agonist phenylephrine (PE). Inhibition of Ca(2+)-activated K(+) channels (with charybdotoxin) and inhibition (with glibenclamide) or activation of ATP-sensitive K(+) channels (with lemakalim) had no effect on resting [Ca(2+)](i) or PE-induced [Ca(2+)](i) oscillations. Thapsigargin was used to deplete sarcoplasmic reticulum Ca(2+) stores in the absence of extracellular Ca(2+). Under these conditions, 4-AP attenuated the peak and sustained components of capacitative Ca(2+) entry, which was observed when extracellular Ca(2+) was restored. Capacitative Ca(2+) entry was unaffected by charybdotoxin, glibenclamide, or lemakalim. In isolated pulmonary arterial rings, 4-AP increased resting tension and caused a leftward shift in the KCl dose-response curve. In contrast, 4-AP decreased PE-induced contraction, causing a rightward shift in the PE dose-response curve. These results indicate that voltage-gated K(+) channel inhibition increases resting [Ca(2+)](i) and tone in PASMCs but attenuates the response to PE, likely via inhibition of capacitative Ca(2+) entry.

A case of Meniere's disease with vertical nystagmus after administration of glycerol

A 62-year-old woman who complained of repetitive vertigo with a left fluctuating hearing loss was admitted to our hospital three times. A glycerol test was done on the third admission. Two hours after the administration of glycerol, the patient complained of rotatory vertigo with a downbeat vertical nystagmus. This nystagmus then changed its direction upward. Her left hearing loss was improved during the glycerol test. On the day after the glycerol test, a caloric test was done. The caloric response of the right ear was remarkably improved. Although she had not felt a hearing loss in the right ear, an overwritten audiogram showed a fluctuation of hearing in the right ear. The bilateral caloric responses fluctuated. From these findings, it appears that the function of the inner ear on both sides fluctuating. We speculate that the administration of glycerol elicited an asymmetry in the function of the inner ear on both sides and ocuured vertigo with vertical nystagmus because of the irritation of both ears.

Capacitative Ca(2+) entry and tyrosine kinase activation in canine pulmonary arterial smooth muscle cells

We investigated the role of capacitative Ca(2+) entry and tyrosine kinase activation in mediating phenylephrine (PE)-induced oscillations in intracellular free Ca(2+) concentration ([Ca(2+)](i)) in canine pulmonary arterial smooth muscle cells (PASMCs). [Ca(2+)](i) was measured as the 340- to 380-nm ratio in individual fura 2-loaded PASMCs. Resting [Ca(2+)](i) was 96 +/- 4 nmol/l. PE (10 micromol/l) stimulated oscillations in [Ca(2+)](i), with a peak amplitude of 437 +/- 22 nmol/l and a frequency of 1.01 +/- 0.12/min. Thapsigargin (1 micromol/l) was used to deplete sarcoplasmic reticulum (SR) Ca(2+) after extracellular Ca(2+) was removed. Under these conditions, a nifedipine-insensitive, sustained increase in [Ca(2+)](i) (140 +/- 7% of control value) was observed when the extracellular Ca(2+) concentration was restored; i.e., capacitative Ca(2+) entry was demonstrated. Capacitative Ca(2+) entry also refilled SR Ca(2+) stores. Capacitative Ca(2+) entry was attenuated (32 +/- 3% of control value) by 50 micromol/l of SKF-96365 (a nonselective Ca(2+)-channel inhibitor). Tyrosine kinase inhibition with tyrphostin 23 (100 micromol/l) and genistein (100 micromol/l) also inhibited capacitative Ca(2+) entry to 63 +/- 12 and 85 +/- 4% of control values, respectively. SKF-96365 (30 micromol/l) attenuated both the amplitude (15 +/- 7% of control value) and frequency (50 +/- 21% of control value) of PE-induced Ca(2+) oscillations. SKF-96365 (50 micromol/l) abolished the oscillations. Tyrphostin 23 (100 micromol/l) also inhibited the amplitude (17 +/- 7% of control value) and frequency (45 +/- 9% of control value) of the oscillations. Genistein (30 micromol/l) had similar effects. Both SKF-96365 and tyrphostin 23 attenuated PE-induced contraction in isolated pulmonary arterial rings. These results demonstrate that capacitative Ca(2+) entry is present and capable of refilling SR Ca(2+) stores in canine PASMCs and may be involved in regulating PE-induced Ca(2+) oscillations. A tyrosine kinase is involved in the signal transduction pathway for alpha(1)-adrenoreceptor activation in PASMCs.

