Milrinone improves lung compliance in patients receiving mechanical ventilation for cardiogenic pulmonary edema

BACKGROUND

Cardiogenic pulmonary edema is a frequent cause of respiratory failure. We investigated whether milrinone improved lung compliance.

METHODS

We selected 10 patients with respiratory failure due to severe cardiogenic pulmonary edema to receive mechanical ventilation. Patients were administered a bolus injection of milrinone (50 microg kg-1) over 10 min, followed by continuous intravenous infusion (0.5 microg kg-1 min-1). Lung compliance, blood gas values, hemodynamic parameters, and sample plasma milrinone levels were assessed over 120 min after the onset of the continuous infusion of milrinone.

RESULTS

Ten min following milrinone infusion, dynamic compliance (Cdyn) and static compliance (Cst) increased from 37 +/- 12 to 42 +/- 12 ml cmH2O-1 and from 40 +/- 13 to 45 +/- 12 ml cmH2O-1, respectively (P < 0.01). Plasma milrinone levels reached a therapeutic level for vasodilator and positive inotropic effect at 10 min after milrinone infusion. A significant decrease in mean pulmonary artery pressure and pulmonary artery wedge pressure occurred simultaneously with an increase in respiratory system compliance. However, an increase in cardiac index was observed later than these changes. There were significant correlations between the mean pulmonary artery pressure and Cdyn (r = -0.39, P < 0.01) and Cst (r = -0.38, P < 0.01).

CONCLUSIONS

Milrinone-induced improvement in lung compliance along with an improvement of hemodynamics was found together with an inverse relationship between compliance and mean pulmonary artery pressure.

Postoperative radiotherapy for squamous cell carcinoma of the maxillary sinus: analysis of local control and late complications

This retrospective study was conducted to analyze the local control and late complications in patients with squamous cell carcinoma of the maxillary sinus treated with postoperative radiation therapy following surgery. Between 1979 and 1998, 41 patients with squamous cell carcinoma of the maxillary sinus were treated with postoperative irradiation following partial or total maxillectomy. Tumor classification according to the TNM classification of the International Union Against Cancer (1997) was T2 in 6 patients, T3 in 21 patients, and T4 in 14 patients. Fourteen patients had negative surgical margins, 23 had microscopically positive margins, and 4 had grossly positive margins. Sixteen patients received preoperative intraarterial chemotherapy. The total dose to the primary tumor bed was 40-70 Gy (median: 54 Gy) with a fraction size of 2 Gy. The median follow-up time of the surviving patients was 93 months (range: 25-179 months). Local recurrence was observed in 17 patients (41%), and the 5-year actuarial overall survival and local control rates were 48% and 55%, respectively. In the univariate analysis, surgical margin status and total dose each had a statistically significant impact on local recurrence. For the patients with negative surgical margins, 8 of 9 (89%) patients achieved local control with a dose of 50-54 Gy, while 7 of 10 (70%) patients with microscopically positive margins achieved local control with a dose of 60-64 Gy. There were 11 late complications found in 9 patients; bone necrosis in 2, soft tissue necrosis in 2, trisumus: 2, cellulitis in 1, retinopathy in 1, and vision impairment in 3 patients. A total dose of 60 Gy or more was administered in all patients who suffered late complications except for 2 patients with vision impairment. These results indicated that an optimal dose of postoperative irradiation according to the surgical margin status was necessary to achieve local control for squamous cell carcinoma of the maxillary sinus following surgery. For patients with negative surgical margins, a total dose of 50-54 Gy in conventional fractionation was appropriate to achieve local control as well as to reduce late complications. On the other hand, a dose of 60 Gy or more was required for the patients with microscopic positive margins.

