First trimester findings of decidual polyp: Caution to avoid polypectomy.

Obstetricians are sometimes faced with a dilemma in that polypectomy, which is a prerequisite for differentiating malignancy, may be associate with miscarriage or preterm delivery. We describe a case with a decidual polyp resulted in first trimester miscarriage after diagnostic polypectomy. Our experience with this patient provides us important information for clinical practice. That is, decidual polyp can be recognized as early as gestational week 5, the roots of cervical polyps should be meticulously observed, a polyp connected to the decidua is suggestive finding of decidual polyp, and suspected decidual polyp can be managed conservatively.

A comparison of morphine concentrations for patient-controlled epidural analgesia following gynecological surgery.

AIM: To compare the analgesic efficacy of a lower (12.5 mg/mL) vs. higher (25 mg/mL) concentration of morphine with 0.2% ropivacaine for patient-controlled epidural analgesia (PCEA) following gynecological surgery. METHODS: In a randomized double-blinded study, 40 ASA physical status I and II gynecological patients who were receiving combined general and epidural anesthesia for surgery and epidural analgesia for postoperative analgesia were assigned to receive 12.5 mg/mL (N=20) or 25 mg/mL (N=20) morphine with 0.2% ropivacaine for PCEA (continuous infusion 4 mL/h, bolus injection 2 ml, lockout interval 15 min). Maximum visual analogue pain scores (VAPS) at rest (VAPS-R max) and movement (VAPS-M max) during the previous 24 hours were assessed at 24 and 48 hours postoperatively, and the cumulative number of self-administrations in PCEA during the postoperative 48 h were also measured. RESULTS: There were no significant differences in VAPS at rest or with movement, and there were no differences in the cumulative boluses of PCEA between the groups. The incidences of nausea, vomiting, pruritus and leg numbness were greater in the 25 mg/mL morphine group, although statistically insignificant. CONCLUSIONS: PCEA using 0.2% ropivacaine and 12.5 mg/mL morphine compared with 0.2% ropivacaine and 25 mg/mL morphine provides equianalgesia with no differences in bolus administration. With respect to the analgesic efficacy and the potential risk for side effects, PCEA using 0.2% ropivacaine and 12.5 mg/ml morphine is a better choice for postoperative gynecological patients.

A comparison of cervical spine movement during laryngoscopy using the Airtraq or Macintosh laryngoscopes.

The Airtraq laryngoscope has an oropharyngeal airway-shaped blade that provides a non-line-of-sight view of the glottis. The configuration of the blade should mean that less movement of the cervical spine is required during laryngeal visualisation. We compared the degree of cervical spine movement in laryngoscopy performed using the Airtraq and conventional Macintosh laryngoscope. In 20 patients requiring general anaesthesia and tracheal intubation, we measured cervical spine movement using radiography in the same patient during consecutive procedures using the two laryngoscopes. Although significant movement of the cervical spine from baseline was noted during all procedures (p < 0.05), cervical spinal extension with the Airtraq was 29% less than that measured during Macintosh laryngoscopy between the occiput and C4, and 44% less at the C3/C4 motion segment (p < 0.05). Anterior deviations of the vertebral bodies from baseline were 32%, 35%, 38% and 40% less at the atlas, C2, C3, and C4 vertebrae, respectively, during Airtraq laryngoscopy than those measured during Macintosh laryngoscopy (p < 0.01). Our study demonstrated that laryngoscopy using the Airtraq laryngoscope involves less movement of the cervical spine compared to conventional procedures using a Macintosh laryngoscope.

Cervical spine movement during laryngoscopy using the Airway Scope compared with the Macintosh laryngoscope.

The Airway Scope is a new rigid laryngoscope. This intubation device provides a non-line-of sight view of the glottis. A non-line-of sight view is expected to cause less movement of the cervical spine during laryngeal visualisation. We compared the degree of cervical spine movement during laryngoscopy with the Airway Scope and conventional direct laryngoscope. Twenty patients requiring general anaesthesia and tracheal intubation were studied. Movements of the cervical spine were measured using radiography in the same patient during laryngoscopy with the Airway Scope and a Macintosh laryngoscope. Cervical spine movement during laryngoscopy with the Airway Scope was 37%, 37% and 68% less than that with the Macintosh laryngoscope at the C0/C1, C1/C2 and C3/C4 motion segments, respectively (p < 0.05). The movement of the atlanto-occipital distance using the Airway Scope was 42% less than that during laryngoscopy using the Macintosh laryngoscope (p < 0.05). Laryngoscopy using the Airway Scope involves less movement of the cervical spine compared to conventional laryngoscopy using the Macintosh laryngoscope.