Toward the best treatment for uncomplicated patients with type B acute aortic dissection: A consideration for sound surgical indication

BACKGROUND

In the treatment of type B acute aortic dissection without complications, better results are obtained if surgery is performed before enlargement of the aorta in patients who are predicted to show aortic enlargement and if drug-based treatment is continued for patients who are predicted to show no enlargement. The purpose of this study was to predict the acute-phase factors that may affect chronic-phase aortic enlargement by studying chronic-phase enlargement of dissections in patients without complications during the acute phase.

METHODS AND RESULTS

In 101 patients with type B acute dissection who had no complications, univariate and multivariate factor analyses were performed to determine the predictors for chronic-phase enlargement (>/=60 mm) of the dissected aorta. The independent predominant predictors for aortic enlargement in the chronic phase were a maximum aortic diameter of >/=40 mm and a patent false lumen during the acute phase. The values of actuarial freedom from aortic enlargement for the patients with a maximum aortic diameter of 40 mm and a patent false lumen at 1, 5, and 10 years were 43%, 33%, and 22%, respectively, whereas in patients with a maximum aortic diameter of <40 mm and a closed false lumen, the values were 97%, 94%, and 84%, respectively.

CONCLUSIONS

These results suggest that patients with type B acute aortic dissection who show a maximum aortic diameter of >/=40 mm and a patent false lumen should undergo surgery earlier during the chronic phase before enlargement of aorta, whereas patients with a maximum aortic diameter of <40 mm and a closed false lumen should continue to receive hypotensive therapy.

Effect of retinoic acid on osteopontin expression in rat clonal dental pulp cells

We studied the effect of retinoic acid on osteopontin synthesis and the mRNA expression in rat clonal dental pulp cells, RPC-C2A. An immunoprecipitation assay clarified that retinoic acid caused an increase in phosphorylated osteopontin synthesis that was dose-dependent, and marked increases were observed at retinoic acid concentrations of 10(-6) to 10(-5) M (1.7-fold). A Northern blotting analysis revealed a similar pattern of increase in osteopontin mRNA expression of up to 6.2-fold of control levels. Because osteopontin has an important role in the mineralization process, these results suggest that retinoic acid regulates mineralization, which takes place in the pulp cavity, including reparative dentin formation.

Endothelial defect mediates attenuated vasorelaxant response to isoproterenol after lung transplantation

We have previously demonstrated that pulmonary vasodilation in response to isoproterenol is attenuated in conscious dogs after left lung autotransplantation (LLA). Our present goal was to identify the cellular mechanism responsible for this dysfunction. Size- and position-matched pulmonary arterial rings were isolated from the right (control) and left (LLA) lungs of 23 dogs 1-14 mo post-LLA. The rings were suspended for isometric tension recording and precontracted, and the vasorelaxant responses to activators of the beta-adrenoreceptor signaling pathway were examined. With the endothelium intact the maximal pulmonary vasorelaxant response to isoproterenol was reduced (P < 0.02) to 57 +/- 9% in LLA rings, compared with 87 +/- 3% in control rings. Responses to the Gs protein activator cholera toxin were also attenuated post-LLA, with the concentration-effect curve shifted to the right (P < 0.01) and no change in the maximal response. In contrast, the vasorelaxant responses to forskolin (adenylyl cyclase activator) or dibutyryl cAMP were similar in endothelium-intact control and LLA rings. In endothelium-denuded rings the maximal vasorelaxant responses to isoproterenol were reduced (P < 0.01) to approximately 25% in both control and LLA rings. In denuded rings cholera toxin, forskolin, and dibutyryl cAMP caused 100% vasorelaxation, and the IC50 values for these agonists were similar in control and LLA rings. Isoproterenol increased (P < 0.05) tissue cAMP to the same extent in control and LLA rings with or without endothelium. In contrast, isoproterenol increased (P < 0.05) tissue cGMP only in endothelium-intact rings, and this effect was reduced (P < 0.05) approximately 50% in LLA rings compared with control. Oxypurinol (endothelial xanthine oxidase inhibitor) restored the pulmonary vasorelaxant response to isoproterenol in endothelium-intact LLA rings. Our results provide the first evidence that activation of the beta-adrenoreceptor signaling pathway in endothelium-intact pulmonary arterial rings results in an increase in cGMP. Moreover, the attenuation in beta-adrenoreceptor-mediated pulmonary vasorelaxation post-LLA is due to inactivation of nitric oxide by endothelium-derived superoxide anion.

