The relation between hospital experience and mortality for patients with AIDS.

To determine whether there is an association between mortality and hospital acquired immune deficiency syndrome (AIDS) experience for all AIDS-related diagnoses, and to determine whether the association is explained by differences in severity of illness, earlier discharge of terminally ill patients, or differences in resource use. Population-based statewide cohort study. All hospitalizations identified for a cohort of AIDS patients diagnosed during 1987 in 40 Massachusetts hospitals were included. All women and all male intravenous drug users (n = 151), and a random sample of all male non-intravenous drug users diagnosed with AIDS during 1987 in Massachusetts (n = 149). Primary end points studied were (1) inpatient mortality and (2) 30-day mortality. Length of stay, cost, and intensive care unit use were also examined. In 806 hospitalizations at 40 hospitals inpatient mortality was 13.2%. Relative risk of mortality at low AIDS experience hospitals was 2.16 (95% confidence interval, 1.43 to 3.26) compared with high AIDS experience hospitals. When logistic regression was used to control for age, sex, race, human immunodeficiency virus transmission mode, severity, payer, admission type, hospital ownership, and teaching status, low hospital experience with AIDS remained a significant predictor of inpatient mortality (relative risk, 2.92; 95% confidence interval, 1.37 to 6.22). Comparisons of 30-day mortality by hospital AIDS experience yielded similar results. Length of stay and intensive care unit use were also significantly higher at low-experience hospitals after controlling for severity of illness (P < .05). We conclude that mortality of AIDS patients is higher at hospitals with less AIDS experience. This finding is not because of greater severity of illness, differences in discharge patterns of the terminally ill, or less intensive use of resources.


A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest.

To determine the relative efficacy of high- vs standard-dose catecholamines in initial treatment of prehospital cardiac arrest. Randomized, prospective, double-blind clinical trial. Prehospital emergency medical system of a major US city. All adults in nontraumatic cardiac arrest, treated by paramedics, who would receive epinephrine according to American Heart Association advanced cardiac life support guidelines. High-dose epinephrine (HDE, 15 mg), high-dose norepinephrine bitartrate (NE, 11 mg), or standard-dose epinephrine (SDE, 1 mg) was blindly substituted for advanced cardiac life support doses of epinephrine. Restoration of spontaneous circulation in the field, admission to hospital, hospital discharge, and Cerebral Performance Category score. Of 2694 patients with cardiac arrests during the study period, resuscitation was attempted on 1062 patients. Of this total, 816 patients met study criteria and were enrolled. In the entire cardiac arrest population, 63% of the survivors were among the 11% of patients who were defibrillated by first responders. The three drug treatment groups were similar for all independent variables. Thirteen percent of patients receiving HDE regained a pulse in the field vs 8% of those receiving SDE (P = .01), and 18% of HDE patients were admitted to the hospital vs 10% of SDE patients who were admitted to the hospital (P = .02). Similar trends for NE were not significant. There were 18 survivors; 1.7% of HDE patients and 2.6% of NE patients were discharged from the hospital compared with 1.2% of SDE patients, but this was not significant (P = .37; beta = .38). There was a nonsignificant trend for Cerebral Performance Category scores to be worse for HDE (3.2) and NE patients (3.7) than for SDE patients (2.3) (P = .10; beta = .31). No significant complications were identified. High-dose epinephrine did not produce longer hospital or critical care unit stays. High-dose epinephrine significantly improves the rate of return of spontaneous circulation and hospital admission in patients who are in prehospital cardiac arrest without increasing complications. However, the increase in hospital discharge rate is not statistically significant, and no significant trend could be determined for neurological outcome. No benefit of NE compared with HDE was identified. Further study is needed to determine the optimal role of epinephrine in prehospital cardiac arrest.


Management of small abdominal aortic aneurysms. Early surgery vs watchful waiting.

To compare two clinical strategies for the management of small abdominal aortic aneurysms (AAAs) less than 5 cm in diameter: early surgery (repair small AAAs when diagnosed) and watchful waiting (measure AAA size every 6 months and repair when the diameter reaches 5 cm). We reviewed data from an earlier longitudinal study of patients with small AAAs to estimate incidence rates of rupture or acute expansion. Estimates for other parameters in the model were obtained by searching the medical literature (MEDLINE, 1966 to present). We constructed a Markov decision tree to compare early surgery with watchful waiting in patients with asymptomatic AAAs less than 5 cm in diameter, with respect to long-term survival in quality-adjusted life years. The average annual rates of rupture or acute expansion for AAAs with a maximal transverse diameter of less than 4.0, 4.0 to 4.9, and at least 5.0 cm, are 0, 3.3, and 14.4 events per 100 patient-years of observation, respectively. At an average rupture rate of 3.3 events per 100 patient-years and an average operative risk for elective surgery (4.6%, 30-day mortality), our model predicts that early surgery improves survival in patients who present with a 4-cm AAA. The benefit of early surgery decreases with increased age at presentation. If the average rupture rate for AAAs less than 5 cm is assumed to be low (eg, 0.4 event per 100 patient-years), watchful waiting if favored, particularly as operative risk increases. The decision in this subgroup, however, is sensitive to possible future increases in operative risk. In the majority of scenarios that we examined, early surgery is preferred to watchful waiting for patients with AAAs less than 5 cm in diameter. Watchful waiting is generally favored, however, for patients with a low risk of AAA rupture or acute expansion, including those patients who present with very small AAAs (eg, < 4 cm). More accurate data concerning the rupture risk of AAAs less than 5 cm would improve clinical decision making.


Latex glove allergy. A survey of the US Army Dental Corps.

To assess the prevalence of latex glove allergy in a population of health care providers (dentists) with a high occupational exposure to latex gloves. A survey instrument was distributed to all active-duty dental officers in the US Army (n = 1628). The survey was designed to identify those individuals who had symptoms of allergy to latex gloves. US Army dental facilities worldwide. The response rate to the survey was 64% (n = 1043). There were 143 (13.7%) responses indicating latex glove allergy. If nonrespondents were assumed to be allergy-free, the prevalence rate would be 8.8%. Latex allergy, as ascertained by self-report in this survey, appears to have a substantial prevalence in this health care provider population.


Diagnostic and therapeutic technology assessment. Distraction/compression osteosynthesis with the Ilizarov device.

Although the Ilizarov device (and technique) to treat problematic fractures and bone deformities has been used since the 1950s in the former Soviet Union, the technique was not introduced to the United States until 1984. Since that time, the technique has become increasingly popular because, in comparison with the alternatives, the Ilizarov technique involves only one surgical procedure and it appears to have fewer complications. In addition, the Ilizarov technique was designed to correct multiple deformities simultaneously. The DATTA panelists thought that the technique was established in terms of safety and effectiveness as a treatment of limb length deformity, bone defects, and angular/rotational deformity of the long bones. The panelists thought that it was promising in terms of safety and effectiveness as a treatment of pseudarthrosis. However, this overall endorsement of the technique was tempered by comments that the technique was associated with a lengthy learning curve, was very labor intensive, and required a large degree of patient cooperation.


Vesiculobullous diseases with prominent immunologic features.

It may be very difficult to differentiate between the many bullous skin diseases. Clinical presentation and age of onset can sometimes be helpful. Consultation with a dermatologist may facilitate diagnosis and treatment. More often, information from skin biopsy and immunofluorescent studies, such as DIF, IIF, or split-skin DIF or IIF, is required to make the diagnosis. It is hoped that current investigative studies will elucidate the role of immunoreactants found within the dermoepidermal basement membrane zone in the pathogenesis of these blistering diseases.


The excess incidence of diabetic end-stage renal disease among blacks. A population-based study of potential explanatory factors.

To investigate whether the excess incidence of diabetic end-stage renal disease (ESRD) among African Americans could be explained by racial differences in putative ESRD risk factors. Population-based, ecologic study using the 1981 and 1982 Maryland Statewide Household Hypertension Survey for data on risk factor prevalence. A total of 2.1 million adults residing within the boundaries of the Maryland Regional ESRD Registry, grouped by race and ZIP code into 26 subpopulations. Incidence rates of treatment for diabetic ESRD between 1980 and 1985 from the Maryland Regional ESRD Registry by subpopulation. Between 1980 and 1985, 442 persons entered treatment for diabetic ESRD. At the level of the subpopulation, diabetic ESRD incidence was positively associated with black race (relative risk [RR], 3.42; 95% confidence interval [CI], 2.84 to 4.13), prevalence of diabetes (RR, 2.35; 95% CI, 1.92 to 2.87), prevalence of poorly controlled hypertension (RR, 1.80; 95% CI, 1.45 to 1.86), lack of a regular source of health care (RR, 1.82; 95% CI, 1.62 to 2.05), and lower socioeconomic status as indicated by lack of college education (RR, 1.41; 95% CI, 1.32 to 1.52) (all, P < .0001). After adjusting for these risk factors, black race remained strongly associated with the overall incidence of diabetic ESRD (RR, 2.70; 95% CI, 1.89 to 3.86; P < .0001). Further analyses suggested that this excess risk among blacks was confined to ESRD related to non-insulin-dependent diabetes (RR, 4.80; 95% CI, 3.09 to 7.46; P < .0001); blacks were at no higher risk than were whites for ESRD related to insulin-dependent diabetes (RR, 0.90; 95% CI, 0.52 to 1.55; P = .70). These data suggest that the excess incidence of diabetic ESRD among blacks is not fully explained by a higher prevalence of diabetes or hypertension in blacks or by racial differences in age, socioeconomic status, or access to health care. Instead, they suggest an increased susceptibility to ESRD resulting from non-insulin-dependent diabetes among blacks as compared with whites.


Renal function change in hypertensive members of the Multiple Risk Factor Intervention Trial. Racial and treatment effects. The MRFIT Research Group.

To evaluate the contribution of mild to moderate hypertension to progressive loss of renal function by analysis of renal function data from the Multiple Risk Factor Intervention Trial. The cohort of men with mild to moderate hypertension (baseline diastolic blood pressure > or = 90 mm Hg), randomized to a special intervention (SI) group or usual care (UC) group, were examined for change in renal function based on individual reciprocal creatinine slopes over an average of 7 years' follow-up as the outcome measure. Contribution of blood pressure control during follow-up, age, race, and blood pressure at entry were assessed. The cohort of 5524 (463 black, 5061 nonblack) hypertensive men receiving no therapy at entry provided the data for the present analysis. Blood pressure control was similar for black and white participants, but significant decline in reciprocal creatinine slope was found for black men (mean slope, -0.0090 +/- 0.0013 dL/mg/y) compared with white men (+0.0018 +/- 0.0004 dL/mg/y) (P < .001 for difference between blacks and whites). Decline in renal function was also greater among individuals with elevated systolic (P < .001) as well as diastolic blood pressure (P < .001), and older individuals (P < .001). No difference between the SI and UC groups was seen in reciprocal creatinine slopes, but in both groups combined, treatment that maintained diastolic blood pressure below an average value of 95 mm Hg was associated with stable or improving renal function, whereas participants whose blood pressure remained 95 mm Hg or greater continued to decline at -0.0013 +/- 0.0009 dL/mg/y (P = .007 for difference). Separate examination of the subset of black men (n = 463) failed to show such a difference. Effective blood pressure control was associated with stable or improving renal function in nonblacks but not in blacks. These findings emphasize the importance of blood pressure control to maintain adequate renal function in hypertensive white men and raise important questions about the relationship of pressure reduction and renal function change in blacks.