Genetic background differences between FVB and C57BL/6 mice affect hypnotic susceptibility to pentobarbital, ketamine and nitrous oxide, but not isoflurane.

BACKGROUND: Pharmacogenomics has allowed us to identify the mechanisms underlying much of the inherited variability in drug response. There have been several reports of strain-dependent anesthetic actions in rodents, indicating that significant genetic differences exist in the hypnotic and antinociceptive effects of various anesthetics. METHODS: Loss of righting reflex was used to compare the hypnotic action of pentobarbital, ketamine, nitrous oxide and isoflurane between two genetically different populations of mice, C57BL/6 with black hair and Friends virus B (FVB) with white hair. RESULTS: C57BL/6 mice were more susceptible than FVB mice to the hypnotic effects of ketamine, pentobarbital and nitrous oxide. However, the sensitivity to isoflurane did not differ between C57BL/6 and FVB mice. CONCLUSION: Genetic background affects the hypnotic susceptibility to some anesthetic agents in mice. Our results indicate that there may be a different genetic basis for the operation of hypnosis between isoflurane and other anesthetics, such as pentobarbital, ketamine and nitrous oxide.

Lysis of adhesions and epidural injection of steroid/local anaesthetic during epiduroscopy potentially alleviate low back and leg pain in elderly patients with lumbar spinal stenosis.

BACKGROUND: Lumbar spinal stenosis causes various forms of back or leg pain, and is recognized with increasing frequency in elderly patients whose physical status is not always suitable for surgery. Epiduroscopy, a new, minimally invasive diagnostic and therapeutic technique, may be useful for pain relief in such patients. We investigated the epiduroscopic findings and immediate and long-term changes in back and leg pain after epiduroscopy in elderly patients with spinal stenosis. METHODS: Patients with degenerative lumbar spinal stenosis (n=58, median age 71 yr) were divided into two groups based on presenting symptoms: a monosegmental group (n=34) and a multisegmental group (n=24). Each patient underwent epiduroscopy, and the findings were evaluated using visual analogue scales for low back and leg symptoms. Epiduroscopy included breaking down adhesions in the epidural space by injections of saline, and injection of steroids/local anaesthetic. RESULTS: Epiduroscopy showed that the amount of fatty tissue and the degree of vascularity were greater in the monosegmental group than in the multisegmental group. Relief of low back pain was observed up to 12 months after epiduroscopy in both groups. Relief of leg pain was evident up to 12 months after epiduroscopy in the monosegmental group, and up to 3 months after epiduroscopy in the multisegmental group. None of the patients showed deterioration of motor or sensory deficits during follow-up. One patient was excluded from analysis because of accidental dural puncture during the procedure. CONCLUSIONS: The findings of epiduroscopy corresponded to the symptoms. Epiduroscopy may reduce low back and leg pain in elderly patients with degenerative lumbar spinal stenosis, particularly those with radiculopathy.

Susceptibility of T cell receptor-alpha chain knock-out mice to ultraviolet B light and fluorouracil: a novel model for drug-induced cutaneous lupus erythematosus.

The anticancer agent 5-fluorouracil (FU) frequently induces cutaneous lupus erythematosus (LE) lesions on sun exposed sites. Based on this observation, we have tried to establish a cutaneous LE model of C57BL/6 J (B6) mice, B6 T cell receptor (TCR)-alpha(-/-) mice and B6 TCR-delta(-/-) mice treated with FU and/or ultraviolet B light (UVBL) in order to clarify the role of T cells and the cytokine profile of cutaneous lupus lesions. Cutaneous LE-like skin lesions could be induced in TCR-alpha(-/-) mice with low FU (0.2 mg) plus UVBL, and in B6 mice treated with a high dose of FU (2.0 mg) plus UVBL. In contrast, low FU plus UVBL induced such skin lesions in TCR-delta(-/-) mice at a very low incidence. Specifically, the skin lesions of TCR-alpha(-/-) mice with low FU plus UVBL appeared more rapidly and were more severe than lesions in B6 mice. The former had the common characteristic features of human chronic cutaneous LE such as typical histology, positive IgG at the dermoepidermal junction, low antinuclear antibody and low mortality. Furthermore, a Th1 response was induced in the development of drug-induced cutaneous LE. FU and UVBL-induced cutaneous LE-like eruption is an excellent model for better understanding the pathomechanisms of skin lesion development in LE.