Familial nasal NK/T-cell lymphoma and pesticide use

Familial occurrence of nasal NK/T-cell lymphoma (NNKTCL) in pesticide users is presented. The proband (71 years old, male) and son (39 years old) were both diagnosed with NNKTCL within interval of 26 months. Laboratory data showed slight anemia, with no abnormal cells in peripheral blood. They and their wives were farmers and used large amounts of pesticides (fungicides and insecticides) in the hothouse. NNKTCL did not develop in the wives. Proband's father was diagnosed with malignant lymphoma of the neck and died of the disease. Genetic analyses of the peripheral blood leukocytes and tumor tissues did not show p53 and k-ras gene mutations and microsatellite instability. Metaphase cells from peripheral blood leukocytes bore specific marker chromosomes (father, 44XY,-14,-17,-18,-22,+2mar; son, 46XY,-17,+1mar). Environmental exposures to pesticides in conjunction with familial or genetic factors might increase the risk for NNKTCL.

Minor cardiac troponin T release in patients undergoing coronary artery bypass graft surgery on a beating heart

OBJECTIVES

To determine whether and to what extent coronary artery bypass graft (CABG) surgery without extracorporeal circulation is associated with cardiac troponin T (TnT) release.

DESIGN

Prospective study.

SETTING

A single university hospital.

PARTICIPANTS

Twenty-three patients scheduled for minimally invasive CABG surgery. Sixteen patients received one coronary anastomosis, and seven received two.

INTERVENTIONS

TnT and creatine kinase-MB (CK-MB) levels were determined immediately before induction of anesthesia (baseline) and at 0, 12, and 24 hours after surgery. Hemodynamic measurements were made, and 5-lead electrocardiograms with continuous automated ST-segment trends were analyzed.

MEASUREMENTS AND MAIN RESULTS

All patients had a good cardiac outcome. Median cumulative coronary artery occlusion time was 27 minutes (range, 10 to 49 minutes). TnT levels were undetectable in 91.3% of patients at baseline when a detection limit of 0.01 ng/mL was employed. TnT and CK-MB showed significant elevations at 12 and 24 hours versus baseline. Postoperatively, TnT was detectable in 91.3% of patients, and 17.4% suffered minor myocardial damage, as evidenced by an abnormal increase in TnT greater than 0.2 ng/mL, excluding those exhibiting myocardial infarction. ST segment changes developed in seven patients, persisting for 13.0 minutes (range, 9.5 to 15.8 minutes) and disappearing immediately after coronary artery clamp release. There were no significant correlations between cumulative coronary occlusion time and peak TnT or CK-MB levels.

CONCLUSIONS

TnT was detected after surgery in most patients, and significant TnT levels indicative of myocardial injury (>0.2 ng/mL) were detected in only 17% of patients, probably as a result of brief periods of coronary artery occlusion.

Local cardiac wall stabilization influences the reproducibility of regional wall motion during off-pump coronary artery pass surgery

OBJECTIVE

Myocardial ischemia is a risk factor during off-pump coronary artery bypass procedures. The development of new regional wall motion abnormalities assessed by transesophageal echocardiography (TEE) is a very sensitive sign of myocardial ischemia. To facilitate anastomosis, the epicardial area of the anastomosis site is often immobilized by a "stabilizer." This study was designed to investigate whether cardiac wall stabilization with an epicardial stabilizer could affect the interpretation of wall motion during coronary anastomosis without cardiopulmonary bypass.

METHODS

The TEE videotapes of 15 adult patients were investigated. Left ventricular (LV) transgastric short and long axis views were divided according to a modified 16-segment method. LV wall motion was scored using a 5-grade scale by two independent blinded investigators during pre-occlusion, occlusion, and reperfusion of anastomosed coronary arteries. The wall motion scores of a stabilized segment combined with two adjacent segments were compared with those of non-stabilized segments. Interobserver agreement was assessed using the weighted kappa statistic.

RESULTS

A total of 216 segments were analyzed by two investigators. The interobserver kappa coefficient in pre-occlusion and reperfusion periods was 0.87, 0.87 and 0.86, 0.87, respectively, indicating high agreements without stabilizer. During the occlusion period in stabilized and non-stabilized segments, it was 0.59 and 0.76, respectively, showing significantly less reproducibility in the presence of stabilizer.

CONCLUSION

Cardiac wall stabilization affects the reproducibility in the interpretation of regional wall motion during off-pump coronary artery bypass surgery. Caution should be used when monitoring for myocardial ischemia using TEE during coronary artery bypass surgery with epicardial stabilizer.

