Impact of regional anesthesia on outcomes of geriatric patients undergoing lower extremity revascularization: A propensity score-matched cohort study

Lower extremity revascularization (LER) for peripheral artery disease in elderly patients is associated with a high risk of perioperative morbidity and mortality. This study aimed to a conduct retrospective review and propensity score matching analysis to determine whether the use of regional anesthesia (RA) instead of general anesthesia (GA) in geriatric patients undergoing LER for peripheral artery disease results in improved short-term mortality and health outcomes. We reviewed medical records of 1271 patients aged >65 years who underwent LER at our center between May 1998 and February 2016. According to the anesthesia method, patients were grouped in the GA and RA groups. The primary outcome was short-term mortality (7-day and 30-day). The secondary outcomes were 5-year survival rate, intraoperative events, postoperative morbidity, and postoperative length of stay. A propensity score-matched cohort design was used to control for potentially confounding factors including patient demographics, comorbidities, American Society of Anesthesiologists physical status, and preoperative medications. After propensity score matching, 722 patients that received LER under GA (n = 269) or RA (n = 453) were identified. Patients from the GA group showed significantly higher 7-day mortality than those from the RA group (5.6% vs 2.7% P = .048); however, there was no significant difference in 30-day mortality between the groups (GA vs RA: 6.3% vs 3.6%, P = .083). The 5-year survival rate and incidence of arterial and central venous catheter placement or intraoperative dopamine and epinephrine use were significantly higher in the GA group than in the RA group (P < .05). In addition, the frequency of immediate postoperative oxygen therapy or mechanical ventilation support was higher in the GA group (P < .05). However, there was no difference in the postoperative cardiopulmonary and cerebral complications between the 2 groups. These results suggest that RA can reduce intraoperative hemodynamic support and provide immediate postoperative respiratory intensive care. In addition, the use of RA may be associated with better short-term and 5-year survival rates in geriatric patients undergoing LER.

Linear indices of ventricular volume on brain computed tomography as markers of effectiveness of epidural blood patch for spontaneous intracranial hypotension: A case report

RATIONALE

Epidural blood patch (EBP) is an effective treatment for spontaneous intracranial hypotension (SIH). However, its effectiveness can only be judged through subjective symptom improvement; no objective markers have been reported. Linear indices of ventricular volume on brain computed tomography (CT) may aid the objective evaluation of the effectiveness of EBP in patients with SIH.

PATIENT CONCERNS

A 45-year-old man was hospitalized due to a 3-week history of orthostatic headache, dizziness, and neck pain. He had visited a local emergency department at symptom onset. His neurological examination results were normal and vital signs were stable.

DIAGNOSES

Brain magnetic resonance imaging (MRI) revealed pachymeningeal enhancement in both convexities with a small subdural hematoma (SDH). Based on the clinical features and MRI findings, he was diagnosed with SIH complicated by SDH.

INTERVENTIONS

Non-targeted EBP was performed, first at the lumbar level and subsequently at the thoracic level. Linear indices of ventricular volume, including the Evans' index, frontal-occipital horn ratio, and bicaudate index, were measured through brain CT performed before and after EBP.

OUTCOMES

After lumbar EBP, there was no symptom relief or increase in linear indices of ventricular volume on brain CT. In contrast, the patient's symptoms completely resolved and the linear indices of ventricular volume increased after thoracic EBP.

LESSONS

The effectiveness of EBP, which is currently evaluated solely based on changes in symptom severity, can be assessed using linear indices of ventricular volume.

Comparison between the coronal diameters of the cervical spinal canal and spinal cord measured using computed tomography and magnetic resonance imaging in Korean patients

Background

Cervical epidural block could cause spinal cord injury if the epidural needle is over-inserted and punctures the spinal cord. However, if the proportion of the spinal cord in the epidural space can be determined under C-arm fluoroscopy, a safe entry point for the epidural needle can be established.

Methods

We retrospectively evaluated the imaging data of 100 patients (50 men and 50 women) who underwent both cervical computed tomography (CT) and cervical magnetic resonance imaging (MRI) at our hospital. We measured the diameters of the spinal canal and spinal cord from the 3rd cervical vertebra to the 1st thoracic vertebra (T1) at each level by using the patients' cervical CT and MR images. The spinal cord and spinal canal diameters were measured in the transverse plane of cervical MR and CT images, respectively.

Results

The spinal cord to spinal canal diameter ratio was the highest at the 4th and 5th cervical vertebrae (0.64 ± 0.07) and the lowest at T1 (0.55 ± 0.06, 99% confidence interval : 0.535 - 0.565).

Conclusions

Our findings suggest that the cord to canal transverse diameter ratio could be used as a reference to reduce direct spinal cord injuries during cervical epidural block under C-arm fluoroscopy. In the C-arm fluoroscopic image, if an imaginary line connecting the left and right innermost lines of the pedicles of T1 is drawn and if the needle is inserted into the outer one-fifth of the left and right sides, the risk of puncturing the spinal cord would be relatively reduced.

Fluid management in patients undergoing neurosurgery

Fluid management is an important component of perioperative care for patients undergoing neurosurgery. The primary goal of fluid management in neurosurgery is the maintenance of normovolemia and prevention of serum osmolarity reduction. To maintain normovolemia, it is important to administer fluids in appropriate amounts following appropriate methods, and to prevent a decrease in serum osmolarity, the choice of fluid is essential. There is considerable debate about the choice and optimal amounts of fluids administered in the perioperative period. However, there is little high-quality clinical research on fluid therapy for patients undergoing neurosurgery. This review will discuss the choice and optimal amounts of fluids in neurosurgical patients based on the literature, recent issues, and perioperative fluid management practices.

Comparison of ultrasound-guided and nerve stimulator-guided interscalene blocks as a sole anesthesia in shoulder arthroscopic rotator cuff repair: A retrospective study

Ultrasound-guided interscalene block (US-ISB) and nerve stimulator-guided interscalene block (NS-ISB) have both been commonly used for anesthesia in shoulder arthroscopic surgery.This study aims to compare which method provides surgical block as a sole anesthesia. In this retrospective study, 1158 patients who underwent shoulder arthroscopic rotator cuff tear repair surgery under ISB between October 2002 and March 2018 were classified into either the US-ISB or NS-ISB anesthesia groups. Demographic and anesthetic characteristics and intraoperative medications were analyzed after propensity score matching and compared between the 2 groups.There was a 0.5% rate of conversion to general anesthesia in the US-ISB group and a 6.7% rate in the NS-ISB group (P < .001). The volume of local anesthetics used for ISB was 29.7 ± 8.9 mL in the US-ISB group versus 38.1 ± 4.8 mL in the NS-ISB group (P < .001). The intraoperative use of analgesics and sedatives such as fentanyl, midazolam and propofol in combination was significantly lowered in the US-ISB group (P < .001).US-ISB is a more effective and safer approach for providing intense block to NS-ISB because it can decrease the incidence of conversion to general anesthesia and reduce the use of analgesics and sedatives during arthroscopic shoulder surgery.