Percutaneous transluminal coronary angioplasty in New York State. Risk factors and outcomes.

To identify significant independent risk factors for major percutaneous transluminal coronary angioplasty outcomes. Retrospective analysis using univariate and logistic regression analysis to identify significant independent risk factors for adverse outcomes. All 31 hospitals performing percutaneous transluminal coronary angioplasty in New York State in 1991. All 5827 patients undergoing percutaneous transluminal coronary angioplasty between January 1, 1991, and June 30, 1991, in New York State. In-hospital mortality, major complication(s) (in-hospital mortality, myocardial infarction, and/or emergency coronary artery bypass graft), and absence of angiographic success (stenosis reduction of less than 20% on any attempted lesion or residual stenosis of at least 50% on any attempted lesion). Before discharge from the hospital, a total of 37 patients (0.63%) died; 67 patients (1.1%) suffered a myocardial infarction, with a mortality rate of 4.5%; and 97 patients (1.7%) underwent emergency coronary artery bypass graft surgery, with a mortality rate of 2.1% (no deaths in 85 patients who were hemodynamically stable and two deaths among 12 patients who were hemodynamically unstable). A total of 187 patients (3.2%) experienced a major complication. Angiographic success was achieved for 88% of all patients. Multivariate analysis found four independent preprocedural variables related to death: female gender, hemodynamic instability, shock, and ejection fraction. Percutaneous transluminal coronary angioplasty outcomes in New York compare favorably with other recent results reported in the literature. Several preprocedural variables markedly increase the incidence of adverse events.


The changing rate of major depression. Cross-national comparisons. Cross-National Collaborative Group.

To estimate temporal trends in the rates of major depression cross-nationally. Nine epidemiologic surveys and three family studies. Approximately 39,000 subjects in population-based samples from nine epidemiologic surveys, and 4000 relatives from three family studies that were conducted independently but using similar methodology in the 1980s in North America, Puerto Rico, Western Europe, the Middle East, Asia, and the Pacific Rim. Age at first onset of major depression by birth cohort and time period. There was an increase in the cumulative lifetime rates of major depression with each successively younger birth cohort at all sites with the exception of the Hispanic samples, in whom the rates in the older cohort (1915 through 1935) were approximately equal to those of the younger cohorts. However, results of fitting statistical models that separate period and cohort effects showed an overall increase in the rates of major depression over time over all countries, although the magnitude of the increase varied by country. The average relative risk of major depression between a particular cohort and the cohort born immediately before varied between 2.6 (95% confidence interval, 1.8 to 3.7) in Florence, Italy, and 1.3 (95% confidence interval, 1.2 to 1.4) in Christchurch, New Zealand. Short-term fluctuations in the rates of major depression during specific time periods and in specific cohorts also varied by country. Cross-nationally, the more recent birth cohorts are at increased risk for major depression. There are, however, variations in the long- and short-term trends for major depression by country, which suggests that the rates in these countries may have been affected by differing historical, social, economic, or biological environmental events. The linking of demographic, epidemiologic, economic, and social indices by country to these changes may clarify environmental conditions that influence the rates of major depression.


Thrombolytic therapy of acute myocardial infarction. Keeping the unfulfilled promises.

To assess the use of thrombolytic therapy for acute myocardial infarction, evaluating whether inclusion and exclusion criteria should be altered as well as the public health implications of any such alterations. Data obtained were from English-language articles on the use of thrombolytic therapy in acute myocardial infarction. Articles that reported on inclusion and exclusion criteria as well as specific complications of this therapy were specifically sought. The review included articles under the terms thrombolytic therapy and acute myocardial infarction in the National Library of Medicine's MEDLINE database. Studies selected for detailed review were those reporting specifics about inclusion and exclusion criteria and efficacy. Data extraction guidelines for assessing data quality included study size, patient population, detail of patient information acquired, and consecutive patient enrollment. Thrombolytic therapy can provide substantial decrements of morbidity and mortality of acute myocardial infarction in the subset of patients who receive this therapy, but is underused in the United States. Advanced age per se should not be an exclusion criterion. Improvements can be made in electrocardiographic diagnosis of acute myocardial infarction. Many of the clinical conditions initially excluded from thrombolytic consideration, such as hypertension or having received cardiopulmonary resuscitation, are only relative contraindications. The benefit/risk ratio in treatment of these patients is often acceptable. Several well-documented points of delay from onset of symptoms to treatment can be minimized, and accelerated therapy can result in a reduction in mortality rates. Significant public health benefits will result from greater use of thrombolytic therapy in acute myocardial infarction.


A multistate outbreak of Salmonella javiana and Salmonella oranienburg infections due to consumption of contaminated cheese.

To determine the source of an outbreak of Salmonella javiana and Salmonella oranienburg infections. Laboratory-based statewide surveillance for Salmonella infections and two separate case-control studies. Community- and industry-based studies conducted from May through October 1989. Thirty-one culture-confirmed outbreak-associated cases of S javiana infection and 60 community controls matched for telephone prefix, gender, and age in case-control study I; 50 cases, 100 community controls, and 64 family member controls in case-control study II. One hundred thirty-six culture-confirmed cases of S javiana infection and 11 cases of S oranienburg infection were associated with the outbreak in Minnesota. Outbreak-associated cases were also identified in Wisconsin (15 cases), and in Michigan and New York (one case each). Cases were more likely than controls to have consumed mozzarella cheese manufactured at a single cheese plant (plant X) or cheese that had been shredded at processing plants that also shredded cheese manufactured at plant X (odds ratio [OR], 7.2; 95% confidence interval [CI], 1.7 to 23.2; P < .01). The outbreak-associated strains of both serovars were isolated from two unopened 16-oz (0.45-kg) blocks of mozzarella cheese produced at plant X. The most probable numbers of Salmonella organisms in these samples were 0.36/100 g and 4.3/100 g. The potential for bacterial pathogen contamination of cheese during manufacture and processing has important epidemiologic implications, particularly because cheese consumption has recently increased in the United States. Low-level contamination of a nationally distributed food product can cause geographically dispersed foodborne outbreaks that may be difficult to detect.


An international foodborne outbreak of shigellosis associated with a commercial airline.

To determine the source of an international outbreak of shigellosis associated with consumption of food served by a Minnesota-based airline. Cohort studies of players and staff of a Minnesota-based professional football team and passengers on flights with a confirmed case of outbreak-associated Shigella sonnei infection. Community- and industry-based studies conducted from October through November 1988. Sixty-five football team players and staff, and 725 airline passengers in the cohort studies. Twenty-one (32%) of 65 football players and staff developed shigellosis that was associated with consumption of cold sandwiches prepared at the airline flight kitchen (relative risk [RR], 17.1; 95% confidence interval [Cl], 2.4 to 120; P < .001). Confirmed or probable shigellosis was identified among 240 passengers on 219 flights to 24 states, the District of Columbia, and four countries between September 14 and October 13. An outbreak-associated strain of S sonnei was isolated from football players and staff, airline passengers, and flight attendants. Thirty (4.1%) of 725 passengers on 13 flights with confirmed cases had confirmed or probable shigellosis. Illness was associated with consumption of cold food items served on the flights and prepared by hand at the airline flight kitchen (RR, 5.7; 95% Cl, 1.4 to 23.5; P < .01). This international outbreak of shigellosis was identified only because of the occurrence of an index outbreak involving a professional football team. Prevention of Shigella transmission in mass catering establishments may require reduction of hand contact in the preparation of cold food items or elimination of these items from menus.


Cognitive development of Yu-Cheng ("oil disease") children prenatally exposed to heat-degraded PCBs.

To compare the cognitive development in Taiwanese children who had been exposed prenatally to high levels of heat-degraded polychlorinated biphenyls (PCBs) with control children who were exposed to background levels. The disorder was called Yu-Cheng, "oil disease," in Taiwan. Matched-pair cohort study. Communities in central Taiwan in which there had been a cooking-oil contamination and mass poisoning by heat-degraded PCBs in 1978 through 1979. One hundred eighteen children born between June 1978 and March 1985 during or after their mothers' consumption of contaminated rice oil; 118 children matched for age, sex, neighborhood, maternal age, and parental education and occupational class; and 15 older siblings of exposed children, born before the poisoning. Cognitive development measured from 1985 through 1990 using the Chinese versions of the Stanford-Binet test and the Wechsler Intelligence Scale for Children, Revised, The exposed children scored approximately 5 points lower on the Stanford-Binet test at the ages of 4 and 5 years and approximately 5 points lower on the Wechsler Intelligence Scale for Children, Revised, at the ages of 6 and 7 years. Children born up to 6 years after their mothers' exposure were as affected as children born within a year or two after exposure when examined at 6 and 7 years of age. Older siblings resembled the control children. Children prenatally exposed to heat-degraded PCBs had poorer cognitive development than their matched controls. The effect persisted in the children up to the age of 7 years, and children born long after the exposure were still affected.


Misconceptions about cancer among Latinos and Anglos.

To collect information regarding knowledge about and attitudes toward cancer in a sample of adult health plan members, self-identified as Latino or Anglo. Cross-sectional survey. Prepaid health plan. A random sample of 844 Latinos (mean age, 50.5 years) and 510 Anglos (51.8 years) completed the interview. Latinos were significantly more likely than Anglos to think that sugar substitutes (58% vs 42%), bruises from being hit (53% vs 34%), microwave ovens (47% vs 23%), eating pork (31% vs 11%), eating spicy foods (15% vs 8%), breast-feeding (14% vs 6%), and antibiotics (32% vs 12%) could cause cancer (P < .001 for each). Compared with Anglos, Latinos more often misidentified constant dizziness (39% vs 25%) and arthralgias (35% vs 20%) as being symptoms of cancer. A higher proportion of Latinos believed that having cancer is like getting a death sentence (46% vs 26%), that cancer is God's punishment (7% vs 2%), that there is very little one can do to prevent getting cancer (26% vs 18%), that it is uncomfortable to touch someone with cancer (13% vs 8%), and that they would rather not know if they had incurable cancer (35% vs 23%; P < .001 for each). Latino ethnicity was a significant predictor of these knowledge and attitude items in multivariate logistic regression models adjusted for sex, education, age, employment, marital status, county of residence, and self-perceived health status. We conclude that misconceptions about cancer are more prevalent among Latinos than Anglos and that selected attitudes about cancer among Latinos fit a cultural theme of fatalismo. These data can enable development of culturally appropriate cancer control interventions for Latinos.