[Early hemodynamic effects of olprinone hydrochloride after coronary artery bypass grafting]

Our purpose was to evaluate the hemodynamic effects of olprinone hydrochloride early after coronary artery bypass grafting (CABG). Fifteen patients undergoing CABG were administered a constant infusion of 0.1 microgram/kg/min of olprinone and continued for 4 hours. No bolus infusion of olprinone was administered before continuous infusion. Systolic systemic arterial pressure, systolic pulmonary arterial pressure, systemic vascular resistance and pulmonary vascular resistance were significantly decreased. There were no significant changes in heart rate, mean central venous pressure, mean left atrial pressure and left ventricular stroke work index. Cardiac index was significantly increased, but a correlation between cardiac index and mixed venous blood oxygen saturation was not found. Double product was significantly decreased, which described above suggest that olprinone achieved improvement of left cardiac function without more myocardial oxygen consumption. Severe transient hypotension (systolic arterial pressure < 80 mmHg) after infusion of olprinone was observed in three patients. Olprinone administered soon after CABG surgery had beneficial effects in terms of improvement of hemodynamic status without more oxygen consumption and reduction of pulmonary vascular resistance. However transient hypotension was a serious clinical problem in patients after open heart surgery, especially in CABG patients who need suitable systolic arterial pressure to keep enough blood perfusion of arterial bypass grafts.

Isolated tricuspid regurgitation caused by a dilated tricuspid annulus

In most of the previously reported cases of isolated tricuspid regurgitation, both tricuspid leaflets and subvalvar tissue have been absent, hypoplastic, or fused. For this reason, tricuspid valvoplasty was difficult and valve replacement was adopted in many cases. In the present case of a 52-year-old man, however, the tricuspid valve showed no abnormalities other than a severely dilated tricuspid annulus. Ring annuloplasty was performed, and this resulted in a subsequent satisfactory course without anticoagulant therapy.

[An emergency aortic valve replacement for cardiogenic shock patient with severe aortic stenosis and regurgitation using percutaneous cardiopulmonary support]

The percutaneous cardiopulmonary support system (PCPS) was used in a 64-year-old woman with cardiogenic shock due to sustained ventricular fibrillation (Vf) caused by severe aortic stenosis and regurgitation. The Vf attack was resistant to cardioversion and adrenaline for lack of left ventricular support by PCPS. She was transported to the operation theater with PCPS in situ and emergency aortic valve replacement was performed. Although preoperative cardiac resuscitation time was long (35 minutes), she was discharged from the hospital on foot without any neurological complications on 84th postoperative day. Because PCPS does not decrease left ventricular systolic stress in poorly contracting dilated heart, early surgical treatment is needed in patients with severely damaged heart.

Halothane attenuates endothelium-dependent pulmonary vasorelaxant response to lemakalim, an adenosine triphosphate (ATP)-sensitive potassium channel agonist

BACKGROUND

Lemakalim, an adenosine triphosphate (ATP)-sensitive potassium (K+(ATP)) channel agonist, causes profound pulmonary vasodilation in conscious dogs, which is attenuated during halothane anesthesia. The goal of the present study was to investigate the mechanism responsible for this attenuating effect of halothane.

METHODS

Isolated canine pulmonary arterial rings were suspended for isometric tension recording in 25 ml organ baths. Rings with and without endothelium were contracted to 50% of their maximal response to phenylephrine, followed by the cumulative administration of lemakalim with or without exposure to halothane (0.5-1.5 minimum alveolar concentration [MAC] in dogs). Lemakalim dose-response curves were also generated in rings pretreated with the nitric oxide synthase inhibitor, Nw-nitro-L-arginine methyl ester (L-NAME); the cyclooxygenase inhibitor, indomethacin; or the K+(ATP) channel antagonist, glybenclamide.