Anesthesia-related mortality and morbidity over a 5-year period in 2,363,038 patients in Japan.

BACKGROUND: Statistical data of mortality and morbidity related to anesthesia have not been reported in Japan since World War II. The need to comprehensively examine the events of cardiac arrest as well as mortality prompted the first national study in Japan. METHODS: Confidential questionnaires were sent to all Japan Society of Anesthesiologists Certified Training Hospitals every year from 1994 through 1998. Collected data were analyzed for incidence of cardiac arrest and other critical events during anesthesia and surgery, and their outcomes within 7 postoperative days. The principal causes of the critical incidents were also analyzed. RESULTS: With an average response rate of 39.9%, a total of 2,363,038 cases were documented over 5 years. The average incidence per year of cardiac arrest during surgery due to all etiologies and that totally attributable to anesthesia was 7.12 [95%CI: 6.30,7.94] and 1.00 [0.88, 1.12]) per 10,000 cases, respectively. The average mortality per year in the operating room or within 7 postoperative days due to all etiologies and that totally attributable to anesthesia was 7.18 [6.22, 8.13] and 0.21 [0.15, 0.27] per 10,000 cases, respectively. The two principal causes of cardiac arrest during anesthesia and surgery due to all etiologies were massive hemorrhage (31.9%) and surgery (30.2%), and those totally attributable to anesthesia were drug overdose or selection error (15.3%) and serious arrhythmia (13.9%). Preventable human errors caused 53.2% of cardiac arrest and 22.2% of deaths in the operating room totally attributable to anesthesia. CONCLUSIONS: The rates in Japan of cardiac arrest and death during anesthesia and surgery due to all etiologies as well as those totally attributable to anesthesia are comparable to those of other developed countries.

Augmentation of monocyte interleukin-8 production by psoralen/UVA-treated CD4+ T cells.

Treatment of cells with psoralen and ultraviolet A light (UVA) modulates their cytokine production. As extracorporeal photochemotherapy has been reported to induce cytokine production by monocytes, we quantified interleukin-8 (IL-8), a representative chemokine produced by monocytes, in culture supernatants from human peripheral blood mononuclear cells (PBMC) treated with 8-methoxypsoralen (8-MOP) and UVA. Lipopolysaccharide stimulated IL-8 production in 8-MOP-phototreated PBMC more efficiently than those untreated or treated with 8-MOP or UVA. More interestingly, when cultured with T-cell-stimulating anti-CD3 and anti-CD28 antibodies, 8-MOP/UVA-treated PBMC produced enhanced amounts of IL-8 with an increased level of IL-8 mRNA expression. Depletion of CD4 but not CD8 T cells from PBMC abrogated this augmented IL-8 elaboration, and CD4 T cells per se secreted no substantial amount of IL-8 even upon CD3/CD28 stimulation. Thus, 8-MOP/UVA-treated CD4 T cells stimulated monocytes to secrete IL-8. The IL-8 overproduction was induced by direct contact of monocytes with 8-MOP/UVA-treated CD4 T cells but not by cytokines from the treated CD4 T cells. These findings imply that in extracorporeal photochemotherapy, monocytes effectively produce IL-8 by cell-to-cell contact with 8-MOP/UVA-treated malignant CD4 T cells. The augmentation of monocyte cytokine/chemokine production by 8-MOP/UVA may be one of the mechanisms underlying the therapeutic efficacy of extracorporeal photochemotherapy.

Spontaneous breathing combined with high frequency ventilation during bronchoscopic resection of a large tracheal tumour.