Campylobacter enteritis outbreaks associated with drinking raw milk during youth activities. A 10-year review of outbreaks in the United States.

To determine the incidence of recognized outbreaks of Campylobacter enteritis associated with drinking raw milk during youth activities. Retrospective survey of 51 state and territorial health departments. The 50 United States and the Territory of Puerto Rico. Persons in preschool through college. Information was obtained for all Campylobacter outbreaks associated with consumption of raw milk during youth activities from 1981 through 1990 that were investigated by state and territorial health departments. Twenty outbreaks were identified in 11 states. Four hundred fifty-eight outbreak-associated cases occurred among 1013 persons who drank raw milk, with an overall attack rate of 45%. At least one outbreak was reported for each year of the 10-year period. Fourteen outbreaks (70%) occurred among children in kindergarten through third grade, compared with one outbreak (5%) among fourth through sixth graders. The remaining five outbreaks (25%) occurred in mixed groups of children and teenagers. Only nine (60%) of 15 outbreaks identified from 1981 through 1988 were reported to the Campylobacter national surveillance system maintained by the Centers for Disease Control and Prevention. Drinking raw milk on school field trips or other youth activities continues despite the occurrence of multiple Campylobacter outbreaks documented from this practice. Such illnesses can be prevented by educating dairy farmers and officials of schools and youth organizations about the hazards of drinking raw milk. Public health organizations need to develop and implement such educational programs.


Induced termination of pregnancy before and after Roe v Wade. Trends in the mortality and morbidity of women. Council on Scientific Affairs, American Medical Association.

The mortality and morbidity of women who terminated their pregnancy before the 1973 Supreme Court decision in Roe v Wade are compared with post-Roe v Wade mortality and morbidity. Mortality data before 1973 are from the National Center for Health Statistics; data from 1973 through 1985 are from the Centers for Disease Control and The Alan Guttmacher Institute. Trends in serious abortion-related complications between 1970 and 1990 are based on data from the Joint Program for the Study of Abortion and from the National Abortion Federation. Deaths from illegally induced abortion declined between 1940 and 1972 in part because of the introduction of antibiotics to manage sepsis and the widespread use of effective contraceptives. Deaths from legal abortion declined fivefold between 1973 and 1985 (from 3.3 deaths to 0.4 death per 100,000 procedures), reflecting increased physician education and skills, improvements in medical technology, and, notably, the earlier termination of pregnancy. The risk of death from legal abortion is higher among minority women and women over the age of 35 years, and increases with gestational age. Legal-abortion mortality between 1979 and 1985 was 0.6 death per 100,000 procedures, more than 10 times lower than the 9.1 maternal deaths per 100,000 live births between 1979 and 1986. Serious complications from legal abortion are rare. Most women who have a single abortion with vacuum aspiration experience few if any subsequent problems getting pregnant or having healthy children. Less is known about the effects of multiple abortions on future fecundity. Adverse emotional reactions to abortion are rare; most women experience relief and reduced depression and distress.


Use of triple-lumen subclavian catheters for administration of total parenteral nutrition.

This study evaluated the safety of triple vs single-lumen catheters in intravenous nutrition. Patients who were judged likely to benefit from a triple-lumen catheter were randomized to receive either a single-lumen catheter, with additional peripheral or central venous access as needed, or a triple-lumen catheter. All patients were at increased risk of catheter-related infection because of one or more of the following conditions: > 60 years of age, breakdown of skin integrity, severe underlying illness, diagnosis of acute pancreatitis, recent head or neck surgery, or presence of a preexisting infection. Patients were excluded who had neutropenia, were immunosuppressed, had body burns > 40%, or had contaminated wounds in the subclavicular area. Of 204 patients entered between June 1989 and November 1991, 177 completed the required > or = 7 days of therapy. Seventy-eight of these patients were randomized to a single-lumen catheter and 99 to a triple-lumen catheter. Catheters were inserted and maintained by the Nutrition Support Team. Dressings were monitored daily and changed weekly using a bio-occlusive dressing. When parameters were met for a possible septic episode, simultaneous peripheral and central catheter blood cultures were obtained using the Isolator method. Catheter-related sepsis was considered present if the colony count from a central catheter lumen was > or = 5 times that of the peripheral blood. The incidence of catheter-related sepsis for single-lumen catheters was 2.6% (2 of 78) compared with 13.1% for triple-lumen catheters (13 of 99) (p < .01). No correlation was found with the number of insertion attempts, catheter days, or patient's age.(ABSTRACT TRUNCATED AT 250 WORDS)


Effect of body positions and splints in bioelectrical impedance analysis.

The objective of this study was to evaluate body composition as measured by bioelectric impedance analysis using splints and body positions differing from the standard supine position. Forty-three patients, randomized into two groups of different body positions, and 101 healthy volunteers were prospectively studied. Resistance and reactance of body tissues were measured by bioelectric impedance analysis. Body composition is described by a three-compartment model composed of body fat, body cell mass, and extra cellular mass. The patients were measured in the standard supine position and then randomized into two groups. They were then remeasured with the appropriate splinting device or position change. Volunteers were measured in the standard supine position and all four alternative positions. There was a statistically significant difference demonstrated in whole body resistance, whole body reactance, body cell mass, and the ratio of extracellular mass to body cell mass in some body positions. The percentage of change with different body positions and splints, when compared with the standard supine position, was generally below 2%, a clinically insignificant difference. We conclude that the reliability of resistance and reactance as measured by bioelectric impedance analysis is clinically valid using any of the tested body positions and/or splints. The three-compartment model may be a useful concept to measure body composition changes in both healthy and sick persons.


Parenteral glutathione monoester enhances tissue antioxidant stores.

Glutathione (GSH) is a potent endogenous antioxidant that protects major organs from oxidant injury. However, present nutrition regimens may inadequately support tissue stores of this tripeptide during critical illness. To determine whether GSH reserves can be enhanced in vivo with intravenous (IV) supplements, rats underwent central venous catheterization, were given chow and water ad libitum during a 2-day recovery period, and were then randomized to receive one of three treatments as an IV bolus: (1) dextrose, (2) glutathione (GSH), or (3) glutathione monoethyl ester. GSH monoethyl ester is transported into cells more easily than is GSH. Tissue and plasma samples were analyzed for GSH at 2 and 4 hours after drug administration. Liver, renal, and ileal mucosal GSH were significantly increased in the GSH-monoethyl ester rats compared with dextrose-treated animals. In addition, plasma GSH was dramatically increased after monoester injection. In contrast, GSH administration depressed liver GSH stores and did not significantly affect GSH concentration in the other organs analyzed. Plasma GSH concentration was elevated 2 hours after GSH administration. We conclude that: (1) the monoethyl ester of glutathione can be used in vivo to enhance tissue and plasma GSH concentration and (2) IV GSH administration does not significantly increase tissue GSH levels and may paradoxically depress hepatic GSH in normal rats. Because the malnourished and critically ill are likely to have depleted GSH stores, nutrition strategies that include the provision of GSH monoester may lend additional support to those organs that are at risk for injury from oxygen free radicals during catabolic states.


Parenteral arginine infusion in humans: nutrient substrate or pharmacologic agent?

When given as a dietary supplement, arginine enhances lymphocyte mitogenesis and improves nitrogen balance. The purpose of this study was to evaluate arginine's ability to mediate these same effects when given as the sole nitrogen source with minimum additional calories. Thirty patients were randomized to receive 20 g/day arginine hydrochloride or a mixed amino acid solution (Travasol) by intravenous infusion for 7 days after abdominal operations. Mean patient age, body weight, gender ratios, and preoperative degree of weight loss were similar between groups. Mean plasma arginine and ornithine levels rose to 228 +/- 50 mumol/L and 191 +/- 76 mumol/L in the arginine group during infusion. Mean nitrogen balance was -8.8 g/day and -9.2 g/day in the arginine and Travasol groups, respectively. Mean lymphocyte stimulation indices to concanavalin A and phytohemagglutinin fell on postoperative day 1 in both groups. No significant differences in patterns of lymphocyte mitogenesis changes were noted between groups. The mean total number of circulating T cells increased in the arginine group at postoperative day 7. Thus, parenteral arginine infusion in postoperative patients provided comparable nitrogen balance to a balanced amino acid solution but did not increase peripheral blood lymphocyte mitogenesis. When arginine is given parenterally as the sole nitrogen source with minimal additional calories to postoperative patients, no enhancement of mitogen-stimulated lymphocyte proliferation could be demonstrated.


Gastroesophageal reflux in intubated patients receiving enteral nutrition: effect of supine and semirecumbent positions.

The incidence of gastroesophageal reflux (GER) in critically ill patients as well as the effect of a nasogastric tube (NGT) and body position as risk factors for GER were determined. Seventy patients with orotracheal intubation receiving enteral nutrition through a NGT for more than 48 hours were prospectively studied with two randomly assigned body positions: supine or semirecumbent. Detection of GER was achieved by scintigraphy after labeling gastric contents with 500 microCi of technetium-99m sulfur colloid administered through the NGT. In 50 patients scintigraphy was performed after subjects had remained in the randomized position for 2 hours with the NGT pinched. Twenty additional patients were studied after the NGT had been removed. In 50 patients with NGT, GER was present in 74% (37 of 50) and was higher in the supine position (81%, 21 of 26) than in the semirecumbent position (67%, 16 of 24), but this difference was not statistically significant (p = .26). In 20 patients without NGT, the incidence of GER was 35% (7 of 20) and it was also higher in the supine (50%, 6 of 12) than in the semirecumbent position (12%, 1 of 8, p = .16). There was a statistically significant difference between GER in patients with and without NGT (74% vs 35%, p = .0002). These data show that there is a high incidence of GER in patients with orotracheal intubation and NGT. The presence of a NGT is a risk factor for GER. Semirecumbency does not prevent GER, but there is less incidence than in the supine position.


Intravenous glutamine fails to improve gut morphology after radiation injury.