RESULTS

Compared with intact rings, the pulmonary vasorelaxant response to lemakalim was attenuated (P < 0.05) in endothelium-denuded rings. Halothane at 0.5 MAC had no effect on the vasorelaxant response to lemakalim. Halothane at 1 MAC attenuated (P < 0.05) the vasorelaxant response to lemakalim in intact rings, but not in endothelium-denuded rings. Halothane at 1.5 MAC attenuated (P < 0.05) the vasorelaxant response to lemakalim in both intact and endothelium-denuded rings. In endothelium-intact rings, indomethacin attenuated (P < 0.05) the vasorelaxant response to lemakalim, whereas L-NAME had no effect. Further, indomethacin, but not L-NAME, abolished the endothelium-dependent, halothane-induced attenuation of the lemakalim vasorelaxation response. Glybenclamide markedly attenuated (P < 0.05) lemakalim vasorelaxation at lemakalim doses less than 10(-6) M.

CONCLUSIONS

Lemakalim-induced pulmonary vasorelaxation involves an endothelium-dependent and vascular smooth muscle component. Further, halothane attenuates the endothelium-dependent pulmonary vasorelaxant response to lemakalim via an inhibitory effect on vasodilator metabolites of the cyclooxygenase pathway.

[Anomalous origin of the right pulmonary artery from the ascending aorta--a report of three operative cases]

Three patients with anomalous origin of the right pulmonary artery from the ascending aorta were reported. Case 1: A 33-day-old premature infant (body weight 984 g) with the right pulmonary artery arising from the ascending aorta (RAPAA) and the patent ductus arteriosus (PDA). Banding of the right pulmonary artery (RPAB) and ligation of PDA were performed as a palliative operation. AT 3-month-old (BW 2,200 g), division and direct anastomosis of the anomalous vessel to the main pulmonary trunk was done as a radical operation under hypothermic cardiopulmonary bypass (CPB). Case 2: A 16-day-old infant with RAPAA and PDA. Division and direct anastomosis of the anomalous vessel to the main pulmonary trunk and ligation of PDA were performed as a radical operation under hypothermic CPB. Case 3: A 74-day-old infant with RAPAA and Ebstein's anomaly. RPAB was performed as a first palliative operation and left Blalock-Taussig shunt as a second operation. Glenn operation is scheduled as third operation prior to Fontan type operation.

[Successful surgical treatment of double-outlet right ventricle with intramural coronary artery, using the modified Aubert procedure--a case report]

The modified Aubert procedure and left ventricular outflow tract reconstruction were performed successfully for double-outleft right ventricle with subpulmonary ventricular septal defect, which showed an unusual Shaher type 5a coronary artery pattern. This pattern was characterized by two coronary ostia arising from the right septal sinus and intramural segment in a left trunk of the coronary artery. In this case, the neo-pulmonary artery was reconstructed without prosthetic materials. However, postoperative echocardiography showed no evident supravalvar pulmonary stenosis. The modified Aubert procedure without prosthetic marerids can be used for double-outlet right ventricle and transposition of the great arteries which show dilated prelimonary artery.

[Intra-operative management during laparotomy for patients under hemodialysis]

We evaluated retrospectively 31 patients under hemodialysis who underwent scheduled laparotomy with a purpose to determine the optimal intra-operative water balance. The patients fell into two different periods according to the difference of the principle of anesthesia. Anesthesia method employed for the former eleven patients (1987.6-1990.12) was NLA with pancuronium for muscle relaxation and they were ventilated mechanically in ICU. More recent twenty patients (1991-1995) had epidural block plus nitrous oxide-oxygen-isoflurane with vecuronium and they were extubated early. These latter patients, compared with the preoperative values, did not show any significant changes in mean arterial pressure or systemic vascular resistance after the operation. Intra-operative water balance showed a positive correlation with PADP (r = 0.57) and a negative correlation with SVR (r = 0.36) at the end of operation. The adequate fluid infusion is necessary to maintain PADP, and the water balance of +3-5 ml x kg-1 x hr-1 is recommended during laparotomy for the patients under hemodialysis.

[Continuous monitoring of blood volume change by measuring hematocrit during cardiopulmonary bypass]

The usefulness of the continuous monitoring system of blood volume change (BV%), by using measured hematocrit, has been evaluated during cardiopulmonary bypass (CPB). Twelve patients for CABG were studied. The optical sensor was incorporated in the venous outlet site of CPB to measure Hct and hemoglobin oxygen saturation. The infusion of the cardioplegia caused a sharp deviation in BV%, and the use of extracorporeal ultrafiltration helped to reduce BV% rapidly. At the end of CPB, BV% was -1.4 +/- 7.7% and showed a good correlation with total water balance during CPB (r = 0.75, P < 0.01). However, the discrepancy between BV% and the positive water balance was observed in a case with LOS. This suggests fluid maldistribution from intra- to extra-vascular space. Continuous BV% monitoring during CPB is useful as an index of water balance and for assessing an optimum blood volume.