Retrospective analysis of risk factors of hypotensive bradycardic events during shoulder arthroscopic surgery under interscalene blockade in the sitting position

Background

Hypotensive bradycardic events (HBEs) are a frequent adverse event in patients who underwent shoulder arthroscopic surgery under interscalene block (ISB) in the sitting position. This retrospective study was conducted to investigate the independent risk factors of HBEs in shoulder arthroscopic surgery under ISB in the sitting position.

Methods

A total of 2549 patients who underwent shoulder arthroscopic surgery under ISB and had complete clinical data were included in the study. The 357 patients who developed HBEs were included in the HBEs group, and the remaining 2192 in the non-HBEs group. The potential risk factors for HBEs, such as age, sex, past medical history, anesthetic characteristics, and intraoperative medications were collected and compared between the groups. Statistically significant variables were included in a logistic regression model to further evaluate the independent risk factors for HBEs in shoulder arthroscopic surgery under ISB.

Results

The incidence of HBEs was 14.0% (357/2549). Logistic regression analysis revealed that the intraoperative use of hydralazine (odds ratio [OR] 4.2; 95% confidence interval [CI] 2.9–6.3), propofol (OR 2.1; 95% CI 1.3–3.6), and dexmedetomidine (OR 3.9; 95% CI 1.9–7.8) before HBEs were independent risk factors for HBEs in patients who received shoulder arthroscopic surgery under ISB.

Conclusions

The intraoperative use of antihypertensives such as hydralazine and sedatives such as propofol or dexmedetomidine leads to increased risk of HBEs during shoulder arthroscopic surgery under ISB in the sitting position.

Comparing the placement of a left-sided double-lumen tube via fiberoptic bronchoscopy guidance versus conventional intubation using a Macintosh laryngoscope, to reduce the incidence of malpositioning: study protocol for a randomized controlled pilot trial

BACKGROUND

A fiberoptic bronchoscope (FOB) is commonly used to identify the proper placement of a double-lumen endotracheal tube (DLT) for good lung isolation during thoracic surgery. We hypothesized that the FOB-guided method for DLT placement composed of tracheal intubation under initial guidance by a FOB via the bronchial lumen and subsequent selective left-bronchial intubation could be used to reduce the incidence of DLT malposition and reduce the time required for completion of DLT placement and confirmation of proper DLT position during intubation using a left-sided DLT, in comparison to the conventional method under direct laryngoscopy using a Macintosh laryngoscope.

METHODS/DESIGN

In this randomized controlled pilot trial, 50 patients, aged 18-70 years, scheduled for elective thoracic surgery will be recruited and randomly assigned to two groups according to the method of DLT placement: a FOB-guided method (F) group and a conventional method (C) group. Regardless of the group, the DLT placement processes will be followed by subsequent confirmation processes, using a FOB. If the DLT is misplaced, the position would be corrected. The primary outcome is the incidence of DLT malpositioning observed via a FOB during confirmation after DLT placement. The secondary outcomes consist of the time required to achieve the entire DLT intubation process, which is the sum of the duration of DLT placement and the duration of confirmation of the proper position, the incidence of failed tracheal intubation on the first and second attempt, and complications associated with the intubation process.

DISCUSSION

This pilot study was designed as the first randomized controlled trial to confirm our hypothesis. This should provide information for a further full-scale trial, and the outcomes of the study should provide clinical evidence on the usefulness of the FOB-guided method for DLT placement, in comparison to the conventional method.

TRIAL REGISTRATION

Clinical Research Information Service; CRIS, ID: KCT0002663 . Retrospectively registered on 24 January 2018.

Peptidylarginine deiminase is involved in maintaining the cornified oral mucosa of rats

BACKGROUND AND OBJECTIVE

Epithelial cells derived from different regions exhibit marked differences in their differentiation capacity, allowing them to provide a suitable protective barrier. We aimed to clarify the role of peptidylarginine deiminase (PAD) in modifying the key epidermal proteins filaggrin (FLG) and keratin 1 (K1) during stratification of the rat palate and buccal mucosa.

MATERIAL AND METHODS

We performed immunofluorescence, immunoblotting, PAD activity assays and 2-dimensional electrophoresis, and developed an organotypic culture model.

RESULTS

PAD1 expression was highest in the palate, whereas PAD2, PAD3 and PAD4 expression was highest in the skin, suggesting the tissue-specific expression of PAD isozymes that leads to differences in calcium dependency. Immunoblotting showed that the FLG monomer, as well as its degradation products and precursor (proFLG), were most abundantly expressed in the skin but had low expression in the palate, whereas only faint proFLG expression was detected in the buccal mucosa. FLG and K1 were colocalized with PAD1 and were likely to be citrullinated in the cornified layers of the skin; this colocalization was not detected on the palatal surface, and dot-like presence of proFLG that might be citrullinated and that of PAD1 were found in the granules of the palate. Organotypic models derived from the rat palate revealed that PAD inhibition reduced the breakdown of FLG, increased its association with K1 together with epithelial compaction, and decreased permeability in a dye permeability assay. Conversely, PAD stimulation had the opposite effects.

CONCLUSION

Citrullination is likely a protein modification that plays an important role in maintaining the structure and function of oral cornified mucosa in a way that is distinctly different from that of the skin.

Fiberoptic bronchoscopic treatment of blood aspiration and use of sugammadex in a patient with epistaxis: A case report

RATIONALE

In patients with oropharyngeal and nasopharyngeal bleeding, blood aspiration can make airway management difficult and lead to severe pulmonary complications.

PATIENT CONCERNS

A 44-year-old male patient with recurrent epistaxis underwent surgery for hemostasis. The patient aspirated blood through the endotracheal tube when he hiccupped during the surgery.

DIAGNOSIS

The patient was diagnosed with blood aspiration after intraoperative fiberoptic bronchoscopy revealed a blood clot and viscous mucus in the airways, but no sign of active bleeding.

INTERVENTIONS

Tracheobronchial suctioning and irrigation with normal saline was performed through the bronchoscope to remove the aspirated blood clot. Prior to emergence from anesthesia, sugammadex was administered to induce complete neuromuscular recovery and enable the patient to cough up any blood remaining in the airways.

OUTCOMES

The patient was successfully extubated and fully recovered with no complications.

LESSONS

Blood aspiration due to oropharyngeal or nasopharyngeal bleeding can be diagnosed and treated by tracheobronchial suctioning via fiberoptic bronchoscopy. In addition, sugammadex can enable patients to recover spontaneous breathing, facilitate extubation, and enable patients to cough up any blood remaining in the airways.