Male Sprague-Dawley rats housed in individual metabolic cages received total parenteral nutrients via chronic indwelling internal jugular catheters to determine whether supplementing parenteral nutrition with glutamine would accelerate recovery of small-bowel morphology after abdominal radiation. After recovering from catheter insertion for 3 days they received either 1000 cGy gamma radiation to the abdomen only or no radiation and immediately thereafter received isonitrogenous and isocaloric intravenous solutions containing either 0% or 2% glutamine at 1.58 mL/h for the next 5 days. Intestinal segments were then assayed for whole-bowel deoxyribose nucleic acid content and villus height. Irradiation caused a 40% decrement in these parameters, which were not restored by glutamine supplementation. Therefore, intravenous glutamine supplementation failed to accelerate recovery of small-bowel morphology in this model of combined surgical and radiation injury.


Arginine enhances T-cell responses in athymic nude mice.

Supplemental L-arginine has been shown to enhance thymic and T-cell responses in rodents. We examined the ability of supplemental dietary L-arginine to induce T-cell function in athymic nude mice that lack a normally developed T-cell system. Groups of male nude (nu/nu) mice (Balb/c background) 7 to 8 weeks old were given for 2 weeks 1.2% arginine hydrochloride solution for drinking, whereas controls received acidified tap water. All mice ingested a standard laboratory chow. In the first experiment, the arginine-supplemented animals had significantly greater number of T cells in the spleen (assessed by the number of Thy 1.2-positive lymphocytes) and these cells had enhanced mitogenic responses to mitogenic stimulation (phytohemagglutinin and concanavalin A). In vivo delayed-type hypersensitivity responses to 2,4-dinitro-1-difluorobenzene were also significantly increased after the 2 weeks of arginine supplementation. In a second experiment, mice maintained under the same conditions were skin grafted with rat tail skin. Animals were observed for 100 days for rejection but no significant difference was noted in skin graft survival. We conclude that dietary arginine can increase extrathymic T-cell maturation and function, but cannot induce in vivo allogeneic graft recognition in athymic nude mice.


Early postprandial energy expenditure and macronutrient use after a mixed meal in cirrhotic patients.

The effect of meal ingestion (9 kcal/kg of body weight, 53% carbohydrate, 30% fat, 17% protein, as a liquid formula) on energy expenditure and oxidation rate of carbohydrate, fat, and protein was assessed by indirect calorimetry and urinary nitrogen excretion before and for 3 hours after eating in stable cirrhotic patients and control subjects of comparable age. Postprandial modifications of substrate and hormone levels were also studied. Compared with basal values, the mean +/- SD resting energy expenditure during the first 3 hours after meal ingestion increased similarly in cirrhotic patients (+0.32 +/- 0.12 kcal/min) and control subjects (+0.31 +/- 0.08 kcal/min). Dietary induced thermogenesis was equivalent to 10% of the energy contained in the meal in both groups. Before eating, the carbohydrate oxidation rate was lower and fat oxidation higher in cirrhotic patients than in the control subjects. After eating, glucose oxidation increased whereas fat and protein oxidation rates were reduced in both groups. As a consequence the amount of fat oxidized in the postprandial period remained higher in cirrhotic patients than in the control subjects. After meal ingestion, serum glucose levels increased whereas plasma free fatty acid and glycerol levels decreased in both groups. The substrates, however, remained significantly higher in cirrhotic patients than in control subjects, despite the higher postprandial insulin increment in the patients group, thus suggesting the presence of insulin resistance. Because the postprandial glucose oxidation rate was normal, the low insulin-mediated glucose uptake observed in cirrhotic patients seems to reflect a defect in the nonoxidative disposal of the glucose ingested.(ABSTRACT TRUNCATED AT 250 WORDS)


Long-term central venous access vs other home therapies: complications in patients with acquired immunodeficiency syndrome.

One hundred and forty silicone catheters were inserted in 127 patients for long-term intravenous access with a cumulative follow-up time of 21,125 catheter-days (58 patient-years). Fifty-six patients had acquired immunodeficiency syndrome (AIDS); 44 were not AIDS patients and were receiving ambulatory home parenteral nutrition, whereas the remaining 27 did not have AIDS and were receiving home antibiotic therapy. Patients had a mean of 1.1 catheters inserted, and the rate of Hickman catheter-related sepsis was 0.18 per 100 catheter days or 0.6 septic episodes per patient year of treatment. Catheter-related sepsis was higher in AIDS patients (p < .01) and in patients receiving parenteral nutrition (p < .05) compared with those receiving antibiotic therapy. Prior catheter infection and AIDS were the most significant predictors of catheter infection (p < .01). Staphylococcus aureus was the most commonly isolated pathogen (61%) in AIDS patients. Fever (p < .001) and relative leukocytosis (p < .02) were the most common signs of infection. Only 14 infected catheters (37.8%) were salvaged by antibiotic therapy after the initial infection episode, and 6 of these catheters (42.9%) had recurrent multiple infections. In addition, inflammatory bowel disease was found to be a risk factor for venous thrombosis (p = .018). We conclude that because immunocompromised patients have a high risk of infection, catheter-related sepsis in these patients should be treated by catheter removal and antibiotics.


Different effects of long-chain and medium-chain triglycerides on glucose oxidation during total parenteral nutrition.

This study was undertaken to clarify differences in the effects of lipid emulsions containing either long-chain or medium-chain triglycerides (MCT) on glucose metabolism during total parenteral nutrition (TPN). Glucose kinetics were assessed in beagle dogs using primed, constant infusions of [14C]- and [6-3H]glucose. The rate of appearance of glucose, the percent of VCO2 derived from the oxidation of glucose, the rate of glucose oxidation, and the percent of glucose uptake oxidized were measured at the end of 72 hours of each of the two TPN regimens, ie, TPN in which soybean oil served as long-chain triglyceride comprising 40% of nonprotein calories (L-TPN), and TPN in which tricaprylin emulsion served as MCT (M-TPN). Glucose intake was 5.9 +/- 0.5 mg/kg per minute in L-TPN and 5.8 +/- 0.2 mg/kg per minute in M-TPN. There was no significant difference in the rate of glucose appearance between L-TPN and M-TPN. The rate of glucose oxidation was higher with M-TPN than with L-TPN (p < .05). Not only the percent of VCO2 derived from the oxidation of glucose but also the percent of glucose uptake oxidized tended to be higher during M-TPN than during L-TPN. These findings suggest that the glucose metabolism of dogs receiving L-TPN is different from that of dogs receiving M-TPN.


Hypermetabolism and hypercatabolism in Guillain-Barré syndrome.

We studied 21 patients with Guillain-Barré syndrome who demonstrated multiple nutritional risk factors upon admission to an intensive care unit: ventilator dependence (71.4%), adynamic ileus (23.8%), significant weight loss in the 2 weeks before admission (53.0%), antecedent viral illness with gastrointestinal sequelae (43.0%), cranial nerve deficits impairing oral intake and gastrointestinal motility (60%), and depressed serum transferrin (85.7%). Patients are hypermetabolic and hypercatabolic because of endocrine, infectious, and inflammatory components of the disease. High-energy (40 to 45 nonprotein kcal/kg), high-protein (2.0 to 2.5 g/kg) nutrition support appears to exert a favorable effect on visceral protein repletion, nitrogen balance, and resistance to pulmonary infection. Immediate attainment of positive energy balance in these hypermetabolic patients, ideally assessed by indirect calorimetry and followed by high-energy, high-protein feedings, may promote positive nitrogen balance early and attenuate muscle wasting in Guillain-Barré syndrome.


A simple technique to redirect malpositioned Silastic central venous catheters.

A simple and noninvasive method to redirect malpositioned Silastic central venous catheters is described. A syringe is connected to the catheter hub, and burst injections of saline cause the tip of the catheter to flip into the correct intravascular position. The present technique has been applied to more than 30 pediatric patients with excellent results. A detailed description of the technique and case examples are presented.


Experimental and clinical applications of molecular cell biology in nutrition and metabolism.

Rapid advances in molecular biology have yielded important new techniques for understanding the cellular mechanisms of normal homeostasis and disease. In particular, molecular laboratory methodologies have become important investigative tools for nutritional studies. Detection techniques for specific DNAs, RNAs, and proteins allow direct examination of cellular regulation of protein expression in health and illness. Construction of transgeneic models by recent techniques of inserting foreign genes into experimental animals has provided novel models for studies of cellular metabolism. In addition, molecular biology has had impact on clinical nutrition and therapy. Molecular techniques not only allow for early diagnosis of many inborn genetic errors of metabolism, recombinant technology has also provided for large-scale production of proteins and hormones of potential therapeutic value. The possibility for direct gene therapies is also nearing reality. Hence, understanding the language of molecular biology and the recent developments in this field is not only of research interest, but is also of clinical relevance.


Prefilter and postfilter cysteine/cystine and copper concentrations in pediatric parenteral nutrition solutions.

Pediatric amino acid products contain lower concentrations of methionine and require the addition of L-cysteine HCl just before infusion. Reports of a potential interaction between cysteine and copper, a routine addition to parenteral nutrition solutions, have appeared in the literature. This study serially evaluated cysteine/cystine and copper concentrations pre- and postfilter (0.22 microns) in two parenteral nutrition formulations prescribed for normal fluid (NF) or fluid-restricted (FR) pediatric patients. Solutions were infused via a peristaltic pump in vitro for 24 hours. Pre- and postfilter samples were obtained immediately after the infusion began (time 0) and at 1, 2, 3, 4, 8, 12, 16, 20, and 24 hours during the infusion. At 24 hours pre- and postfilter, cysteine/cystine were quantitated at 87.3% and 85% of the initial concentrations, respectively, for the NF solution and 92% and 91.5% for the FR solution. Pre- and postfilter copper was quantitated at 87.5% and 92.5% of the initial concentrations, respectively, for the NF solution and 88.2% and 95.2% for the FR solution. The 24 hour area under the curve for cysteine/cystine was 88.4% for the NF solution and 96.4% for the FR solution. For copper, the area under the curve for the NF solution was 99% and 96.7% for the FR solution. There was no visual evidence of incompatibility or precipitation. We conclude that copper-containing parenteral nutrition solutions with L-cysteine HCl added immediately before infusion are relatively stable after compounding and infusion over 24 hours.


Diagnosis of pleural effusions.

Sixty patients of pleural effusion with different aetiology are described. Various microbiological and biochemical parameters were done simultaneously in blood and pleural fluid to differentiate tuberculosis and non-tuberculosis effusions. Some biochemical tests were thought to be helpful in differential diagnosis but no single parameter was found diagnostic. Routine investigations of pleural fluid, sputum and pleural biopsy still remain the best method of diagnosis.