Effect of periodontal treatments on serum IgG antibody titers against periodontopathic bacteria

Serum IgG antibody titers to 7 periodontopathic bacteria in periodontitis patients were measured at the 1st visit and after various periodontal treatments with clinically successful improvement, in order to evaluate what kind of factors are associated with changes of serum antibody titers. 20 patients (10 male and 10 female from 23 to 61 years old) with adult, rapidly progressive periodontitis were enrolled in this study. All patients received initial preparation and most of them also underwent surgical procedure. After the treatments, the mean probing pocket depths decreased from 3.72 mm to 1.56 mm. Serum samples were collected from patients at the initial and final examinations. Serum IgG antibody titers against sonicated antigens of Porphyromonas gingivalis FDC 381, Prevotella intermedia ATCC 25611, Prevotella loescheii ATCC 15930, Fusobacterium nucleatum subspecies nucleatum ATCC 25586, Actinobacillus actinomycetemcomitans FDC Y4, Eikenella corrodens FDC 1073 and Capnocytophaga ochracea # M 12 were determined by enzyme-linked immunosorbent assay. The mean antibody titers to P. gingivalis and P. intermedia decreased significantly after the treatment as compared to their pretreatment levels. The antibody titer to P. gingivalis, especially, decreased in all of the patients examined. A significant relationship was found between the decreased antibody titer to P. gingivalis and the number of teeth which received periodontal surgery, as well as treatment length, and the relationship between the decreased antibody titer to P. intermedia and the number of extracted teeth was also significant. These results suggest that the changes of serum IgG titers against P. gingivalis and P. intermedia are related to the suppression of such pathogens in subgingival plague.

[Anoxic spell in an adult case for intracardiac repair]

We report a 51-year-old male patient with tetralogy of Fallot who had an anoxic spell during pre-bypass period before intracardiac repair. Immediately after starting sternotomy, SpO2 decreased suddenly from 83% to 30% with PaO2 of 26 mmHg. Heart rate showed an increase to 120-140 bpm with little change in blood pressure. We considered that the causes of this spell were 1) light level of anesthesia, 2) hypoxemia and 3) lack of intravascular blood volume. This case warns us that we should take care to avoid an anoxic spell in an adult case for intracardiac repair.

[Atrial pacing with the A-V paceport pulmonary artery catheter]

Atrial pacing is often necessary during cardiac surgery. A total of 20 patients undergoing cardiac surgery were atrially paced with either a multipurpose pulmonary artery catheter (PAC) or an A-V paceport PAC (n = 10 each). Atrial pacing was successful in all the patients before cardiopulmonary bypass. The output threshold was 4.2 +/- 0.7 mA for a multipurpose PAC and 3.8 +/- 0.7 mA for A-V paceport PAC. Atrial pacing with both PAC's was readily performed and useful during cardiac surgery.

[Perioperative myocardial infarction due to graft atheroembolism during coronary artery bypass surgery]

We presented a female patient who had complicated perioperative myocardial infarction resulting from intraoperative embolization with atheromatous debris during coronary artery bypass surgery. On separation from cardiopulmonary bypass, ventricular function was poor and she suffered from severe low cardiac output syndrome postoperatively. The intraoperative electrocardiographic monitoring showed conduction abnormalities, elevation of the ST-T segments and new Q waves. Though it is difficult to diagnosis the onset of perioperative myocardial infarction early, adequate treatment is necessary to preserve ischemic myocardium and to reduce the size of myocardial necrosis.

[Perioperative management for type A acute aortic dissection]

Twenty nine cases of type A acute aortic dissection were subjected to a retrospective study concerning perioperative management. Two keys pointed out for the management were as follow; (1) An optimal control of blood pressure is the most important measure to avoid advance of aortic dissection or rupture of dissecting aneurysm. Both pericardiac tamponade and aortic valve insufficiency should be taken care of from their onset, since they are often complicated after aortic dissections and their onset is fatal. (2) Separated brain perfusion and profound hypothermia with total circulatory arrest might involve a high risk of inducing postoperative brain damage and mortality, especially for old patients.