Perioperative management of left ventricular diastolic dysfunction and heart failure: an anesthesiologist's perspective

Anesthesiologists frequently see asymptomatic patients with diastolic dysfunction or heart failure for various surgeries. These patients typically show normal systolic function but abnormal diastolic parameters in their preoperative echocardiographic evaluations. The symptoms that are sometimes seen are similar to those of chronic obstructive pulmonary disease. Patients with diastolic dysfunction, and even with diastolic heart failure, have the potential to develop a hypertensive crisis or pulmonary congestion. Thus, in addition to conventional perioperative risk quantification, it may be important to consider the results of diastolic assessment for predicting the postoperative outcome and making better decisions. If anesthesiologists see female patients older than 70 years of age who have hypertension, diabetes, chronic renal disease, recent weight gain, or exercise intolerance, they should focus on the patient's diastologic echocardiography indicators such as left atrial enlargement or left ventricular hypertrophy. In addition, there is a need for perioperative strategies to mitigate diastolic dysfunction-related morbidity. Specifically, hypertension should be controlled, keeping pulse pressure below diastolic blood pressure, maintaining a sinus rhythm and normovolemia, and avoiding tachycardia and myocardial ischemia. There is no need to classify these diastolic dysfunction, but it is important to manage this condition to avoid worsening outcomes.

Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft: A case report

INTRODUCTION

In fetuses who are predicted to be at risk of catastrophic airway obstruction at delivery, the ex utero intrapartum treatment (EXIT) procedure is useful for securing the fetal airway while maintaining fetal oxygenation via placental circulation. Factors, including poor posture of the fetus and physician, narrow visual field, and issues of contamination in the aseptic surgical field, make fetal intubation during the EXIT procedure difficult. Herein, we report our experience of the usefulness of the GlideScope video laryngoscope (GVL) for intubation during the EXIT procedure.

SYMPTOMS AND CLINICAL FINDINGS

A 28-year-old woman presented with a fetus having a cystic neck mass diagnosed on prenatal ultrasound at 25 weeks of gestation. We planned the EXIT procedure in conjunction with cesarean delivery at 38 weeks of gestation, as the mass enlarged to 4.9 cm × 3.2 cm, protruded externally at the neck, and subsequently resulted in polyhydramnios.

THERAPEUTIC INTERVENTION AND OUTCOMES

After induction of anesthesia using intravenous thiopental (300 mg), adequate uterine relaxation was achieved with sevoflurane (2.0-3.0 vol%) combined with continuous intravenous infusion of nitroglycerin (0.5-1.0 μg/kg/min) for maintaining uteroplacental circulation. After hysterotomy, the head and right upper limb of the fetus were partially delivered, and fetal heart tones were monitored with a sterile Doppler probe. After oropharyngeal suctioning to improve the visual field, the fetus was intubated successfully using a sterile GVL by an anesthesiologist, and the passage of the endotracheal tube beyond the vocal cords was confirmed on the screen of the GVL system. Immediately after the fetal airway was definitely secured, the fetus was fully delivered with umbilical cord clamping. After delivery, nitroglycerine administration was ceased and sevoflurane administration was reduced to 0.5 minimum alveolar concentration. Additionally, oxytocin (10 units) and carbetocin (100 μg) were administered for recovery of uterine contraction. Cesarean delivery was successfully performed without any problems, and the neonate successfully underwent surgery for removal of the neck mass under general anesthesia on the 7th day after delivery. The neonate is developing normally.

CONCLUSION

The GVL approach may be a useful noninvasive approach for establishing a clear fetal airway during the EXIT procedure.

Comparison of a tube-holder (Rescuefix) versus tape-tying for minimizing double-lumen tube displacement during lateral positioning in thoracic surgery: A prospective, randomized controlled study

BACKGROUND

Double-lumen endotracheal tubes (DLTs) are often displaced during change from the supine to the lateral decubitus position. The aim of this study was to determine whether Rescuefix, a recently developed tube-holder device, is more effective than the traditional tape-tying method for tube security during lateral positioning.

METHODS

Patients were randomly assigned to a Rescuefix (R) group (n = 22) or a tape (T) group (n = 22). After intubation with a left-sided DLT and adjustment of the appropriate DLT position using a fiberoptic bronchoscope, the DLT was fixed firmly at the side of the mouth by either Rescuefix or Durapore tape. "Tracheal depth" (from the tracheal carina to the elbow connector of the DLT) and "bronchial depth" (from the left bronchial carina to the elbow connector of the DLT) were measured in the supine position using the fiberoptic bronchoscope. After positional change, tracheal and bronchial depths were measured as described above. As the primary endpoint, displacement of the DLT during positional change was evaluated by obtaining the difference in depths measured when the patient was in the supine and lateral decubitus positions. In addition, after lateral positioning of the patient, any requirement for repositioning the DLT was recorded.

RESULTS

After lateral positioning, there were no significant differences in changes in tracheal and bronchial depths between the groups (tracheal depth 6.1 ± 4.4 mm [R group] and 9.1 ± 5.6 mm [T group], P = 0.058; bronchial depth 6.5 ± 4.4 mm [R group], and 8.5 ± 4.6 mm [T group], P = 0.132). Although the amount of change in tracheal and bronchial depths was not different between the groups, the need to reposition the DLT was significantly lower in the R group than in the T group (32% vs 68%, P = 0.016).

CONCLUSION

This study demonstrated that use of Rescuefix did not reduce the amount of DLT displacement, but it did significantly lower the incidence of DLT repositioning compared with the tape-tying method. Therefore, Rescuefix appears to be an effective alternative to minimizing DLT displacement during lateral positioning in thoracic surgery.

TRIAL REGISTRATION

http://cris.nih.go.kr identifier: KCT0001949.

Comparison Between Ultrasound-Guided Supraclavicular and Interscalene Brachial Plexus Blocks in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective, Randomized, Parallel Study

Although supraclavicular brachial plexus block (SCBPB) was repopularized by the introduction of ultrasound, its usefulness in shoulder surgery has not been widely reported. The objective of this study was to compare motor and sensory blockades, the incidence of side effects, and intraoperative opioid analgesic requirements between SCBPB and interscalene brachial plexus block (ISBPB) in patients undergoing arthroscopic shoulder surgery. Patients were randomly assigned to 1 of 2 groups (ISBPB group: n = 47; SCBPB group: n = 46). The side effects of the brachial plexus block (Horner's syndrome, hoarseness, and subjective dyspnea), the sensory block score (graded from 0 [no cold sensation] to 100 [intact sensation] using an alcohol swab) for each of the 5 dermatomes (C5-C8 and T1), and the motor block score (graded from 0 [complete paralysis] to 6 [normal muscle force]) for muscle forces corresponding to the radial, ulnar, median, and musculocutaneous nerves were evaluated 20 min after the brachial plexus block. Fentanyl was administered in 50 μg increments when the patients complained of pain that was not relieved by the brachial plexus block. There were no conversions to general anesthesia due to a failed brachial plexus block. The sensory block scores for the C5 to C8 dermatomes were significantly lower in the ISBPB group. However, the percentage of patients who received fentanyl was comparable between the 2 groups (27.7% [ISBPB group] and 30.4% [SCBPB group], P = 0.77). SCBPB produced significantly lower motor block scores for the radial, ulnar, and median nerves than did ISBPB. A significantly higher incidence of Horner's syndrome was observed in the ISBPB group (59.6% [ISBPB group] and 19.6% [SCBPB group], P < 0.001). No patient complained of subjective dyspnea. Despite the weaker degree of sensory blockade provided by SCBPB in comparison to ISBPB, opioid analgesic requirements are similar during arthroscopic shoulder surgery under both brachial plexus blocks. However, SCBPB produces a better motor blockade and a lower incidence of Horner's syndrome than ISBPB.