Bone tuberculosis in Abbottabad.

Eighty patients of bone and joint tuberculosis were diagnosed and treated at DHQ Teaching Hospital, Abbottabad from August, 1987 to December, 1990. Majority of them were children and young adults. There were more females (57.5%) than males (42.5%). A major fraction of the cases were Afghan refugees. Most of the patients were malnourished and belonged to low socioeconomic class.


Emotional and behavioural problems among school children in Pakistan.

The prevalence of emotional and behavioural problems in school children using Rutters children behavioural questionnaire was 9.3% with antisocial disorders being the commonest one. These disorders are not only present in this culture but also differ in terms of psychopathology with different levels of schooling. The findings are discussed in terms of their relevance to mental health of children with comparison of results from other countries.


Adhesion formation to incisional abdominal wound in response to polyamide "6" and polyglactin "910" sutures.

Frequency of adhesion formation to laparotomy wound scar in response to absorbable and non-absorbable synthetic sutures and closure technique was studied. Polyglactin "910" (synthetic absorbable) and polyamide "6" (synthetic non-absorbable) sutures were compared employing both mass and layered closure technique. Layered closure with polyglactin "910" closure developed maximum number of adhesions to laparotomy scar.


Non-Hodgkin's lymphoma--clinicopathological pattern.

A study of histopathological and clinical features of non-Hodgkin's lymphoma in 495 consecutive cases, diagnosed at AFIP during 1984-1989 is presented. Children below the age of 15 years were not included in this study. The relative frequency of non-Hodgkin's lymphoma was 4.29% in our material. Non-Hodgkin's lymphoma was more frequent than Hodgkin's disease, ratio being 2.44:1. Lymphadenopathy (78.78%), fever (33.08%), weight loss (31.62%) and anemia (30.14%) were the main presenting features. New working formulation was used for morphological characterisation. Follicular lymphoma constituted 8.08% of all cases. Follicular lymphoma was seen only in older age whereas diffuse lymphoma occurred in all age groups. Intermediate and high grade lymphoma represented 73.54% of all NHL. Small lymphocytic lymphoma was common in low grade tumours (13.13%). Extra nodal lymphoma was encountered in a significant proportion (21.22%), gastrointestinal tract being the most frequent site. This study outlines certain interesting features of NHL in Pakistan.


Gastric ulcer in Karachi.

Of 138 endoscopically or surgically confirmed cases of gastric ulcer, 102 (74%) were males and 36 (26%) females. Both sexes were affected most commonly in the 6th decade of life. Pain, vomiting and gastrointestinal bleeding were the major presenting symptoms, with a median duration of 6 months. Cigarette smoking was the most common (44%) addiction and 10% were on analgesics or nonsteroidal anti-inflammatory drugs (NSAID). Family history of ulcer was uncommon (2%) and no predilection for any blood group was noted. Among males 53% were skilled workers while 94% of females were housewives. Forty five percent patients were migrants from India and the rest belonged to different provinces of Pakistan. Presentation and behaviour of different sites of gastric ulcers though varied but the results were not significant. Healing rates with H2 receptor antagonists were 33% at 4 weeks and 78% at 8 weeks.


Heroin addiction and sex hormones in males.

To investigate the effects of illicit heroin abuse on the endocrine system a study was carried out in North West Frontier Province (NWFP) where heroin addiction is prevalent. Sixty-eight subjects were included in this study. Thirty-three were untreated heroin addicts visiting "drug abuse treatment centres" in Peshawar and 35 age matched normal males. Urine samples of all addicts showed the presence of morphine. The serum concentrations of testosterone (T) in addicts was 228 ng/ml, leutinizing hormone (LH) 10.7 mlU/ml and folical stimulating hormone (FSH) 4.9 mlU/ml whereas the corresponding values for control males were T 630 ng/ml, LH 14.3 mlU/ml and FSH mlU/ml, respectively. Heroin exerts a depletion effect on T and FSH levels in more or less all the groups studied irrespective of age, amount of heroin intake per day and period of contact with heroin. LH levels remained affected and are within clinically accepted normal range.


Prevalence of mutans streptococci and dental caries in Pakistani children.

The caries status of two hundred and eighteen 12 year old school children from four schools of Karachi and Lahore was determined through a WHO pathfinder survey. In addition, the levels of mutans streptococci in the sample were estimated in order to define the proportion of children with high and low mutans levels. A mean DMFT of 1.82 (1.67-0.03-0.12), for decayed and filled teeth respectively; 42% were caries free. Four mutans streptococci; 22% had mutans class 0, 22% class 1, 31% class 2 and 25% class 3. The mean DMFT was respectively, 1.0 + 1.23, 0.98 + 1.52, 2.03 + 2.36 and 3.04 + 3.08. The difference was statistically significant. Twenty four children had 5 or more DMF all except two of them, belonging to mutans classes 2 or 3.


Simple, efficient and simultaneous determination of anabolic steroids in human urine.

A high performance liquid chromatographic method for the determination of free anabolic drug "sustanon 250" (Organon) is developed. Four testosterone esters, propionate, phenylpropionate, isocaproate and decanoate were detected simultaneously and quantitatively in only 15 minutes. The percentage extraction in dichloromethane of the four testosterone esters from doped urine was 88, 87, 89 and 94% respectively. The separation recorded at 254 nm using analytical column ODS-C18 and methanol as an eluent, showed no interference of naturally occurring steroids. This method can be used for pharmacokinetic studies, routine analysis in pharmaceutical industry, routine therapeutic surveillance and in drug abuse by sportsmen.


Electrophysiologic changes before onset of ventricular tachyarrhythmias during partial reperfusion following severe myocardial ischemia in dogs.

We examined the electrophysiologic changes before an onset of ventricular tachyarrhythmia during partial reperfusion following severe myocardial ischemia. The left anterior descending coronary artery was occluded and cannulated below the occluded portion in 26 dogs. To deplete collateral flow into the ischemic myocardium, retrograde blood flow was induced for 20 min. Then, in all dogs except 7 with ventricular fibrillation during retrograde blood flow, partial reperfusion through collateral flow into the ischemic myocardium was produced by stopping the retrograde flow. Within 2 min of partial reperfusion, sustained ventricular tachycardia (VT) occurred in 7 dogs (group A) and non-sustained VT degenerating ventricular fibrillation occurred in 11 dogs (group B) of the remaining 12 dogs. In 6 dogs of group A and 9 of group B, epicardial conduction block appeared 5.0 +/- 2.2 and 3.5 +/- 1.3 min after ischemia. This was followed by fractionated electrical activities 15.2 +/- 3.2 and 11.7 +/- 3.3 min after ischemia. In group A, the fractionation had a slight change in configuration and a small increase in amplitude before the onset of VT during reperfusion; in group B, new deflections with large amplitude emerged before it. There was a significant difference in the amplitude (0.38 +/- 0.2 vs 0.67 +/- 0.3 mV, p < 0.025) between the 2 groups, although there was no significant difference in the amplitude (0.33 +/- 0.2 vs 0.23 +/- 0.1 mV) of the fractionation just before reperfusion. Our results show that slight improvement in fractionation induces sustained VT, and new deflections induce non-sustained VT degenerating ventricular fibrillation, even during partial reperfusion.


Intermittent anterior divisional block and far advanced right bundle branch block induced by vasospasm during exercise testing.

A patient is reported in whom exercise induced reversible ischemic left anterior fascicular block and far advanced right bundle branch block. Master's two step exercise test for pre-operative check-up revealed significant ST elevation in leads V1-5, negative U waves in leads V3-5 and fascicular blocks with retrosternal anginal chest pain. Long acting nitrate and nicorandil relieved the fascicular blocks.


Long-term follow-up study of three patients with the long QT syndrome.

We studied three women with the long QT syndrome. They were aged 42, 52 and 25 years and had experienced recurrent syncopal attacks. We followed case 1 for 17, case 2 for 18, and case 3 for over 6 y. The attacks tended to occur during the premenstrual stage in case 1 and case 2; case 3 often experienced attacks after exercise. The QT(U)c intervals on admission were 0.68, 0.62, and 0.50 in case 1, 2, and 3, respectively. Torsade de pointes followed by ventricular fibrillation was documented in case 1 and case 2. Although each was treated with a beta-blocker, none was fully compliant with the regimen. In case 1, estrogen therapy administered to maintain the hormonal balance premenstrually effectively prevented attacks. Despite the inconsistent use of beta-blockers, the attacks in case 1 and case 2 tended to decrease with age. Case 2 experienced no attacks after menopause. Cause 3 took medication consistently and remained free of attacks for over 6 y. Although she discontinued beta-blocker therapy because of pregnancy, she has experienced no attacks to date. These case studies suggest that hormonal status may be important in the development of syncopal attacks in female patients with the long QT syndrome.


Segmental asynergy of the left ventricle in a case of tight aortic stenosis associated with mild ischemic heart disease.

Emergency aortic valve replacement with double aorto-coronary bypass surgery was performed to treat severe intractable congestive heart failure in an 82-year-old man. Mild circumflex and left anterior descending artery lesions were present and the pressure gradient across the aortic valve was 80 mmHg despite a low cardiac output. The preoperative anteroseptal akinesia seen by two-dimensional echocardiography was normalized after surgery. Thus, even in patients with segmental left ventricular dysfunction, tight aortic stenosis might be present when concomitant mild ischemic heart disease is present.


The studies of cell damaging and cell growth factors which induce cardiomyopathy.

We demonstrated that phosphatidylinositide-specific phospholipase C (PLC) activity was greater in cardiomyopathic hamster hearts (BIO 14.6 and BIO 53.58) then in hamster controls (F1b). Inositol trisphosphate (IP3) production was markedly greater in both of the cardiomyopathic hamsters, BIO 14.6 and BIO 53.58. We have also determined the sarcoplasmic reticulum (SR) function of heart. Calcium uptake into SR markedly increased in BIO 14.6. On the other hand, it significantly decreased in BIO 53.58 compared with F1b. It is well known that IP3 stimulates calcium release from SR. In BIO 14.6, calcium release from SR stimulated by IP3 increased, but its effect decreased in BIO 53.58 compared with F1b. These results suggest that PI response may produce high intracellular calcium levels in both BIO 14.6 and BIO 53.58 myocytes. In addition, in the BIO 53.58 hamster the sarcoplasmic reticulum deteriorate in function. It was concluded from these results that a prolonged high intracellular calcium level may lead to the death of BIO 53.58 myocytes. The expression of angiotensinogen mRNA was observed in the hamster heart. There was no differences in its expression level between F1b, BIO 14.6 and BIO 53.58. There was no effect of ages on its expression in these hamster hearts. We have also determined the distribution of angiotensinogen in these hamsters. At 4 weeks of age, the immunohistochemical study revealed that angiotensinogen was widely distributed in subendocardium in these hamsters. There was no difference in its distribution between F1b, BIO 14.6 and BIO 53.58. But at 20 weeks old of age its immunoreactivity decreased in BIO 53.58.(ABSTRACT TRUNCATED AT 250 WORDS)


Mitochondrial DNA mutations in cardiomyopathy.