[Post-operative respiratory management of patients with ventricular septal defect with pulmonary hypertension (VSD+PH)]

Post-operative respiratory management was evaluated in patients with VSD+PH. Comparison was made between Group I (6 patients under 6 months) and Group II (10 patients 6 months or above). Oxygenation after surgical operation in Gp I was poor and the patients needed longer period of mechanical ventilation (MV), while Gp II patients required shorter duration of MV. In Gp I, the duration of MV after the cardiac surgery correlated with the length of cardiopulmonary bypass. In conclusion, cardiopulmonary bypass may influence the post-operative pulmonary function and patients who require longer period of MV are younger infants or newborns whose pulmonary function is immature and PH is severe.

[Clinical observation of hemodynamic changes during anaphylactic reaction]

Four cases of anaphylactic shock are reported. In two patients who underwent A-C bypass operation, we evaluated hemodynamic changes systemically when the anaphylactic reaction occurred. At that time it was observed that arterial pressure, central venus pressure, left atrial pressure and systemic vascular resistance decreased and that cardiac index increased. In other two patients it was not possible to evaluate hemodynamic changes during reaction. But one of these two patients developed coronary spasm accompanied with anaphylactic shock and the other patient who had depressed cardiac function and had developed cardiogenic shock, died of cardiac failure after 47 days. It is suggested that hemodynamic changes in anaphylactic reaction varies depending on different general conditions of the patient.

[Rapidly progressive periodontitis combined with plasma cell gingivitis: a case report]

A case of rapidly progressive periodontitis combined with plasma cell gingivitis with marked enlargement of the gingiva was presented. Clinically, in the plasma cell gingivitis, the gingiva appear red, friable and bleed easily; usually it does not induce loss of attachment. Histologically, a dense infiltration of the normal plasma cells in the connective tissue is a common finding. A hypersensitivity reaction to some antigens, often flavorings or spices, is generally recognized. In this case, a rapidly progressive loss of attachment was observed, so rapidly progressive periodontitis was diagnosed. Differential diagnosis of the plasma cell gingivitis could be determined by histological and ultrastructural examination. Allergens, however, could not be identified. Conventional periodontal therapy, including intensive plaque control, could not cure the plasma cell gingivitis completely but recurrence of gingival enlargement and loss of attachment could be well controlled.

[Conversion to 2nd degree from 1st degree atrioventricular (AV) block by the reversal of neuromuscular blockade]

A case of intraoperative conversion to 2nd degree from 1st degree AV block by the reversal of neuromuscular blockade was reported. A 78 year old male, who originally suffered from 1st degree AV block, underwent choledocholithotomy and T-tube drainage for choledocholithiasis. He was administered 4 mg of pancuronium at the time of intubation. The operation lasted for 160 minutes under epidural anesthesia, NLA and nitrous oxide-oxygen. The patient started spontaneous breathing and the recovery was confirmed after the operation which finished without any problem. Neuromuscular blockade was reversed with atropine 0.5 mg and neostigmine 1.0 mg that were administered simultaneously taking 3 minutes. Then he was extubated without any troublesome stimulation. Suddenly, however, he suffered from the worse condition of bradycardia with the 2nd degree AV block. It took about 45 minutes until he recovered to the original 1st degree AV block despite atropine treatment. We believe that this accident was induced by a vasovagal reflex which was triggered by extubation under the effect of neostigmine which acts longer than that of atropine. We should be careful in reversing the effect of the non-depolarizing neuromuscular blockade. A short acting neuromuscular blockade, i.e. vecuronium, is preferable so as to avoid neostigmine reversal, and extubation should be performed when the effect of neuromuscular blockade is confirmed to be exhausted.