Adsorption of desflurane by the silica gel filters in breathing circuits: an in vitro study

Background

During general anesthesia, a heated breathing circuit (HBC) is used to replace the heat and moisture exchange function of the upper airway. One HBC uses an air dryer filter that employs silica gel (SG) as a desiccant. SG is capable of adsorbing many organic compounds. Therefore, we undertook an in vitro study of the adsorption of desflurane by SG filters.

Methods

An HBC was connected to an anesthesia machine, and a test lung was connected to the circuit. The test lung was mechanically ventilated with 2 or 4 L/min of fresh gas flow, with and without the air dryer filter. Desflurane was administered at a 6 vol% on the vaporizer dial setting. The experiment was repeated 15 times in each group. The end-tidal concentrations were measured during the experiments. The air dryer filter weights were measured before and after the experiments, and the times required to achieve the specific end-tidal desflurane concentrations were determined.

Results

Significant differences in the end-tidal concentrations of desflurane were observed between the control and filter groups (P < 0.001). The filter weights increased significantly after the experiments (P < 0.001). The times required to achieve the same end-tidal desflurane concentrations were different with the application of the air dryer filter (P < 0.001).

Conclusions

The adsorption of desflurane with the use of an air dryer filter was verified in this in vitro study. Careful attention is needed when using air dryer gel filters during general anesthesia.

Role of calcium channels responsible for phenylephrine-induced contraction in rat aorta 3 days after acute myocardial infarction

Background

Phenylephrine (PE) produces tonic contraction through involvement of various calcium channels such as store-operated calcium channels (SOCCs) and voltage-operated calcium channels (VOCCs). However, the relative contribution of each calcium channel to PE-induced contraction has not been investigated in isolated rat aorta of early acute myocardial infarction (AMI).

Methods

Endothelium-denuded rat aortic rings from rats 3 days after AMI or sham-operated (SHAM) rats were prepared in an organ chamber with Krebs-Ringer bicarbonate solution for isometric tension recording. We assessed the PE dose-response relationships in 2.5 mM calcium medium for both groups. The same procedure was repeated using rings pretreated with the SOCC inhibitor 2-aminoethoxydiphenyl borate, sarco/endoplasmic-reticulum calcium ATPase inhibitor thapsigargin (TG), diacyl glycerol lipase inhibitor RHC80267, and sodium-calcium exchanger inhibitor 3,4-dichlorobenzamil hydrochloride for 30 minutes before addition of calcium. When ongoing tonic contraction was sustained, dose-response curves to the VOCC inhibitor nifedipine were obtained to assess the relative contribution of each calcium channel under various conditions.

Results

The effect of SOCC induction with TG pretreatment on PE-induced contraction was significantly lower in the AMI group compared to the SHAM group. In addition, there were significant decreases in the sensitivity and efficacy of the VOCC inhibitor nifedipine on PE-induced contraction in the AMI group.

Conclusions

Results suggest that the change of vascular reactivity of PE in rat aorta 3 days after AMI is characterized by a decreased contribution of L-type VOCCs. The enhanced VOCC-independent calcium entry mechanisms after AMI can be mediated by enhanced capacitative calcium entry through the activation of SOCCs.

Rocuronium-induced withdrawal movement: influence of ketorolac or a combination of lidocaine and ketorolac pretreatment

Background

Pain on injection of rocuronium is a common clinical problem. We compared the efficacy of lidocaine, ketorolac, and the 2 in combination as pretreatment for the prevention of rocuronium-induced withdrawal movement.

Methods

For this prospective, randomized, placebo-controlled, double-blind study a total of 140 patients were randomly allocated to one of 4 treatment groups to receive intravenously placebo (saline), lidocaine (20 mg), ketorolac (10 mg), or both (n = 35 for each group), with venous occlusion. The tourniquet was released after 2 min and anesthesia was performed using 5 mg/kg thiopental sodium followed by 0.6 mg/kg rocuronium. The withdrawal response was graded on a 4-point scale in a double-blind manner.

Results

The overall incidence of withdrawal movements after rocuronium was 34.3% with lidocaine (P = 0.001), 40% with ketorolac (P = 0.004), and 8.6% with both (P < 0.001), compared with 74.3% with placebo. There was a significantly lower incidence of withdrawal movements in patients receiving the lidocaine/ketorolac combination than in those receiving lidocaine or ketorolac alone (P = 0.009 and 0.002, respectively). The incidence of moderate to severe withdrawal movements was 14.3% with lidocaine, 17.2% with ketorolac, and 2.9% with lidocaine/ketorolac combination, as compared to 45.7% with the placebo. There was no significant difference in withdrawal movement between the lidocaine group and the ketorolac group.

Conclusions

Ketorolac pretreatment had an effect comparable to that of lidocaine in attenuating rocuronium-induced withdrawal movements and the lidocaine/ketorolac combination pretreatment, compared with lidocaine or ketorolac alone, effectively reduced withdrawal movements during rocuronium injection.

Massive hemothorax immediately after removal of central venous catheter -A case report-

Hemothorax is a possible immediate complication of central venous catheterization. We experienced a patient who suffered from massive hemothorax 72 hours after right subclavian venous catheterization. A 29-year-old female patient with Marfan's syndrome underwent the Bentall's operation and aortic arch replacement with an artificial graft, which was performed uneventfully. She recovered favorably in the intensive care unit and was transferred to the general ward on postoperative day 3. Immediately after the removal of the catheter in the general ward, massive hemothorax developed and emergent thoracotomy should have been performed to control bleeding. We report this case to re-emphasize the careful monitoring even after removal of central venous catheter and the need for ultrasound guidance during insertion of central venous catheters.

The effect of the intravenous phenylephrine on the level of spinal anesthesia

Background

Spinal anesthesia causes hypotension and bradycardia due to sympathetic nerve block and it is difficult to predict the level of sensory block and the duration of blockade. Recent studies have reported that intravenous phenylephrine can reduce the rostral spread of spinal anesthesia in pregnant women. We think a phenylephrine infusion will be useful for maintaining the baseline blood pressure by reducing the rostral spread of spinal anesthesia during the elective surgery of non-obstetric patients.

Methods

Sixty patients who were undergoing urologic surgery were randomized into two groups: Group C (the control group without phenylephrine) and Group P (with the addition of phenylephrine). After a bolus infusion of 50 µg phenylephrine following the spinal injection, phenylephrine was continuously infused at the rate of 200 µg/hr. We compared the dermatomal spreads of spinal anesthesia, the hemodynamic parameters (blood pressure, heart rate) and the incidences of hypotension between the two groups.