Deletions and point mutations of mitochondrial DNA (mtDNA) of patients with dilated or hypertrophic cardiomyopathy were analyzed using the polymerase chain reaction and fluorescence-based direct sequencing. The patients included are with hypertrophic cardiomyopathy associated with left ventricular dilatation, a patient with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), and a patient with fatal infantile cardiomyopathy. Deletions were frequently seen in mtDNA in patients with dilated cardiomyopathy. The mtDNA was sequenced and the direct repeat at each edge of deletion was identified as (5'-CATCAACAACCG-3') which was located in the ATPase6 gene and in the D-loop region. In a patient with hypertrophic cardiomyopathy associated with left ventricular dilatation, another mutant mtDNA was found not to have directly repeated sequence, and was revealed to jump from nucleotide position 8,992 to position 16,072 of mtDNA resulting in a 7,079 bp deletion. This patient had unique point mutation in the tRNA genes. A G-to-A transition in the tRNA(Cys) gene (nucleotide position 5,821) at the aminoacyl acceptor stem and an A-to-G transition in the tRNA(Thr) gene (nucleotide position 15,951) were identified. In a patient with MELAS, an A-to-G transition in the tRNA(Leu)(UUR) gene (nucleotide position 3,243) was observed. This mutation was located at the 5' end of the dihydrouridine loop of this tRNA molecule, and would disturb its function. In a patient with hypertrophic cardiomyopathy associated with lactic acidosis, mutations of mtDNA should be suspected.(ABSTRACT TRUNCATED AT 250 WORDS)


Dilated cardiomyopathy with special reference to humoral immunity.

The question of whether the etiology of DCM is immune or autoimmune has been increasingly discussed. Abnormal findings on humoral immunity in DCM were investigated, especially those regarding anti-heart antibodies (AHA), IgG subclasses and soluble interleukin-2 receptor (sIL-2R). The heterophile type AHA was detected in 64.7% of cases by the indirect immunofluorescence technique (IF) with rat heart, by indirect IF with human heart AHA in 57.8% of cases, and by thin-layer chromatogram with human glycolipids AHA in 44% of cases. Also, 57.1% of the specimens were found to bind IgG on perimyocytes by direct IF with biopsy specimens taken from patients with DCM. The epitope of an antigen which reacted with the heterophile type AHA is a Gal alpha 1-3Gal structure. 200 Kd, 70 Kd and 40 Kd antigens were reacted with AHA detected by indirect IF with human heart. The possible mechanisms of AHA in the pathogenesis could be either complement dependent cytotoxicity or interference to cardiac metabolism. The concentration of sIL-2R and IgG3 in sera from patients with DCM were elevated. These results suggest that immunological abnormalities occur continuously in DCM.


Negative washout rate of myocardial thallium-201--a specific marker for high grade coronary artery narrowing.

A decline is usually observed in the myocardial uptake of thallium-201 in delayed imaging compared with initial imaging. In patients with severe coronary artery disease (CAD), the uptake is sometimes higher in the delayed than in the initial imaging, which is expressed as negative washout rate. To evaluate the diagnostic implications of this negative washout rate the findings of dipyridamole thallium scintigraphy in 582 patients with coronary artery disease were evaluated. The negative washout rate was present in 201 of 582 patients (35%). It had a significant association with high grade coronary artery narrowing of > or = 90%. Sensitivity in detecting patients with this high grade narrowing by negative washout rate was 48%, its specificity was 93%, and its positive predictive value was 94%. Sensitivity to detect individual coronary artery narrowing of > or = 90% did not decrease according to the extent of CAD, with the highest detection in the left anterior descending coronary artery and the lowest in the left circumflex coronary artery. Since patients with high grade coronary narrowing often require coronary intervention, the results of this study suggest the diagnostic importance of negative washout rate in the identification of the particular subset of patients with CAD.


Echocardiographic evaluation of pulmonary arterial hypertension in patients with progressive systemic sclerosis and related syndromes.

In order to evaluate the usefulness of echocardiography in detection and characterization of pulmonary arterial hypertension (PAH) in scleroderma patients, we performed M-mode, two-dimensional, and Doppler echocardiography in 71 patients with progressive systemic sclerosis (PSS) and related syndromes: mixed connective tissue disease (MCTD) and overlap syndromes. We estimated systolic pressure gradients across the tricuspid valve from the peak velocity of tricuspid regurgitation (TR) by color-flow guided continuous wave Doppler. TR velocities of analyzable quality for gradient estimation were obtained in 28 patients (39%), of whom 12 showed PAH (peak TR velocity > or = 2.5 m/sec). In comparison, analyzable TR was recorded in 19 (35%) of 55 patients with left-sided cardiac disease. None of the 12 with Doppler-estimated PAH showed left ventricular dilatation or decreased fractional shortening by M-mode and two-dimensional measurements. Nonsimultaneous cardiac catheterization confirmed PAH in 8 of 9 with Doppler-estimated PAH and in 3 of 12 without analyzable TR who had hemodynamic study. Doppler-estimated right ventricular systolic pressures (RVSP) correlated well with catheterization-measured pulmonary arterial systolic pressures (PASP) (< 0.01). Our results indicate that Doppler echocardiography is useful in detecting subclinical PAH and estimating PASP in patients with collagen vascular disease. The results of pulmonary function studies suggest that PAH in MCTD is mainly caused by pulmonary vasculopathy.


Alteration of pulmonary blood flow in tetralogy of Fallot: pre- and postoperative study with macroaggregates of 99mTc-labeled human serum albumin.

The pulmonary blood distribution was examined in 17 patients with tetralogy of Fallot (TOF) pre and postoperatively with macroaggregates of 99mTc-labeled human serum albumin. Most of the patients with TOF demonstrated an abnormal preoperative distribution pattern. The abnormalities included not only an unbalanced distribution between the right and left lungs but also a maldistribution of peripheral vessels in each lung. The Right/Left lung counts ratio and Pulmonary Peripheral Index (calculated in order to express the severity of peripheral maldistribution) correlated neither to the diameter nor the cross-sectional area of either right or left pulmonary arteries which were measured angiographically. Postoperatively, the pulmonary blood was shunted toward the developed side of the lung which further contributed to maldistribution of blood flow and unbalanced pulmonary growth. Since the patients with an unbalanced pulmonary blood distribution demonstrated a higher right ventricular pressure one year after the operation, a palliative operation facilitating the growth of the underdeveloped side of the lung might be considered as an effective procedure to precede intracardiac repair.


The effect of acute hypoxia on left ventricular function with special reference to diastolic function--an analysis using ultrasonic method.

In order to evaluate the effect of acute hypoxia on left ventricular (LV) contractility and diastolic function, hemodynamics and LV wall motion were investigated in anesthetized open-chest paced dogs using M-mode or pulsed Doppler echocardiography. Animals were ventilated with 10% oxygen (Hypo 1) and 6.3% oxygen (Hypo 2). LV contractility and diastolic functions were enhanced under "Hypo 1" and at an early phase of "Hypo 2". However, LV functions, both systolic and diastolic, were simultaneously reduced in the presence of hypercapnic acidosis by "Hypo 2". Peak velocities of diastolic rapid filling flow (R) and atrial contraction flow (A) were increased under "Hypo 1", but showed a biphasic change (an increase and a subsequent decrease) under "Hypo 2". The ratio of A/R, known as an index of LV diastolic function, was not altered under hypoxia alone or even under hypercapnic acidosis. Even when hypoxia seems to enhance LV contractility, LV function has already begun to be depressed with a reduction of pH. This seems, however, to be compensated for by LV dilatation and increase in preload, or preservation of left atrial performance.


[Effect of intravenous pirenzepine on hemodynamics and gastric juice volume as well as pH in surgical patients].

The effects of pirenzepine on blood pressure, heart rate and gastric juice volume as well as pH were evaluated and compared with those after atropine and cimetidine in 54 adult patients divided into five groups. Patients in Groups A, P, AP, AC and ACP received atropine, pirenzepine, atropine plus pirenzepine, atropine plus cimetidine, or atropine, cimetidine plus pirenzepine, respectively. Atropine 0.5 mg and cimetidine 200 mg were given intramuscularly 60 min before induction of anesthesia, and pirenzepine 10 mg was given intravenously 5 min before induction. Gastric juice was aspirated just after, 60 and 120 min after induction of anesthesia. Mean blood pressure and heart rate remained unchanged following intravenous pirenzepine in Group P, whereas heart rate increased significantly in Groups AP and ACP. There were no significant differences in mean volume and pH of gastric juice among the groups just after and 120 min after induction of anesthesia, although gastric volume in Group AC was significantly less than in Groups P, AP and ACP 60 min after induction. Gastric pH increased gradually and gastric volume decreased slightly following intravenous pirenzepine. The incidence of samples with a pH higher than 2.5 was greater in Group AC than in Group P just after and 60 min after induction, whereas there was no difference between the two groups after 120 min. We conclude that intravenous pirenzepine 10 mg is effective to reduce gastric juice volume and acidity, and it should be given at least 60 min before induction of anesthesia.


[Ventilation under high spinal anesthesia--the effect of hypotension].

The ventilatory changes during the course of high spinal anesthesia and the effect of hypotension on ventilation during high spinal anesthesia were studied. Spinal anesthesia with hyperbaric tetracaine was applied to 30 patients scheduled for elective surgery. Patients breathed by mask for ten minutes at rest before and after receiving spinal anesthesia. Respiratory parameters were measured in supine position during (1) pre-anesthetic period under resting condition, (2) anesthetic period when analgesia with pin prick extended to T4 level and (3) anesthetic period when analgesia extended to T1 level. The patients were divided into two groups; those with and without hypotension. In hypotension group, tidal volume and minute ventilation decreased significantly for 30% compared with the control values after spinal anesthesia. PaO2 decreased and PaCO2 increased. In non-hypotension group, tidal volume and minute ventilation after spinal anesthesia increased for 10% compared with the control values. In conclusion, hyperventilation tended to occur in patients with high spinal anesthesia unless hypotension was severe enough. Once severe hypotension had occurred, obvious hypoventilation and respiratory irregularity were observed. Decrease of tidal volume and minute ventilation, hypoxia, hypercarbia and increase in VD/VT were significant during hypotension. The results suggest that during high spinal anesthesia severe hypotension causes hypoventilation and if not treated respiratory arrest ensues.