[Perioperative hemodynamic changes and management of hemodialysed patients]

Perioperative hemodynamic changes of hemodialysed patients were investigated and the changes of emergency cases (group E, n = 8) were compared with those of scheduled ones (group S, n = 13). By preoperative hemodialysis (HD), the values of blood urea nitrogen, serum creatinine, serum potassium, serum bicarbonate, and hematocrit were adjusted within normal range in group E, with no significant difference from those of group S. On the other hand, concerning the effect of preoperative removal of body water by HD, cardio-thoracic ratio (CTR, 53.6 +/- 3.1%) and pulmonary artery diastolic pressure (PADP, 11.6 +/- 5.0 mmHg) of group E were significantly higher than those of group S (CTR = 46.9 +/- 4.5%, PADP = 7.8 +/- 3.0 mmHg), indicating that the removal of body water by preoperative HD might be less in group E. However, group E patients required more administration of fluid and pressor agents in order to maintain their blood pressure and/or cardiac output during operation. Although with less water removal preoperatively and more fluid intraoperatively, postoperative PADP was significantly reduced (8.3 +/- 3.0 mmHg) in group E, suggesting that the requirement of perioperative water is more in group E. We conclude that the safe perioperative hemodynamic management for emergency surgery of hemodialysed patients requires following points; (1) The excessive removal of body water by preoperative HD should be avoided. (2) Intraoperative fluid infusion should be adequate so that they do not fall into hemodynamic collapse.

[Intraoperative coronary artery spasm--retrospective review of 10 cases]

Ten cases of intraoperative coronary artery spasm were reviewed retrospectively. Four cases were open heart surgeries, one was a surgery for aortic dissecting aneurysm, and the other five were abdominal ones. In the cases of open heart surgery under anesthesia with high dose fentanyl, coronary artery spasm occurred at weaning period from cardio-pulmonary bypass. In the cases of abdominal surgery, all under neuroleptanesthesia with continuous epidural block, coronary artery spasm occurred within one hour after the beginning or before the end of operation. In four of five abdominal surgeries, systolic blood pressure became less than 90 mmHg when coronary artery spasm occurred. Coronary artery spasm brought severe depression of myocardial contractility and life threatening arrhythmias by which weaning from cardiopulmonary bypass became difficult during open heart surgery. There was a case which required several hours before hemodynamics became stable also in abdominal surgery. It was suggested that general anesthesia with continuous epidural block could be a triggering factor of coronary artery spasm when hypotension and insufficient depth of general anesthesia are present simultaneously.

[Anesthesia for patients receiving hemodialysis--a report of 122 cases]

A hundred and twenty-two cases of anesthesia for patients receiving hemo-dialysis were reported and peri-operative management of them was analyzed, retrospectively. For the past ten years, most of the patients were anesthetized with neurolept-anesthesia and post-operative mechanical ventilation was continued until the patients regained stable hemodynamics and complete awareness. The procedures of pre-operative hemo-dialysis and intraoperative management were almost compatible with previous reports. In the cases of emergency operation, pre-operative control was not enough and intra-operative water intake was larger than that of scheduled cases. The detailed analysis of peri-operative management of water which affects the pathophysiological state of each patient will be the problem in future.

[Intraoperative management of emergency coronary artery bypass grafting]

Intraoperative hemodynamics during emergency coronary artery bypass grafting (CABG) for acute evolving myocardial infarction (26 cases) were measured and compared with those during elective CABG (39 cases). Before cardiopulmonary bypass period, it was strongly suggested that the cardiac function of emergency cases was worse than that of elective cases because of the following 5 factors; (1) hypotension, (2) tachycardia, (3) low stroke volume index, (4) pulmonary congestion and (5) metabolic acidosis. Proper usage of inotropic supports, vasodilators, anesthetic agents, and control of acidosis and hypoxemia seemed to be more important in emergency CABG. These prudent intraoperative hemodynamic managements have played important roles in the progress of the operative outcome of emergency CABG.

[Anesthesia in patients undergoing valvular replacement and coronary artery bypass grafting]

We investigated the intraoperative hemodynamic changes in patients who underwent combined valvular replacement (VR) and coronary artery bypass grafting (CABG). The data of 8 patients who under went VR + CABG were compared with those of 50 patients who underwent VR during the same period (1986). Heart rate before the institution of cardiopulmonary bypass (CPB) was not different between these two group, but blood pressure of VR + CABG cases was significantly higher than that of VR cases. This required a higher dosage of fentanyl in VR + CABG cases.