Results

At 20 minutes, the level of the upper dermatome blocked against cold sensation was a median of T8 (interquartile range: T8-T10) for the phenylephrine group, as compared with T4 (interquartile range: T4-T6) for the control group (P < 0.001).

Conclusions

Intravenous phenylephrine can decrease the rostral spread of spinal anesthesia during urologic surgery.

Treatment of autoimmune diseases in MRL/lpr mice by allogenic bone marrow transplantation plus adult thymus transplantation

MRL/lpr mice (H-2(k)) with Fas gene mutation develop severe autoimmune diseases, and their haematolymphoid cells such as bone marrow and spleen cells showed a low apoptotic activity by irradiation. Therefore, conventional bone marrow transplantation (BMT) cannot be used to treat autoimmune diseases in these mice (chimeric resistance). In the present study, we examine the effects of additional adult thymus transplantation (TT) from the same donor on successful BMT. When the MRL/lpr mice were lethally irradiated (9 x 5Gy) and reconstituted with 3 x 10(7) of C57BL/6 mouse (H-2b) bone marrow cells (BMCs) in conjunction with TT, the mice significantly survived long term and showed a high donor-derived chimerism in comparison with those treated with BMT alone. Interestingly, the numbers of not only donor-derived T cells but also B cells increased significantly in the mice treated with BMT plus TT, even at the early phase of BMT. The number of aberrant CD3+B220+ cells decreased significantly, and the numbers of lymphocyte subsets were also normalized 4 weeks after the treatment. Finally, the autoimmune diseases in MRL/lpr mice could be cured by BMT with TT. These results indicate that the combination of BMT plus TT can overcome the chimeric resistance and treat the autoimmune diseases in MRL/lpr mice.

Relationship of p53, Bcl-2, Ki-67 index and E-cadherin expression in early invasive breast cancers with comedonecrosis as an accelerated apoptosis

AIMS

To study the relationship between comedonecrosis formation and morphology, apoptosis, and p53, Bcl-2, Ki-67 index and E-cadherin expression in early invasive breast cancer.

EXPERIMENTAL DESIGN

Early invasive breast cancers were first divided into two groups according to the presence (CN+ tumours) or absence (CN- tumours) of comedonecrosis. The histological grade, apoptosis, and expression of E-cadherin, Ki-67, p53 and Bcl-2 in the cancer-affected area, and in normal ducts from the specimen, were then examined.

RESULTS

Less tubule and gland formation was seen in CN+ tumours than in CN- tumours, although the histological grade between the groups was not different. During early comedonecrosis, cells undergo apoptosis and subsequent necrosis. p53 was higher in CN+ tumours than in CN- tumours and normal ducts, whereas Bcl-2 was lower in CN+ tumours than in CN- tumours and normal ducts. Both tumours had higher Ki-67 than in normal ducts, but no difference was evident between the tumours. CN+ tumours had slightly higher E-cadherin than that in CN- tumours, but lower than that in normal ducts. The level of comedonecrosis was positively correlated with p53, but inversely correlated with Bcl-2 in all tumours, and p53 and Bcl-2 were inversely correlated with each other. Furthermore, comedonecrosis and p53 were correlated with Ki-67 in CN+ tumours, and Bcl-2 was correlated with Ki-67 in CN- tumours.

CONCLUSION

Comedonecrosis may be actively regulated through an apoptotic procedure in massive cancers for their survival and progression, and the above proteins may be associated cooperatively in this process. CN+ and CN- tumours may have opposite proliferative systems under the p53-Bcl-2 pathway.

Rapidly progressive tabes dorsalis associated with selective IgA deficiency

Tabes dorsalis is uncommon and progresses slowly from infection to clinical manifestation. We report a rare case of rapidly progressive tabes dorsalis associated with selective IgA deficiency (sIgAD). A 28-year-old man was hospitalized with lightning back pain, nausea, and bladder bowel dysfunction. Serum and cerebrospinal fluid (CSF) revealed high titers of Treponema pallidum antibody, and the serum IgA level was less than 5 mg/dl. Thl-dominant cytokine expression was observed, as is usually seen in neurosyphilis. He was treated with Ceftriaxone and CSF pleocytosis disappeared. We postulate sIgAD influenced the atypical rapid clinical course of tabes dorsalis in this patient.

Myelodysplasia associated with acquired immunodeficiency syndrome

Two cases of acquired immunodeficiency syndrome with myelodysplasia are presented. Case 1 was admitted because of Pneumocystis carinii pneumonia. Mild anemia, thrombocytopenia and hypersegmented neutrophils were observed. After the administration of trimethoprim-sulfame-thoxazole and antiretroviral therapy, pancytopenia progressed. Bone marrow (BM) showed dysplastic hematopoiesis, suggesting human immunodeficiency virus-myelopathy. Case 2 was hospitalized due to progressive multifocal leukoencephalopathy. BM specimen obtained for thrombocytopenia showed myelodysplasia similar to myelodysplastic syndrome, suggesting that HIV may have an influence on hematopoietic progenitor cells.

Conjugation with L-Glutamate for in vivo brain drug delivery

In vitro studies have shown that conjugation of a model compound [p-di(hydroxyethyl)-amino-D-phenylalanine (D-MOD)] with L-Glu can improve D-MOD permeation through the bovine brain microvessel endothelial cell monolayers (Sakaeda et al., 2000). The transport of this D-MOD-L-Glu conjugate is facilitated by the L-Glu transport system. In this paper, we evaluate the in vivo brain delivery of model compounds (i.e. D-MOD, p-nitro-D-phenylalanine (p-nitro-D-Phe), 5,7-dichlorokynurenic acid (DCKA) and D-kyotorphin) and their L-Glu conjugates. DCKA was also conjugated with L-Asp and L-Gln amino acids. The analgesic activities of D-kyotorphin and its L-Glu conjugate were also evaluated. The results showed that the brain-to-plasma concentration ratio of D-MOD-L-Glu was higher than the D-MOD alone; however, the plasma concentration of both compounds were the same. The plasma concentration of p-nitro-D-Phe-L-Glu conjugate was higher than the parent p-nitro-D-Phe; however, the brain-to-plasma concentration ratio of p-nitro-D-Phe was higher than its conjugate. On the other hand, both DCKA and DCKA conjugates have a low brain-to-plasma concentration ratio due to their inability to cross the blood-brain barrier (BBB). The L-Asp and L-Glu conjugates of DCKA have elevated plasma concentrations relative to DCKA; however, the DCKA-L-Gln conjugate has the same plasma concentration as DCKA. For D-kyotorphin, both the parent and the L-Glu conjugate showed similar analgesic activity. In conclusion, conjugation of a non-permeable drug with L-Glu may improve the drug's brain delivery; however, this improvement may depend on the physicochemical and receptor binding properties of the conjugate.

Relapsing polychondritis: a report of eight cases

OBJECTIVE

To investigate clinical manifestations of relapsing polychondritis and to clarify the significance of type II collagen antibody in the disease.