[Effect of epidural buprenorphine on postoperative respiratory function].

The effects of epidural buprenorphine on postoperative respiratory function were studied using respiratory inductive plethysmography (RIP) in two groups of patients [(1) 0.1 mg (2) 0.2 mg] after upper abdominal surgery. Buprenorphine 0.1 mg group showed decreased respiratory rate and increased tidal volume. Decreases in the respiratory rate and the tidal volume were seen in buprenorphine 0.2 mg group and continued for 3-4 hrs after the epidural administration. However, there was no severe respiratory depression in either group. It seems that 0.1 mg of epidural buprenorphine may give a satisfactory postoperative pain relief and less respiratory depression, and RIP is a useful method for the measurement of postoperative respiratory function.


[Postoperative pain relief by continuous epidural infusion of bupivacaine and buprenorphine].

Continuous postoperative pain relief produced by epidural block with bupivacaine and buprenorphine was evaluated in 12 patients after thoracotomy, 19 patients after upper abdominal surgery, and 14 patients after lower abdominal surgery. Patients initially received 8 ml of 0.25% bupivacaine and 0.1 mg of buprenorphine at recovery room in operating theater and continuously received the mixture of 0.25% bupivacaine and 5 micrograms.ml-1 buprenorphine at a rate of 1 ml.h-1 using a portable pump. About fifty percent of the patients did not need additional narcotics during 48 postoperative hours. About ninety percent of the patients needed one additional narcotics during 48 postoperative hours. The authors conclude that epidural analgesia with the mixture of bupivacaine and buprenorphine produces satisfactory postoperative pain relief.


[Changes in myocardial blood flow and systemic hemodynamics during hypotensive anesthesia induced by adenosine triphosphate with or without dipyridamole].

The changes in myocardial blood flow and systemic hemodynamics during hypotensive anesthesia with adenosine triphosphate (ATP) or ATP with dipyridamole (0.5 mg.kg-1) were studied in 20 mongrel dogs anesthetized with 0.7% halothane in 100% oxygen. In both groups, mean arterial blood pressure (MAP) was reduced to 60 mmHg by intravenous administration of ATP. During hypotensive anesthesia, coronary blood flow, myocardial blood flow and cardiac index increased significantly in both groups. Lactic acid and uric acid increased significantly during hypotensive anesthesia in the group 1. Heart rate, MAP, systemic vascular resistance and coronary vascular resistance decreased significantly during hypotensive anesthesia in both groups. Mean pulmonary arterial pressure, pulmonary arterial wedge pressure and central venous pressure showed no significant changes in both groups. Base excess in the group 1 increased markedly compared with the group 2. We conclude that pretreatment with dipyridamole can prevent metabolic acidosis that occurs during hypotensive anesthesia induced by ATP.


[Changes in forehead and sole tissue temperature during cardiopulmonary bypass for acquired cardiac disease].

The forehead tissue temperature (FT-T) and the sole tissue temperature (ST-T) were measured and recorded by a deep body thermometer (Terumo Corp.) during open heart surgery. The changes in FT-T and ST-T after cardiopulmonary bypass (CPB) showed two characteristic patterns; the convergence pattern and the dissociation pattern. It is said that the dissociation pattern can notes a poor peripheral circulation. The deverging point of the two patterns was studied in 65 patients with acquired cardiac disease. We divided the patients into two groups taking 3.5 degrees C of the FT-T and ST-T difference (DT) after 2 hour weaning from CPB. The number of the patients in convergence group (group I) was 42, and that in the dissociation group (group II) was 23. The two groups were compared with the DT and the time required for the rise in each temperature from CPB rewarming to CPB weaning. There was no intergroup difference in the DT when the FT-T began to rise upon CPB rewarming. However, the DT was 3.8 +/- 2.3 (mean +/- SD) degrees C in group I and 7.1 +/- 1.8 degrees C in group II when the ST-T began to rise, and 4.2 +/- 2.5 degrees C in group I and 6.9 +/- 1.4 degrees C in group II when the FT-T reached its peak; the figures were significantly lower in group I (P < 0.01). The time required for the rise in ST-T was significantly shorter in group I (14.8 +/- 17.1 min) than in group II (25.8 +/- 14.7 min).(ABSTRACT TRUNCATED AT 250 WORDS)


[Effects of propentofylline on hypoxia-hypoglycemia-induced calcium accumulation in gerbil hippocampal slices].

The xanthine derivative propentofylline (HWA 285) has been reported to show protective effects against neuronal damage induced by cerebral ischemia. In the present study, we investigated the effect of propentofylline on the hypoxia-hypoglycemia-induced intracellular calcium accumulation in gerbil hippocampal slices using microfluorometry. When slices were superfused with hypoxic-hypoglycemic medium that did not contain propentofylline, an acute increase in calcium accumulation was detected 75-200s (mean latency of 123s) after the start of hypoxic-hypoglycemia. When slices were superfused with hypoxic-hypoglycemic medium that contained 10 microM, 100 microM and 1mM propentofylline, the latency period before acute increase in calcium accumulation was prolonged in all subregions of the hippocampus in a dose-dependent manner: mean latencies in field CA 1 were 146, 168, and 197s after hypoxic-hypoglycemia, respectively. This retardation in calcium accumulation may be involved in the mechanisms by which propentofylline diminishes ischemic injury.


[The function of red blood cells under open-heart surgery with extracorporeal circulation without donor blood].

In 18 patients scheduled for open-heart surgery with extracorporeal circulation without donor blood, P50, 2, 3-DPG, intracellular sodium and potassium in red blood cells, and erythrocyte deformability were measured for the purpose of investigating the influence of severe hemodilution on oxygen transport and function of red cells. P50 and 2, 3-DPG in red cells showed no significant changes until the end of cardiopulmonary bypass (CPB). At the end of operation, 2, 3-DPG content decreased significantly without a significant change of P50. This is probably due to the rightward shift of oxyhemoglobin dissociation curve as compensation for the hemodilution without donor blood. On the first postoperative day, P50 value and 2,3-DPG content decreased significantly but returned to previous values on the second day. As the result of changes of red cell sodium contents and deformability, erythrocyte morphology recovered soon after the end of CPB, but the membrane function of red cells was restored a few days later. In conclusion, oxygen transport in red cells may be disturbed after open-heart surgery with extracorporeal circulation without donor blood.


[Mathematical simulation of intracranial condition--Part 1. Linear model stimulation].

We developed a linear mathematical model of the intracranial vessels, which reflects changes of the pulse wave (pulse pressure) of intracranial pressure after ligation of the internal jugular vein. The model composed of eight major variables: 1. resistance of arteries, 2. resistance of small arteries and capillary vessels, 3. resistance of veins, 4. resistance of internal jugular and vertebral veins, 5. compliance of arteries, 6. compliance of small arteries and capillary vessels, 7. compliance of veins and 8. intracranial compliance. All variables are presumed to have linear elements and replaced with electrical elements. The model of neck dissection is expressed as the change of resistance of the internal jugular and vertebral veins. Intracranial condition is expressed as the pulse wave (pulse pressure) of intracranial pressure and driving pressure. After unilateral ligation of the internal jugular vein, the pulse wave of intracranial pressure increased 24% and, after bilateral ligation of the internal jugular vein, it increased 55%. After unilateral ligation of the internal jugular vein, the pulse wave of intracranial pressure increased 27%, and, after bilateral ligation, it increased 79%. When intracranial compliance is normal, the respective ratios of pulse wave of intracranial pressure and driving pressure to cross-sectional area decreased, whereas those after increase of intracranial compliance increased.


[Integration of informations gained from heterogeneic world of myocardial function and ischemia].

Currently, heterogeneity is the word to describe any inhomogeneous phenomenon observed in the ever changing living creatures. Myocardial function is dynamic in nature which is a summation of many inhomogeneous components. In fact, heterogenic phenomenon has been observed both at cellular and at ventricular levels during myocardial contraction and relaxation. However, this heterogenic behavior of myocardial activities serves as a source of monitoring parameters by which we can grasp what is happening in the patient. Reliance on only one of those parameters would lead to a wrong diagnosis and judgement in the heterogenic world. We, therefore, need to integrate those parameters to form more realistic image about patient's status. We have to have a cut off point to divide what is right and what is wrong. Although the truth may not be reached eventually from heterogeneous informations, an appropriate method to integrate informations in the heterogenic world will aid us to come closer to the reality.


[Utility of intra-bladder pressure monitoring during closure of abdominal wall defects in newborn infants].

Recently, it was demonstrated that intra-bladder pressure (IBP) measured through a transurethral catheter accurately reflects intra-abdominal pressure (IAP). We monitored IBP during closure of abdominal wall defects in three newborn infants with gastroschisis. We were able to avoid complications due to increased IAP by keeping IBP below 20 mmHg. IBP correlated well with inferior vena cava pressure (r = 0.93) which reflects IAP. We advocate the use of IBP monitoring as a simple and reliable means of indirectly determining IAP during operations for closure of abdominal wall defects in newborn infants with omphalocele or gastroschisis.


[The use of a Swan-Ganz catheter with a fast-response thermistor for the measurement of right ventricular performance during anesthetic management of pheochromocytoma].

We used a Swan-Ganz catheter with a fast-response thermistor to measure the right ventricular ejection fraction (RVEF) during the anesthetic management of two patients with epinephrine-dominant pheochromocytomas. Pre-operatively, one patient received alpha adrenergic blocking agents (prazocine, doxazocine) to control the blood pressure but the other patient did not receive any agents. In the latter patient who did not receive alpha adrenergic blocking agents, right ventricular function was depressed post-operatively in the recovery room. The importance of preoperative preparation with alpha adrenergic blocking agents was confirmed by the reductions in RVEF and RVEDVI (right ventricular end-diastolic volume index) after resection of the tumor. Not only left heart monitoring but also right heart monitoring with RVEF and RVEDVI are recommended for the proper management of a patient with pheochromocytoma.


[Simulation in anesthesia].

Simulation in anesthesia is reviewed. Its aim includes education/training, analysis of phenomena, explanation or interpretation of phenomena and instrument checks. It deals with pharmacokinetics/pharmacodynamics of inhalational and intravenous agents, respiration and circulation, action and behavior of anesthesiologists and income analysis. Simulations are accomplished mainly by using computers, yet few use physical models or a physical model combined with computers. For writing this review, CD-ROM's of Medline data were used. Problems in searching literatures through this route are discussed. Finally, the problem of the distribution of softwares is also discussed.