Hypercholeresis with cholate infusion in dogs with pigment gallstones

We previously reported that dogs with pigment gallstones infused with taurocholate produce higher bile flow than normal dogs due to an increase in bile-acid independent bile flow. Since dogs with pigment gallstones are taurine-depleted and secrete large amounts of unconjugated bile salt, we hypothesized that the observed increased bile flow is secondary to the presence of unconjugated bile salts in the biliary tract, and cholate infusion was compared in normal and pigment gallstone dogs. Cholate increased bile flow significantly (P < 0.05) from 5.2 and 8.2 to 31 and 57 microliter/kg/min in normal and pigment gallstones dogs, respectively. Plots of bile flow versus bile acid output yielded separate linear relationships with a higher slope in gallstone dogs, but mannitol clearance indicated that excess flow originated in the canaliculus. Extended cholate infusion (570 min) severely taurine depleted normal dogs and increased cholate secretion, but bile flow remained significantly lower (P < 0.05) in normal dogs than in gallstone dogs. Choleretic activity of cholate in normal dogs was similar to that of taurocholate, but was nearly twice that of taurocholate in gallstone dogs. Choleretic activity increased in both groups with extended cholate infusion, suggesting adaptive changes in a biliary system bathed with unconjugated bile salts. These results are important since the increased bile flow in dogs with pigment gallstones would increase delivery of all biliary components to the gallbladder contributing to the high concentrations of gallbladder bile calcium previously observed in these dogs. It also has important physiological implications concerning the formation of bile in the proximal biliary tree. The data are most consistent with either direct hepatocyte stimulation to secrete another anion or with cholate/anion exchange at the canalicular, rather than ductal, level.

[High tissue concentration of 5-FU reduced local recurrence after administration of tegafur suppositories]

Forty-two patients with head and neck cancer were treated with tegafur suppository for 7 days preoperatively and clinical value of this treatment was assessed. In a group which indicated tumor tissue concentrations of 5-FU were more than 0.5 micrograms/g, local recurrence decreased in the period of postoperative observation for 42 months. A survival rate of this group was better than others. From these results, preoperative tegafur suppository treatment seemed to have a role in expectation of improvement of local control in head and neck cancer therapy.

Hypertension and hemodilution during cerebral ischemia reduce brain injury and edema

The extent of cerebral injury and edema was determined in isoflurane-anesthetized rats (n = 32) after 180 min of middle cerebral artery occlusion (MCAO) and 120 min of reperfusion. One of the following was employed during the occlusion period only: 1) control, mean arterial pressure [MAP = 131 +/- 7 (SD) mmHg] and hematocrit (43 +/- 2%) were not manipulated; 2) hemodilution, the hematocrit was reduced to 30% with 5% albumin (MAP = 104 +/- 19 mmHg); 3) hemodilution-normotension, hemodilution was established, and MAP was maintained at 131 +/- 9 mmHg with phenylephrine; 4) hemodilution-hypertension, hemodilution was established, and MAP increased to 161 +/- 2 mmHg with phenylephrine. Brain injury was determined with 2,3,5-triphenyltetrazolium chloride, and cerebral edema was assessed by microgravimetry. Brain injury and cerebral edema were less in both phenylephrine groups, compared with the control and hemodilution groups (P less than 0.05). These results are consistent with the premise that if normotension is maintained, hemodilution reduces ischemic brain injury and edema. They also indicate that the addition of phenylephrine-induced hypertension to hemodilution therapy results in a further reduction of ischemic injury without exacerbating cerebral edema.

An alternative approach to nonpalpable breast biopsies

Traditionally, when a negative specimen radiograph is obtained during biopsy of a nonpalpable breast lesion, immediate re-excision is performed in an attempt to successfully remove the lesion. Based on a retrospective study of the biopsy results of 792 nonpalpable breast lesions, the authors suggest delaying the re-excision, despite a negative specimen x-ray, until postoperative mammography confirms the persistence of the lesion. Utilization of this approach was associated with a comparably low incidence of missed lesions (3%) and had the added advantages of preserving breast tissue and decreasing operative time.