METHODS

Clinical manifestations and antibody titers were examined in eight cases of relapsing polychondritis which had been treated at Otolaryngology Department, Hokkaido University during the eight years from 1991 to 1998. Anti-type II collagen antibody titer was measured by ELISA method.

RESULTS

The most frequent symptom was auricular chondritis; it was seen in 88% (7/8) of the cases. Ocular symptom, nasal chondritis, arthritis, respiratory tract chondritis, and audio-vestibular symptom were also common in the cases. Compared with previous reports, no difference was recognized in the manifestation frequency. Considering none of the samples from the controls was positive for anti-type II collagen antibody, two samples from the disease group were positive. The antibody positive rate was 25% (2/8).

CONCLUSION

Though the measurement of type II collagen antibody titer is not a decisive factor for detection of relapsing polychondritis, it is useful as one of the complementary factors for the diagnosis, since there is no specific test for this disease.

Left atrial systolic function assessed by left atrial ejection force in patients with sick sinus syndrome and paroxysmal atrial fibrillation

We evaluated left atrial systolic function using left atrial ejection force (LAEF) in 19 patients with sick sinus syndrome (SSS) and in 20 with paroxysmal atrial fibrillation (Paf) whose ages ranged from 48 to 80 years. We also evaluated 35 normal individuals for comparison. The LAEF was calculated as 1/3 x mitral valve area x (peak velocity of A wave)2 using two-dimensional and pulsed-Doppler echocardiography according to Newton's law of motion and hydrodynamics. In normal individuals, LAEF positively correlated with age (r = 0.82, p < 0.01). Normal LAEF was calculated as 0.098 x age - 0.74 (kdynes) from the regression line. Because of this correlation, we used age-corrected LAEF (%LAEF) that was calculated as (measured LAEF / normal LAEF) x 100. The results showed that this value was 53+/-26% in patients with SSS and 54+/-26% in patients with Paf. Both were significantly lower than normal individuals (p < 0.001). Among SSS subtypes, %LAEF was lower in types II and III than in type I (51+/-14%, 37+/-19%, and 81+/-35%, respectively). In conclusion, left atrial systolic function is depressed in patients with Paf and SSS, in particular, types II and III. These results suggest that the pathological abnormalities extend not only to the sinus node but also to the left atrial muscle in patients with SSS and Paf.

High fever, renal failure, disseminated intravascular coagulation and myelodysplasia accompanied with enhanced angiogenesis possibly due to overexpression of vascular endothelial growth factor

A 44-year-old woman suffered from recurrent fever, edema and fatigue. Laboratory data revealed renal dysfunction, low proteinemia, disseminated intravascular coagulation (DIC) and myelodysplasia. A renal and lymph node biopsy showed a marked angiogenesis. Serum levels of vascular endothelial growth factor (VEGF), and interleukin (IL)-6 were markedly increased, suggesting a pathogenesis related to VEGF-induced angiogenesis. The symptoms were remitted after treatment with cyclosporin A. No evidence of solid tumors, malignant lymphoma, Castleman's disease or POEMS (polyneuropathy, organomegaly, endocrine disorder, M-proteinemia and skin change) syndrome, reported to induce a high serum VEGF level, was obtained. This case may have involved an unknown mechanism which induced an overexpression of VEGF and IL-6.

Direct detection of apoptotic cells in peripheral blood from highly pathogenic SHIV-inoculated monkey

Apoptosis in peripheral blood leukocytes (PBL) has been estimated by the enhancement of spontaneous apoptosis after in vitro culture, because apoptotic cells have not been observed directly in freshly isolated PBL in the course of HIV/AIDS. In monkeys infected with a highly pathogenic simian/human immunodeficiency virus (SHIV), which corresponds to rapid progressors of HIV infection, a high frequency of apoptotic cells was directly detected in fresh PBL by electron-microscopic studies. Peripheral blood apoptosis transiently occurred after intense plasma viremia, and peaking at 3 weeks postinfection; occurrence was not limited specifically to lymphocytes, but also occurred in other types of leukocytes. Apoptosis in peripheral lymph nodes was also detected following intense plasma viremia. However, the in vivo apoptosis was not detected in nonpathogenic SHIV-infected monkeys that showed no cell loss. Thus, we directly showed the apoptosis of PBL, which might be associated with pathogenic SHIV produced during the time of plasma viremia.

Mental stress test is an effective inducer of vasospastic angina pectoris: comparison with cold pressor, hyperventilation and master two-step exercise test

BACKGROUND

Cold pressor, hyperventilation and exercise stress tests were usually used for inducing an angina attack in patients with vasospastic angina pectoris. We induced vasospastic angina attack using the mental calculation stress test, and compared the results with those using other stress tests.

SUBJECTS AND METHODS

Subjects were 29 patients with vasospastic angina pectoris. Their ages were 60.8+/-8.4 years. Coronary vasospasm was induced by an acetylcholine infusion test during coronary angiography. The mental stress test was performed as follows; after memorizing six digits numbers, they repeated these numbers in reverse for 5 min, and performed serial subtraction of 17 from 1000 for 5 min. Blood pressure, heart rate and ECG were recorded every 1-5 min during the mental stress test. The serum concentrations of epinephrine and norepinephrine were measured before and during the mental stress test. We compared these results with those obtained using cold pressor, hyperventilation and the Master two-step exercise stress test.

RESULTS

(1) Eight of the 29 patients (28%) showed ischemic ST-T change, which was caused by the mental stress test. (2) The increase in norepinephrine was greater in patients with an ST-T change than without an ST-T change (0.11+/-0.06 vs. 0.04+/-0.04 ng/ml, P<0.01). (3) The incidence of the ST-T change caused by the mental stress test (28%) was similar to the cold pressor test (27%) and greater than that caused by the hyperventilation test (13%). The incidence of ST-T change caused by the Master two-step test was 55%.

CONCLUSIONS

The mental stress test is an effective inducer of vasospastic angina attack, and attack may be induced by neurohumoral vasoconstrictive reflex and/or increased left ventricular afterload.

Estimation of the systolic pulmonary arterial pressure using contrast-enhanced continuous-wave Doppler in patients with trivial tricuspid regurgitation

Noninvasive estimation of pulmonary arterial pressure is important for hemodynamic monitoring of patients with heart disease. In patients with tricuspid regurgitation (TR), the peak velocity of TR on continuous-wave (CW) Doppler can be used to estimate the systolic pulmonary arterial pressure (PAPs) using the simplified Bernoulli equation. We evaluated a new technique of contrast-enhanced CW Doppler for calculating PAPs in patients with trivial TR. Forty-one patients without visible TR detected by color Doppler, pulsed Doppler or CW Doppler were evaluated. Age ranged from 19 to 73 (55 +/- 12) years old. Tricuspid flow signals were recorded on CW Doppler after intravenous administration of indocyanin green (ICG) or Albunex. PAPs was calculated as; PAPs = 4 x VTR2 + 10 mmHg, where VTR is the peak velocity of TR. PAPs calculated using contrast-enhanced CW Doppler was compared with PAPs measured by the following cardiac catheterization. 1) TR signals were recorded using the contrast-enhanced CW Doppler technique in 39 of 41 patients (95%) after intravenous administration of contrast agents. 2) The error of estimate of PAPs using the contrast-enhanced CW Doppler technique was -2.4 +/- 7.5 mmHg, and the percent error was -10.7 +/- 32.4% in all patients. In 20 of 39 patients (51%), the error of estimate was within +/- 5 mmHg. 3) PAPs was overestimated by 12.2 +/- 6.1 mmHg in patients with good contrast enhancement of TR signals. The contrast-enhanced CW Doppler technique is useful for estimating PAPs noninvasively in patients with trivial TR. It is better to assume the right atrial pressure as 3-5 mmHg, not 10 mmHg, in patients with good enhancement of trivial TR. Physiological TR may be enhanced by contrast agents in these patients.