[The epidemiology and clinical features of anaphylactic and anaphylactoid reactions in the perioperative period in Japan].

In an attempt to review the Japanese epidemiology of the anaphylactic and/or anaphylactoid reactions in the perioperative period, we investigated 105 cases with clinical features of anaphylactic and/or anaphylactoid reaction, which are reported in the Japanese anesthesiology-related journals from 1952 to 1990. Eighty-nine percent of the cases were reported during the last decade. There were 66 males and 34 females. The majority of the patients were below 60 years of age, and most of the patients were in their teens and fifties. Ninety percent of the patients had no past history of drug-induced allergy nor tendencies of atopy. Ninety-four percent of the patients recovered completely without any sequelae, and 0.95 percent of them recovered with serious complications. Deaths occurred in 4.67% of the patients. Most frequent clinical signs were cardiovascular (91.4%) and cutaneous (84.8%) manifestations. Respiratory, signs appeared in 41% of the patients. Patients are frequently unconscious and covered with drapes, and early signs and symptoms of anaphylaxis can be masked. In 25% of the patients cardiovascular collapse, including cardiac arrest and undetected blood pressure, appeared as the first noticeable sign. Causative drugs were confirmed immunologically in 5.7% of the patients. In other cases, causative drugs were presumed based on clinical course. Causative drugs and presumed causative drugs were varied, including blood and blood products (24 cases), intravenous anesthetics (19 cases), local anesthetics (15 cases), and muscle relaxants (9 cases), which were used generally in the perioperative period.


[Influence of nicardipine on the renin-angiotensin system ina hypertensive crisis during operation in elderly patients].

We studied the influence of nicardipine on renin-angiotensin (RA) system in twelve elderly patients, because the suppression of RA system, the decrease in reactivity of its feedback mechanism, and a high probability of arteriosclerosis and hypertension are well recognized in elderly patients. In hypertensive crisis during operation, intravenous bolus injection of nicardipine was done promptly by anesthesiologists in charge. Plasma renin activity (PRA), angiotensin I (A I), and angiotensin II (A II) were measured with RIA methods before administration of nicardipine and after hemodynamics were stabilized. Changes of systemic arterial pressure and heart rate were simultaneously recorded. Concentrations of PRA, A I, and A II were not significantly elevated, whereas systemic and diastolic blood pressures decreased significantly at 5 min, 15 min, 30 min and 60 min after administration of nicardipine. Heart rate was unchanged. But in a few cases there was an increase in PRA and A I. Average total dose of nicardipine was 26.8 micrograms.kg-1 and average fall of blood pressure was 23.9%. In conclusion, we can use intravenous nicardipine safely and stabilize hemodynamics easily without activation of RA system and rebounding of its feedback mechanism.


[Interaction of nicardipine and inhalational anesthetics--comparison between enflurane and isoflurane].

The effects of nicardipine 1 mg bolus injection under enflurane anesthesia were compared with those under isoflurane anesthesia. Twelve neurosurgical patients were divided into 2 groups, enflurane group (n = 6) and isoflurane group (n = 6). In all patients anesthesia was induced with midazolam, thiamylal, fentanyl and vecuronium. Anesthesia was maintained with fentanyl, nitrous oxide, pancuronium plus enflurane (enflurane group) or plus isoflurane (isoflurane group). After incision of dura mater, nicardipine 1 mg was given through forearm venous line. For about 30 minutes before and after nicardipine injection, concentration of inhalational anesthetics was kept constant and no drugs were given. Blood pressure (BP), heart rate (HR), rate pressure product (RPP), and serum concentrations of catecholamine and nicardipine were monitored for 30 minutes after nicardipine injection. In isoflurane group, BP decreased more and longer, and increases of HR and serum concentration of catecholamine continued longer compared with enflurane group. Elimination half life of nicardipine was shorter, area under the curve (AUC) was smaller and clearance of nicardipine was larger in isoflurane group than in enflurane group. It was concluded that isoflurane increased the effects of nicardipine, which were BP depression and reflex sympathetic stimulation, than enflurane and that metabolism and elimination of nicardipine were accelerated more by isoflurane than by enflurane.


[Effect of isoflurane, enflurane and halothane on hemodynamics during the induction of anesthesia].

The effects of isoflurane(I), halothane(H) and enflurane(E) on hemodynamics of 36 patients (12, 11 and 13, respectively) were studied during the inhalation of 1.5 MAC of each anesthetics before the surgery. Mean arterial pressure(MAP), heart rate(HR), cardiac index(CI), systemic vascular resistance index(SVRI), and stroke volume index (SVI) were measured noninvasively using the automatic blood pressure manometer and the ultrasonic Doppler method (Accucom). MAP decreased with I, E and H, but a larger decrement was observed with E than with H. CI and SVI with H were less than with E. SVRI decreased with I and E but a significant difference was observed between E and H. Each value with I was between those with H and E. These results indicate that isoflurane causes the depression of blood pressure mostly by its effect to decrease afterload during the induction of anesthesia, although its depressing effect is less than that of enflurane.


[A study of cerebral circulation following cervical sympathetic ganglion block].

Cerebral circulation following cervical epidural block or stellate ganglion block at the transverse process of the 6th cervical vertebra (C6-SGB) was evaluated by single photon emission computed tomography of inhaled Xenon-133. Cerebral blood flow before and 15 min after both blocks was measured in eight patients after cervical epidural block and ten patients after C6-SGB. Cerebral blood flow decreased slightly following cervical epidural block, but it was not a statistically significant difference. Cerebral blood flow following C6-SGB could be separated into two groups; in one it increased and in the other it decreased slightly. In conclusion, cerebral circulation is not influenced by cervical epidural block, but it is probably affected by C6-SGB. The manner in which C6-SGB increases cerebral blood flow seems that local anesthetics reached the superior cervical ganglion and block it. C6-SGB without superior cervical ganglion block does not influence cerebral circulation, and it only dilates extracranial vessels.


[Pulmonary reaction after protamine reversal of heparin in goats and rabbits].

Protamine reversal of heparin is often associated with severe hemodynamic side-effects, including pulmonary hypertension in cardiovascular surgery. However, the precise mechanism of this transient pulmonary hypertension is not clear. Recently, it was reported that pulmonary intravascular macrophages (PIM) react avidly with and phagocytize various foreign particles (liposome, latex, red cells). Sheep, goat and pig have a large population of PIM, but rabbit, rat and human have few. To investigate whether the pulmonary reaction after protamine reversal is related to PIM, we compared the pulmonary reaction after protamine reversal between goats and rabbits. We also studied it in patients for cardiac surgery. Protamine sulphate (2 mg.kg-1) was injected in 2.5 min into femoral artery at five min after heparin sodium (200 IU.kg-1) injection in goats and rabbits. Mean pulmonary arterial and peak airway pressures increased significantly after protamine reversal in goat. On the other hand, in rabbit and human, mean pulmonary arterial and peak airway pressures showed no significant changes. Goat was far more sensitive to protamine reversal than rabbit and human. We conclude that PIM may be the main cause of the pulmonary reaction after protamine reversal.


[Effect of hypotensive anesthesia on tissue oxygen tension of the heart, kidney and liver].

The effects of hypotensive anesthesia by prostaglandin E1 (PGE1: 8 dogs) or trimetaphan (TMP: 8 dogs) on tissue oxygenation were studied in 16 mongrel dogs anesthetized with pentobarbital. Mean blood pressure (MBP), heart rate (HR), cardiac output (CO), blood gases (BG), the blood flow and tissue oxygen tension of the heart, the kidney and the liver were measured. The blood flow and oxygen tension were measured by electromagnetic flowmeters and by polarographic oxygen electrodes respectively. PGE1 or TMP was injected intravenously to decrease MBP by 30%. MBP, CO, HR and BG of PGE1 were not significantly different with those of TMP. Coronary blood flow decreased for 12% with PGE1 and for 33% with TMP. Though blood flows of the renal and the hepatic arteries were well maintained with PGE1, they decreased for 36% and 34% respectively with TMP. Oxygen tensions of the myocardium (both outer and inner layers) and the liver were well maintained with PGE1. But with TMP, oxygen tension decreased for 23% in outer layer, for 16% in inner layer and for 31% in the liver. Oxygen tension of the kidney remained unchanged with PGE1 and TMP. The results suggest that PGE1 is more useful for the maintenance of the tissue oxygenation than TMP during hypotensive anesthesia.


[A relationship between plasma ANP concentration and hemodynamics during PEEP--evaluation by transesophageal ECHO cardiography].

This study was undertaken to find which cardiac function indices as judged by transesophageal ECHO cardiography (TEE) would accurately predict the plasma ANP levels during PEEP. Fourteen patients who underwent orthopedic surgery were the subjects of the study. PEEP 10 cmH2O or 15 cmH2O was added with a PEEP valve during mechanical ventilation under general anesthesia. The cardiac function indices were measured using a 5 MHz TEE probe and plasma ANP levels were evaluated by radioimmunoassay. There were significant reductions in the left atrial diameter, cardiac output and pulmonary venous flow during PEEP, while A/R and CVP were significantly increased. The plasma ANP concentration decreased significantly from 39.2 +/- 4.8 pg.ml-1 at pre PEEP period to 26.8 +/- 3.1 pg.ml-1 at PEEP 15 cmH2O (mean +/- SE, P less than 0.05). However, we could not find any significant correlation between the cardiac function indices and ANP levels. The secretion of ANP from the heart is regulated mainly by stretch tension of the atrium. PEEP increases the pericardial pressure. Therefore, it seems to be difficult to predict the stretch tension of the atrium using TEE under PEEP.


[A study of postoperative respiratory function].

The purpose of this study is to investigate the causes of postoperative respiratory failure from the point of view of respiratory movement and respiratory function, using a respigraph. Thirty patients who had laparotomy, thoracotomy or both were studied. A-aDo2 increased after operation. The values recovered slowly in the order of thoracotomy, laparotomy, was thoraco-laparotomy group. Percent vital capacity (% VC), one second timed force expiratory volume (FEV1), and peak expiratory flow (PEF) were suppressed immediately after operations and increased slowly, but showed still lower values even on the 7th day. VT, V min, f, TI/TT, VT/TI and PaCO2 were almost at the same levels among the three groups. Percent rib cage (% of RC) increased and remained high on the 7th day after laparotomy and thoraco-laparotomy, but showed no remarkable changes after thoracotomy. Between A-aDo2 and % RC in laparotomy group, there was a good correlation. Not only FRC but also the change of % RC seemed to have caused postoperative hypoxemia. The movement of the abdomen affected respiratory dysfunction more than the movement of the thorax after thoracic and abdominal surgery.