A patient with learning difficulties had a large tracheal tumour at the carina that caused severe respiratory distress. I.v. anaesthesia with propofol, spontaneous breathing through a tracheal tube, and high frequency jet ventilation were successfully employed during bronchoscopic resection of the tumour.

[Questionnaires on patient-controlled analgesia to the nursing staff in the surgical ward].

Thirty-one nurses in the surgical ward engaged in delivering postoperative analgesia using patient-controlled analgesia (PCA) were asked to complete questionnaires on postoperative analgesia and PCA. Ninety-seven per cent of respondents agreed that the postoperative analgesia is beneficial for postoperative recovery, and answered that the desirable goal in postoperative analgesia is "no pain at rest". Not only "pain at movement" or "pain on coughing", but also "decreased conscious level while analgesia is achieved" were selected as undesirable conditions during postoperative course. Although no one had learned the concept of PCA in their nursing schools, 94 per cent of respondents approved PCA as a method for postoperative analgesia. Seventy seven per cent responded that PCA is effective in the pain relief during position change, pulmonary physiotherapy and induced early ambulation. In addition, 65 per cent of respondents chose PCA as a method for postoperative analgesia when they receive thoraco-abdominal surgery. On the other hand, some problems on pain management using PCA, such as taking care of patients' ambulation with carrying a PCA pump, extra time for instruction of PCA and extra support for patients' psychological state were listed. In conclusion, these results suggest that PCA is accepted as an excellent method for postoperative analgesia among our nurses in the surgical ward, and education in postoperative pain management including PCA is required in nursing school as well as after graduation.

[Perioperative mortality and morbidity for the year 1999 in 466 Japanese certified anesthesia-training hospitals: with special reference to operative regions--report of Committee on Operating Room Safety of Japanese Society of Anesthesiologists].

Perioperative mortality and morbidity in Japan for the year 1999 were analyzed retrospectively with special reference to operative regions. The total number of analyzed cases was 701,940. The percentages for each operative region were as follows, craniotomy 4.5%, thoracotomy 3.3%, heart and great-vessels 3.9%, thoracotomy with laparotomy 0.8%, laparotomy except caeserian-section 31.7%, ceserian-section 3.2%, head-neck and otolarynx 14.5%, chest-abdomen-perineum 11.1%, spine 3.5%, extremity including peripheral-vessel 16.5%, and others 6.9%. The incidence of serious events, including cardiac arrest and severe hypotension and hypoxemia suggesting impending cardiac arrest was 34.58 per 10,000 cases in all operative regions. The events were observed more frequently in heart and great-vessels 247.26, thoracotomy with laparotomy 128.91 and thoracotomy 61.55, and less frequently in chest-abdomen-perineum 13.52 and extremity including peripheral-vessel 16.99. Regarding the prognosis of events, the cases with no sequela were 69.9% in all operative regions. While there were fewer cases with no sequela in craniotomy 50.4%, thoracotomy with laparotomy 54.3% and heart and great-vessels 58.6%, there were more cases in head-neck and oto-larynx 95.2% and chest-abdomen-perineum 90.5%. The incidence of serious events totally attributable to anesthetic management was 7.79 per 10,000 cases in all operative regions. The events were observed more frequently in thoracotomy 12.82, heart and great-vessels 12.29 and spine 11.06, and less frequently in extremity including peripheral-vessel 5.17 and chest-abdomen-perineum 6.05. Regarding the prognosis of events, the cases with no sequela were 93.1% in all operative regions. There were fewer cases with no sequela in thoracotomy with laparotomy 80.0% and craniotomy 81.8%. The main cause of events in thoracotomy and spine was the inadequate airway management, and in heart and great-vessels was the overdose or miss-selection of drugs. Although the incidence of serious events totally attributable to anesthetic management was one fourth of all events, most of them resulted from human factors. Thus, the more efforts are necessary to improve the outcomes. While the total deaths from 701,940 cases, including death on the operation day or within 7 days after it, were 528 cases (7.52 per 10,000 cases), the deaths totally attributable to anesthesia were 7 cases (0.10 per 10,000 cases).

Percutaneous peptide immunization via corneum barrier-disrupted murine skin for experimental tumor immunoprophylaxis.