Termination of ventricular tachycardia by an implantable atrial pacemaker and external pacemaker activator

An atrial pacemaker was implanted in a patient who had dilated cardiomyopathy, sinus node dysfunction, and drug-resistant ventricular tachycardia (VT). VT episodes were terminated by atrial overdrive pacing using an implanted pacemaker and a newly developed hand-held external programmer/transmitter. Although successful cases of termination of intractable VT by ventricular pacing have recently been reported, the ventricular method might increase the risk of accelerating VT. Atrial overdrive pacing is a safer method since it minimizes the possibility of tachycardia acceleration and, combined with antiarrhythmic drugs, it appeared to be a unique and useful approach for the treatment of drug-resistant VT.

[Left ventricular peak filling velocity and its relevant factors in hypertrophic hearts]

To evaluate the relevant factors of left ventricular peak filling velocity, M-mode echocardiograms showing the left ventricular cavity were recorded and digitized for 81 patients with hypertrophic hearts (HTH) due to hypertensive heart disease (HHD, n = 30), hypertrophic cardiomyopathy (HCM, n = 25), aortic valve stenosis (AS, n = 9), and HHD and HCM with congestive heart failure (HHD and HCM with CHF, n = 17). Peak rates of increase or decrease in dimension (Vf and Ve, respectively) and peak values of instantaneous circumferential fiber lengthening and shortening velocities (Vf/D and Ve/D, respectively) were determined by computer analysis of left ventricular internal dimensions. Systolic excursion (SE), percent fractional shortening (%FS), mean circumferential fiber shortening velocity (mVcf), thickness of the interventricular septum and posterior wall at end-diastole and the sum of them (WThivs, WThpw, and WThivs + pw, respectively) were also calculated. Their variables were compared with those of normal subjects (n = 24). The results obtained were as follows: Systolic functions in HTH without CHF were similar to those of the normal subjects, but Vf and Vf/D were significantly decreased. Differences in Vf and Vf/D between various HTH without CHF were not significant. In AS and HTH with CHF, Vf and Vf/D were significantly decreased together with systolic function. Vf correlated significantly with WThivs + pw, SE, Ve, and WThivs, and Vf/D with %FS, SE, Ve/D, and Ve.(ABSTRACT TRUNCATED AT 250 WORDS)

Longer survival and fewer metastases by levamisole and tegafur in 1, 2-dimethylhydrazine-induced murine colonic cancers

The anticancer effects of levamisole, tegafur and their combination were experimentally compared in rats on the 1, 2-dimethylhydrazine (DMH)-induced colonic cancers. DMH at 20 mg/kg of body weight was injected subcutaneously to Donryu rats once a week for 24 weeks long. Nineteen weeks after the start of DMH administration, early colonic cancers were induced and, 28 weeks after, they developed into advanced cancers with distant metastases. From 19 weeks after the start of DMH injection, subcutaneous administration of levamisole at the dose of 2 mg/kg, oral administration of tegafur at 90 mg/kg and their combination were given to the rats daily for nine weeks. The animals were sacrificed 28 weeks after the start of DMH administration. Tegafur was effective, but levamisole with or without tegafur was not effective against early cancer. From 28 weeks after the start of DMH injection, levamisole, tegafur and their combination were administered to the rats daily for four weeks. All of the rats were necropsied when they died. The survival rate and mean survival days were significantly higher and longer in the levamisole groups than in the control rats (p less than 0.05). The incidence of distant metastases was also significantly lower in the levamisole groups than in the control group.