Diversity of IgG antibody responses in the patients with various types of periodontitis

Serum IgG antibodies to seven periodontopathic bacteria were assessed with an enzyme-linked immunosorbent assay (ELISA) in 56 patients with periodontitis. Patients were selected according to the severity of bone loss, and were also classified into three categories by age: juvenile periodontitis (JP), advanced destructive periodontitis (ADP), and adult periodontitis (AP). Bacteroides gingivalis, B. loescheii, Fusobacterium nucleatum, Actinobacillus actinomycetemcomitans, Eikenella corrodens, B. intermedius, and Capnocytophaga ochracea were the bacterial strains of interest. Antigens were prepared by cold ultrasonication of washed bacterial cells. Association of high- or low-IgG antibody titer to the bacteria was evaluated. High or low titers of IgG were based on ELISA measurements in 28 healthy subjects. Values exceeding 100% above or below the normal standard deviation were classified as high or low titers, respectively.

Most patients with three types of periodontitis (76.8%) exhibited high-IgG antibody titers against various periodontopathic bacteria. The sera mostly included high-IgG titer against one or some of B. gingivalis, E. corrodens, F. nucleatum, and/or A. actinomycetemcomitans. B. gingivalis was predominantly associated with three categories of periodontitis (60.7%). However, high-IgG antibody titer against B. gingivalis alone was found in relatively low percentage (21.4%). Most of the cases were associated with one or more of the other periodontopathic bacteria. High-IgG titer against A. actinomycetemcomitans was found in a few patients (12.5%), who showed severe and more rapid bone loss. Nine patients (16.1%) showed lower IgG antibody titer than did the healthy control subjects. Of the nine, three patients who belonged to the JP category showed the chemotaxis dysfunction of their PMNs. Some immunodepression was suspected in these patients.

Antiepileptic effects of globulin-N, an intact human immunoglobulin and its tissue-distribution in kindled cats

The antiepileptic effects of globulin-N, an intact human immunoglobulin was examined, using the amygdaloid kindled animals prepared by the method of Goddard et al. [1969] and Wada et al. [1974 b]. In the non-treated kindled cats, kindled convulsion and after-discharge (AD) were simultaneously created at 24-hour intervals by electrically stimulating generalized seizure-triggering threshold (GST) in amygdala, hippocampus and neocortex. The kindled cats, treated intravenously with 200 mg/kg of globulin-N, the generalized convulsion and AD produced by GST-stimulation disappeared entirely from 30 min to 8 days in 8 out of 10 cases. Furthermore, kindled cats treated with phenobarbital and phenytoin showed inhibition of GC and AD by GST-stimulation for 24-48 hours. Globulin-N was determined to have a plasma half-life of about 10 days in the kindled cats, and was presented immunohistochemically in the visceral organ, brain and spinal cord. The administered globulin-N passed through the BBB easily in the kindled cats with GST stimulation induced epileptic seizures, and was apparently taken up by the nerve and glial cells in the cerebral cortex and other deep structures of the central nervous system. These results may not only yield clues for the elucidation of the antiepileptic mechanisms of globulin-N, but may also support the clinical use of globulin-N in patients with intractable epilepsy [Ariizumi et al. 1982], including epileptic psychosis.

[Antiepileptic effects of globulin-N as an intact human immunoglobulin and its tissue-distribution in kindled cats]

The antiepileptic effects of Globulin-N as an intact human immunoglobulin were examined using the amygdaloid kindled animals, which was prepared by the method of Goddard et al (1969) and Wada et al (1974). In the non-treated kindled cats, generalized convulsion (GC) and after-discharge (AD) in amygdala, hippocampus and neocortex was caused synchronously by electrical stimulation with generalized seizure-triggering threshold (GST) at constant intervals of 24 hours. By contrast, in kindled cats treated intravenously with 200 mg/kg Globulin-N, the GC and AD due to the GST-stimulation disappeared entirely for the period 4 to 8 days after medication in 8 out of 10 cases. Further, kindled cats treated with anticonvulsant, phenobarbital or phenytoin inhibited GC and AD to GST-stimulation until 24-48 hours after medication. On the other hand, the plasma half-life of Globulin-N was determined as about 10 days in the kindled cats, and Globulin-N was distributed immunohistochemically not only in the visceral organ-tissues but also in the tissues of the brain and spinal cord. The administered Globulin-N or 14C-human immunoglobulin pass through the blood-brain barrier easily in kindled cats with GST induced-epileptic seizure, and was apparently taken up by the nerve cells and glial cells in the cerebral cortex and other extensive deep structure involved in the central nervous system. These results seem to support the clinical usefulness of Globulin-N in patients with epilepsy (Ariizumi et al, 1982) and also epileptic psychosis.