Percutaneous peptide immunization is a method in which tumor-specific cytotoxic T lymphocytes (CTL) are primed in the lymph nodes and spleen following application of tumor peptides to corneum barrier-disrupted murine skin. Immunized mice are protected against subsequent challenge with corresponding tumors and suppress the growth of established tumors. CTL expansion after peptide application seems to be mediated by epidermal Langerhans' cells. In the human, disruption of permeability barrier by tape stripping also induces activation of epidermal Langerhans' cells. Thus, percutaneous peptide immunization provides a simple and noninvasive means of inducing potent antitumor immunity that may be exploited for cancer immunotherapy in the human.

Photoactivational cytokine-modulatory action of 8-methoxypsoralen plus ultraviolet A in lymphocytes, monocytes, and cutaneous T cell lymphoma cells.

Treatment with 8-methoxypsoralen (8-MOP) and ultraviolet A light (UVA) has been reported to modulate cytokine production in various cells. Our study was conducted to see the effects of 8-MOP/UVA on the expression/production of cytokines in peripheral blood lymphocytes and monocytes in relation to the therapeutic mechanisms of extracorporeal photochemotherapy. 8-MOP/UVA augmented the expression of mRNAs for interferon-gamma (IFN-gamma) and interleukin (IL)-2 and reduced those for IL-4 and IL-10 in peripheral blood mononuclear cells (PBMCs) from normal subjects and Sézary syndrome patients. This enhancement of Th1 cytokines was caused by increment of cytokine production by Th1 cells but not by conversion of Th2 cells to produce Th1 cytokines. The number of IFN-gamma-secreting lymphocytes was markedly increased in 8-MOP/UVA-treated PBMCs 20 h after treatment, and its amount was elevated in culture supernatants. However, this enhanced production of IFN-gamma was found only until three days after 8-MOP phototreatment, and its level was rapidly declined by five days after treatment. In addition to this Th1-polarized action, 8-MOP/UVA-treated PBMCs produced enhanced amounts of IL-8 upon stimulation with anti-CD3/CD28 antibodies. Phototreated CD4+ but not CD8+ cells provided excellent T cell help for monocytes to produce IL-8 via a direct cell-to-cell contact mechanism. These findings suggest that 8-MOP/UVA has a transient but biologically active Th1-skewing action in T cells, and the phototreated T cells simultaneously stimulate monocytes to produce IL-8. It is suggested that 8-MOP/UVA exerts a beneficial therapeutic effect on malignant Th2 neoplasms as a Th1-skewing cytokine modifier and that 8-MOP-phototreated CD4+ T cells allow monocytes to become effective tumor antigen-presenting cells for tumor-specific cytotoxic T cells.

Hypersensitivity to mosquito bites as the primary clinical manifestation of a juvenile type of Epstein-Barr virus-associated natural killer cell leukemia/lymphoma.

Hypersensitivity to mosquito bites or mosquito allergy is a mysterious disorder that has been reported mainly in Japanese patients (at least 58 patients) in the first two decades of life. The skin lesion at bite sites is typically a bulla that develops into necrosis. Patients simultaneously exhibit a high temperature and general malaise and subsequently may experience lymphadenopathy and hepatosplenomegaly. Recent studies have revealed that this mosquito hypersensitivity is associated with chronic Epstein-Barr virus infection and natural killer cell leukemia/lymphoma. The natural killer cell, infected with monoclonal (or oligoclonal) Epstein-Barr virus, seems to be involved in the pathogenesis of the hypersensitivity. Half of the patients reported died of hemophagocytic syndrome (or malignant histiocytosis), granular lymphocyte proliferative disorder, or lymphomas. We propose that this disease, defined as the triad of hypersensitivity to mosquito bites, chronic Epstein-Barr virus infection, and natural killer cell leukemia/lymphoma, is a clinical entity mostly seen in Asians.

[Anesthetic management of a morbidly obese patient undergoing laparoscopic gastric bypass surgery].