Changes of left ventricular pressure-diameter-velocity relations by alterations of heart rate in conscious dogs

Changes of left ventricular (LV) pressure-diameter-velocity relations by alterations in heart rate (HR) were investigated in 6 conscious dogs, instrumented with a pair of ultrasonic crystal probe, a micromanometer in LV and pacing electrodes on the left atrium. By atrial pacing the following four stages of HR were produced: stage (S)-I 112, S-II 134, S-III 158 and S-IV 179 bpm (mean HR). These alterations in HR were repeated before and during acute pressure loadings by methoxamine infusion. LV pressure-diameter and pressure-velocity relations were evaluated by the slope value of LV peak systolic pressure (LVSP)-end-systolic diameter, E (D) max, and by the ratio of changes in mV cf (mean velocity circumferential fiber shortening) and LVSP before and during pressure loading, delta mVcf/delta LVSP, respectively. The average of E(D) max at each stage of HR was 9.45, 12.63, 12.59, 11.22 mmHg/mm, and delta mVcf/delta LVSP was -0.009, -0.006, -0.007, -0.009 circ./sec.mmHg, respectively. E(D) max increased more at S-II and S-III than at S-I, and reversely, E(D) max decreased more at S-IV than at S-II. Similarly, delta mVcf/delta LVSP increased more at S-II than at S-I and decreased more at S-IV than at S-II, while delta LVSP and delta EDD (end-diastolic diameter) were not different between stages. These changes in E(D) max and delta mVcf/delta LVSP presented the mountainous pattern effected by alterations in HR, whose changes were almost similar to that of LV peak positive dp/dt and mVcf before pressure loading. Thus, E(D) max is augmented by an increase in HR, which suggests the Bowditch-effect. Reversely, a decrease in E(D) max at a higher rate indicates a depressed inotropic state. E(D) max is dependent on HR and is a sensitive indicator of the contractility of LV.

[Maximum tolerated dose of tegafur in rats]

Maximum Tolerated Dose of Tegafur was estimated by per-oral administration in male Donryu rats. Tegafur was administered for 24 weeks at respective doses of 90 mg, 120 mg and 150 mg/kg/day. Six of 10 (60%) died during the treatment in those groups administered with 120 mg and 150 mg/kg/day, respectively. The cause of death of these rats was severe pneumonia. All 10 of the group given 60 mg/kg/day survived until end of the administration and were sacrificed for histological examination of organs. These rats showed apparent suppression of body weight gain compared with controls (p less than 0.001). Slight inflammation of the lungs was observed in all rats, congestion of the liver and local degeneration and necrosis of the liver cells in a few rats and cellular degeneration of bone marrow in one rat. There was no remarkable change in the digestive tract, kidney, thymus or reproductive organs. Accordingly, the Maximum Tolerated Dose of Tegafur was determined to be 90 mg/kg/day.

Reconsideration of heart rate-cardiac output relationships and resting cardiac function in patients with brady-arrhythmias

Different types of heart rate (HR)-cardiac output (COP) relationships were compared with their clinical features and hemodynamic findings in 56 patients with brady-arrhythmias (BA). HR was raised by increments of 10 beats per minute (bpm) at 3 min intervals, from spontaneous rates to 100 or 110 bpm by right ventricular pacing. Cardiac and left ventricular (LV) functions at BA were evaluated by intra-cardiac pressures, COP measured by the thermo-dilution method and echocardiographic data. HR-COP relationships were divided into the following 3 types: 24 patients of flat (F), 18 of peaked (P) and 14 of increased (I) type. There were more patients with complete atrio-ventricular block, particularly His-ventricular block, and cardiomyopathic patients with the "P" type than with the other types. Cardiac index, stroke index, stroke work index and systemic vascular resistance were greater in "I", but these differences were not significant. LV peak systolic pressure (LVSP) and end-diastolic pressure (EDP) in "I" increased more than in "F". EDP, LV end-diastolic and end-systolic dimension (ESD) in "P" increased more than in "F". Systolic excursion and LVSP/ESD ratio in "I" increased more than in the other types. Heart failure prior to implantation of pacemaker (PM) and post-PM occurred more frequently in "P". "F" and "I" patients showed comparatively good clinical courses after PM. Thus, cardiac and LV function during BA are maintained in "F" and are impaired in "P", as reported previously. On the other hand, cardiac functions are maintained in "I" as they are in "F", mainly due to contributions of the Frank-Starling mechanism and partly due to maintenance or slight augmentation of contractility.