Radial forearm free-flap reconstruction following radiotherapy and total laryngectomy

The authors' experience with six patients who underwent radial forearm free-flap reconstruction following radiotherapy and total laryngectomy is presented. All patients had undergone previous irradiation of 57.8 Gy on average as primary treatment for laryngeal cancer. A patch graft of the radial forearm free flap was used for pharyngoesophageal wall reconstruction in three patients, a radial forearm free flap for cervical soft tissue in one patient, and a double-folded radial forearm free flap for simultaneous pharyngoesophageal wall and cervical soft tissue in two patients. The free-flap transfers were successful in all patients. There was one patient who developed a small pharyngocutaneous fistula, which closed spontaneously. The radial forearm free flap is demonstrated to be a versatile technique for reconstruction of a moderate-sized defect in the treatment of laryngeal cancer.

An elderly man with Klinefelter syndrome associated with hypertrophic cardiomyopathy, sick sinus syndrome, and coronary arteriovenous fistula

Hypertrophic cardiomyopathy (HCM) is a rare cardiac complication in patients with Klinefelter syndrome. We report the case of a 67-year-old Japanese man with Klinefelter syndrome, HCM, sick sinus syndrome, and coronary arteriovenous fistula, in whom the 47XXY/46XY mosaic pattern was revealed by chromosomal study. Echocardiography revealed HCM with an interventricular septum thickness of 17 mm and a left ventricular posterior wall thickness of 10 mm. Sick sinus syndrome type III was diagnosed by paroxysmal atrial fibrillation (longest sinus arrest 9.0 sec) on 24-h Holter ECG recording. Coronary arteriovenous fistula was detected from the left anterior descending artery to the right ventricle by coronary arteriography. To our knowledge, this is the first case report of Klinefelter syndrome with HCM. As there have been a few reports of patients with Klinefelter syndrome in association with skeletal muscular diseases such as Becker-type muscular dystrophy or myotonic dystrophy, the gene mutation that causes Klinefelter syndrome may occur in the cardiac muscle. HCM may represent another variable expression of this chromosomal abnormality.

Contrast-enhanced radiographic computed tomographic findings in patients with straight back syndrome

Straight back syndrome (SBS) is usually diagnosed by physical and chest radiographic findings. Radiographic computed tomographic (CT) findings are very useful for the diagnosis and the evaluation of its severity. The purpose is to evaluate the relationship between chest X-ray film and CT findings.

SUBJECTS

We evaluated 26 patients (SBS group) and 11 normal subjects (control group). SBS group consisted of 15 patients without structural heart disease (group I) and 11 patients with other heart disease (group II).

METHODS

(1) On the chest X-ray film, antero-posterior diameter (APD) of the thorax, transthoracic diameter (TTD), and APD/TTD ratio were measured. (2) On the CT image, three parameters were calculated; APD of the left atrium (LA diameter), APD/transverse diameter ratio of the heart (flattening ratio) and left side shift ratio of the heart (shifting ratio). (3) CT parameters were compared with APD/TTD ratio in patients and control group.

RESULTS

(1) APD/TTD ratio was smaller in group I and II than control group (30.0 +/- 5.4, 30.5 +/- 4.0 v 44.6 +/- 2.7%, p < .001). (2) LA diameter was smaller in group I and II than control group (23.2 +/- 4.1, 26.0 +/- 8.6 v 30.0 +/- 6.5 mm, p < .01). Flattening ratio was also smaller in group I and II than control group (59.2 +/- 9.4, 61.8 +/- 8.6 v 75.4 +/- 13.2%, p < .01). Shifting ratio was greater in group I and II than control group (10.9 +/- 5.0, 11.9 +/- 4.5 v 8.4 +/- 4.0%, p < .01). (3) APD/TTD ratio correlated with LA diameter (r = .39, p < .05) and flattening ratio (r = .53, p < .001). APD/TTD ratio did not correlate with shifting ratio (r = -.27, NS).

CONCLUSIONS

APD/TTD ratio correlated with LA diameter and flattening ratio rather than shifting ratio. LA diameter and flattening ratio on the CT image were more useful for evaluating the severity.

Short- and long-term effects of nisoldipine on cardiac function and exercise tolerance in patients with hypertrophic cardiomyopathy

Nisoldipine is a second generation dihydropyridine calcium antagonist having characteristics of strong coronary artery dilating effect and less negative inotropic action. The purpose of this study was to evaluate the effect of nisoldipine on the cardiac function (systolic and diastolic) and the exercise tolerance, in patients with hypertrophic cardiomyopathy (HCM).

SUBJECTS

Twenty-three patients with HCM were studied.

METHODS

We measured the following indices using M-mode and pulsed wave Doppler echocardiography before and after nisoldipine therapy; left ventricular fractional shortening (LVFS), isometric relaxation time (IRT), deceleration half-time (DHT) of early diastolic mitral (E) flow, late diastolic mitral (A) flow and A/E ratio. Symptom-limited treadmill exercise test was performed. Exercise tolerance (EX) time was measured. Nisoldipine of 10 mg/day was orally administered. Same tests were repeated on day 14 and after 6 months.

RESULTS

1) Short-term effects; LVFS did not change (55.9 +/- 5.9%-->57.0 +/- 7.4%, NS) after 2 weeks. However, LV diastolic function significantly improved (IRT; 92.1 +/- 7.7 ms-->85.2 +/- 11.6 ms, p < 0.05, DHT; 70.7 +/- 16.2 ms-->63.3 +/- 3.7 ms, p < 0.05). EX time increased (8.9 +/- 2.6 min-->10.0 +/- 3.3 min, p < 0.05), 2) Long-term effects; LV diastolic function had a tendency toward improvement, but is statistically not significant (IRT; 91.1 +/- 7.6-->83.8 +/- 11.6 ms, DHT; 73.1 +/- 23.4-->61.0 +/- 11.4 ms, A/E; 1.26 +/- 0.29-->1.11 +/- 0.36) after 6 months. EX time was significantly increased (9.4 +/- 1.7--> 10.1 +/- 1.7 min, p < 0.05).

CONCLUSIONS

Nisoldipine improved LV diastolic dysfunction and exercise tolerance in patients with HCM. These effects were similar to the first generation calcium antagonists. LV diastolic dysfunction may be improved due to the reduction of intracellular calcium concentration and the relief of myocardial ischemia by strong coronary artery dilating effect. However, nisoldipine did not affect the LV systolic function because of its less negative inotropic effect.

[Peripheral blood stem cell transplantation for rapidly spreading myeloma]

We report a case of rapidly spreading myeloma of immature cell morphology treated by peripheral blood stem cell transplantation (PBSCT). A 54-year-old man had a right orbital tumor, which subsequently was removed and proved to be plasmacytoma. Three years later a mass lesion appeared in his left lung and bilateral kidneys. The specimen obtained at lung biopsy confirmed the diagnosis of plasmacytoma. Serum M-protein, IgG lambda was increased, but there was no increase in plasma cells in the bone marrow. Since chemotherapy with VAD did not show any improvement, a high dose etoposide (500 mg/day, 4 days) was administered. When bone marrow suppression recovered, PBSCs were harvested (3.3 x 10(6)/kg). After conditioning therapy with cyclophosphamide (2.0 g/day, 2 days), etoposide (200 mg/day, 3 days) and ranimustine (200 mg/day, 2 days), the stored PBSCs were injected. Minor response was obtained and he was discharged. 2 months thereafter, it was found that plasma cells increased in the bone marrow. He died of pulmonary bleeding soon. Autopsy revealed immature plasma cell infiltration in multiple organs including the heart, liver, spleen, kidneys, intestine, bone and bone marrow.

[An ELISA for the detection of anti-neutrophil cytoplasmic antibodies using the cytoplasmic alpha-fraction--clinical use for the diagnosis of Wegener granulomatosis and for monitoring its activity]

Anti-neutrophil cytoplasmic antibodies (ANCA) have been reported to be a disease-specific marker for Wegener's granulomatosis (WG). In the present study we developed an enzyme-linked immunosorbent assay (ELISA) for detecting and quantifying ANCA. The cytoplasmic alpha-fraction of neutrophils obtained from healthy human donors was used as an antigen. The alpha-fraction was purified from supernatants of homogenized neutrophils by sucrose gradient centrifugation. Peroxidase conjugated rabbit anti-human IgG was used as a secondary antibody. Diluted sera from 13 patients with WG, 15 with Sjögren syndrome, 1 with polymorphic reticulosis, 3 with relapsing polychondritis, 4 with other collagen diseases, 4 with sinusitis and 18 healthy donors were examined. It was concluded that this ELISA was sufficiently specific and sensitive for WG, and the ELISA units correlated individually with the ANCA titers as determined by an indirect immunofluorescence technique. This ELISA provides precise ANCA quantitation and will be useful for the diagnosis of WG and for monitoring its activity.

Autopsy report of acute necrotizing opticomyelopathy associated with thyroid cancer

We report an autopsied case of paraneoplastic necrotizing myelopathy. The patient had bilateral blindness, quadriplegia, and dyspnea of acute onset and died without remission 7 weeks later. The severe tissue necrosis and demyelination were found in the optic chiasm and from the medulla oblongata throughout the whole length of spinal cord. A papillary carcinoma was found in the thyroid gland at autopsy. In the present case IgG, myelin basic protein and activated helper T cells were increased in the CSF at onset, suggesting a mechanism of autoimmune demyelination for the condition.

[Clinical significance of anti-neutrophil cytoplasmic antibody (ANCA) for the diagnosis of Wegener's granulomatosis in the early stage]

In recent years, the prognosis of Wegener's granulomatosis (WG) has been dramatically improved by treatment with cyclophosphamide and glucocorticoids, if the diagnosis is made correctly in the early stage of the disease. However, it is often difficult to diagnose of WG relying only on clinical symptoms and histological confirmation with biopsy specimens. Anti-neutrophil cytoplasmic antibody (ANCA) has already been reported to have high sensitivity and specificity for WG. Since February, 1991, we examined this antibody level in the sera of patients suspected of having WG using an indirect immunofluorescence technique, and have experienced nine WG patients who were ANCA positive. Six of the 9 patients showed limited forms of WG before active generalized symptoms developed, and only 3 were diagnosed as having WG with pathologic findings from their biopsy samples. These results show that correct diagnosis of WG is possible with the aid of ANCA determination, even if the patient has a limited form of the disease and even without evidence of characteristic pathologic features of WG on biopsy specimens. Therefore, it is apparent that ANCA determination is a valuable tool for diagnosing WG as early as possible. In Japan, the ANCA test is not as yet a common laboratory examination and has only rarely been used as seromarker for the diagnosis and treatment of WG. We believe that ANCA determination is essential for the diagnosis of WG, especially in its early stage, which leads to a better prognosis for WG patients.

Dose-dependent platelet stimulation and inhibition induced by anti-PIA1 IgG

The PIA1 antibody produces several clinically distinct and severe thrombocytopenias. Investigations have demonstrated divergent effects on platelet function; prior reports demonstrated inhibition, while a conflicting publication showed platelet activation. We have resolved this conflict using anti-PIA1 IgG produced by a patient with posttransfusion purpura. Relatively low concentrations stimulated platelet aggregation and release of adenosine triphosphate (ATP) whereas high concentrations inhibited platelet function, producing a thrombasthenia-like state. The number of molecules of platelet-associated IgG necessary to initiate aggregation and ATP release (2,086 +/- 556) or produce maximum aggregation (23,420 +/- 3,706) or complete inhibition (63,582 +/- 2654) were measured with a quantitative radiometric assay for bound anti-PIA1. Preincubation of platelets with high concentrations of PIA1 antibody inhibited platelet aggregation with 10 mumol/L adenosine diphosphate and blocked 125I-labeled fibrinogen platelet binding. Platelet activation with nonfibrinogen dependent agonist, 1 U/ml thrombin, was not inhibited by this high concentration of PIA1 IgG. In conclusion, anti-PIAI IgG produces (1) stimulation of platelet aggregation and ATP release that is initiated with 2000 molecules IgG per platelet and is associated with an increase of 125I-fibrinogen binding; (2) conversely, inhibition of platelet aggregation is observed with maximum antibody binding, 63,000 molecules IgG per platelet, and is mediated via a blockade of fibrinogen binding.

The complementary role of indium-111 labeled leukocyte imaging, ultrasonography and computed tomography in the evaluation of postoperative infection or abscess

We report our experiences with the combined use of indium-111 labeled leukocyte imaging (In-III WBC scan.), computed tomography (CT) and ultrasonography (US) for evaluation of suspected postoperative infection or abscess, and discuss the complementary roles of these modalities. Postoperative abscesses or infections were diagnosed in 9 of 20 patients. All patients were correctly diagnosed by In-111 WBC imaging and 4 patients could not be diagnosed by US because of bowel gas. One false-positive CT examination and another artifact on CT images due to respiratory movements were obtained. The three modalities were found to be complementary: CT and US were efficient imaging methods for diagnosis and treatment of abscess. In-111 WBC imaging could estimate the activity of inflammation.