[Studies on the effect of lentinan on human immune system. II. In vivo effect on NK activity, MLR induced killer activity and PHA induced blastic response of lymphocytes in cancer patients]

Immunological activities of lymphocytes were studied in patients with cancer of digestive organs and mamma after administration of lentinan. When 11 cancer patients received lentinan i.v. 2 mg, NK activity of lymphocytes was increased in 4 patients on the following day. With the same condition, MLR induced killer activity against Raji cell of lymphocytes was increased in 3/7 patients and PHA response was also increased in 3/7 patients. These activities were returned to values before the administration of lentinan. Then each activity was examined after administration of lentinan twice a week. NK activity, MLR induced killer activity and PHA response were increased in 4/15, 8/12 and 5/11 patients, respectively.

[Left ventricular performance during exercise in patients with constant heart rate]

In order to evaluate the response of left ventricular (LV) performance in pacemaker implanted patients (PMI pts) with constant heart rate during exercise, supine bicycle ergometer exercise was performed simultaneously in 21 PMI pts and 4 age-matched normal subjects. PMI pts were classified into two groups; Group I consisted of 16 pts with relatively good physical work capacity (maximal load: male; 80 watt or more, female; 60 watt or more), and Group II consisted of 14 pts with depressed physical work capacity (maximal load: male; 60 watt or less, female; 40 watt or less). During dynamic exercise LV end-diastolic dimension (EDD), stroke excursion (SE), percent fractional shortening (%FS) and posterior wall velocity (PWV) showed a significant increase and LV end-systolic dimension (ESD) showed a significant decrease in Group I in contrast with Group II and normal subjects. Systolic blood pressure (sBP) and sBP/ESD ratio significantly increased in Group I and normal subjects than in Group II. Furthermore, resting cardiac parameters were more impaired in Group II than Group I. Thus, it was suggested that Group I adapted to exercise according to Frank-Starling mechanism (increased EDD) and contractility due to probably increasing circulatory catecholamine (increased PWV and decreased ESD). On the other hand, Group II did not adapt sufficiently to exercise because of the limitation of preload-reserve and contractility-reserve on exercise and also at rest.

[Genetic epidemiological approach to large bowel cancer]

Incidence of large bowel cancer under predominant genetic influence is estimated to occupy about one tenth of general large bowel cancer population. They are defined to include hereditary gastrointestinal polyposes (adenomatosis coli, Peutz-Jeghers syndrome and juvenile polyposis) and the non-polypotic familial (hereditary) large bowel cancer (Cancer Family Syndrome and allied conditions). The strategy for the genetic cancer high-risk group under these conditions based on the central registration system was described. Our experiences indicated the approach was actually effective for the polyposes a and was also promising for the non-polyposis familial of large bowel cancer.

[Diastolic murmur in non-obstructive hypertrophic cardiomyopathy]

Diastolic murmur (DM) in patients with non-obstructive hypertrophic cardiomyopathy (non-obst HCM) was studied regarding incidence, phonocardiographic disposition, mechanism, and also clinical characteristics of patients with DM. The results were as follows: 1) DM was recorded in 17 of 115 patients with non-obst HCM (15%), and was classified into three types of a mid-diastolic murmur, presystolic murmur, presystolic murmur and these combination. Mid-diastolic murmur showed low-pitched character mimicking a flow rumble around apical area in most patients. On the other hand, a presystolic murmur was relatively medium-pitched and spindle-shaped over the 4th left sternal border. Additionally, there were 7 patients of mitral opening sound coincided with the "O" point of the apex cardiogram, and 3 patients of an undefined sound or vibration during atrial contraction. 2) Impaired left ventricular (LV) compliance by pressure-volume analysis and decreased diastolic descent rate (DDR) in the mitral echocardiogram observed in patients with DM suggested that mechanism of these DM is mainly attributed to the disturbance of LV filling. Furthermore, mitral regurgitation was detected by LV angiography in a half of patients, indicating that DM might be partially related to increased mitral flow. 3) Clinically, DM was more common in younger patients of familiar occurrence and death, and with impaired physical work capacity. Therefore, auscultatory or phonocardiographic assessment of DM was clinically useful in the evaluation of patients with non-obst HCM.