We describe a successful anesthetic management of a morbidly obese patient, weighing 170 kg, height of 170 cm and body mass index of 58.8 kg.m-2, who received gastric bypass surgery performed using laparoscopic assist. After arriving in the operating room, an epidural catheter was inserted into the epidural space at the T 7-8 intervertebral space. The trachea was intubated nasally under bronchofiberscopic assist, after which anesthesia was induced with propofol and maintained with nitrous oxide and oxygen (FIO2 = 0.5), i.v. propofol, fentanyl, and epidural anesthesia. Propofol infusion rate was determined using the corrected body weight drawn by Servin et al. Anesthetic management and recovering from anesthesia were uneventful. For propofol anesthesia, infusion rates determined using the corrected body weigh, was preferable for morbidly obese patients.

Interleukin-10 expressed at early tumour sites induces subsequent generation of CD4(+) T-regulatory cells and systemic collapse of antitumour immunity.

We investigated the relationship between transforming growth factor-beta (TGF-beta)-secreting T-regulatory (Tr) cells and anti-B16 melanoma immunity, and studied the association of early cytokines expressed at tumour sites with the generation of Tr cells. A large number of CD4(+) Tr cells producing interleukin (IL)-4, IL-10 and TGF-beta accumulated with functionally depressed CD8(+) cytotoxic T lymphocytes (CTLs) at tumour sites on day 20 after subcutaneous (s.c.) inoculation of B16 tumour cells. Tr cells consisted of two populations, which were termed T helper 3 (Th3) and Tr1 cells. B16-infiltrating Tr cells strongly inhibited the generation of B16-specific T helper 1 (Th1) cells in a TGF-beta-dependent manner and were assumed to suppress effective generation of CTLs. In addition, B16 cells markedly progressed in mice transferred adoptively by the cultured B16-infiltrating Tr cells compared with untreated mice. The capacity of these Tr cells to produce TGF-beta was hampered by neutralizing anti-IL-10 and partly anti-IL-4 monoclonal antibodies (mAbs) injected intralesionally during the early development of B16 tumours, and this treatment markedly attenuated B16 growth. Furthermore, a lesional injection of recombinant mouse IL-10 at an early tumour site resulted in the vigorous progression of B16 tumours. These results provide evidence that Tr cells, belonging to the T helper 3/T-regulatory 1 (Th3/Tr1) type, are activated in B16-bearing hosts under the influence of T helper 2 (Th2) cytokines, mainly IL-10 (produced at early tumour lesions), and that this regulatory T-cell population functions as a suppressor of anti-B16 immunity.

[Annual study of perioperative mortality and morbidity for the year of 1999 in Japan: the outlines--report of the Japan Society of Anesthesiologists Committee on Operating Room Safety].

Anesthetic mortality and morbidity in Japan Society of Anesthesiologists (JSA) Certified Training Hospitals (CTH) for the year 1999 were reported as continuation of annual studies started in 1993. The JSA Committee on Operating Room Safety (CORS) sent confidential questionnaires to 774 CTH and received valid responses from 60.3% of hospitals. A total number of 793,840 anesthetics were documented. The respondents were asked to report all cases of cardiac arrests and other critical incidents (serious hypotension, serious hypoxemia and others), and their outcomes (death in operating room, death within 7 days, transfer to vegetative state and rescue without sequelae) as well as one principal cause for each incident from list of 52 items. They were also requested to submit the tabulation of patients by ASA physical status, age distribution, surgery sites and anesthetic methods. Analysis was made by total incidents under anesthesia/surgery, and also by incidents totally attributable to anesthetic management (AM), due to preoperative complications (PC), due to intraoperative pathological events (IP) and due to surgery (SG), with special reference to each of four tabulation groups and the whole group of patients. This paper focused analysis on all patients, as analyses with special reference to ASA physical status, age distribution, surgery sites and anesthetic methods were previously reported. Total incidence of cardiac arrest under anesthesia/surgery was 6.53 per 10,000 anesthetics. PC, IP and SG represented principal causes in 42.9%, 22.0% and 21.4% causes of total cardiac arrest cases, respectively. AM was noted as the principal cause in 12.0% of cases, with an incidence rate of 0.78 per 10,000. In 52 more detailed classification of principal causes, the most frequent cause of cardiac arrest was preoperative hemorrhagic shock, 20.3% of all cardiac arrests. The second cause was massive hemorrhage and/or hypovolemia due to surgical procedures (13.1%), and the third was intraoperative myocardial infarction/coronary ischemia/coronary spasm (9.5%). Prognoses of cardiac arrest cases declined due to PC: 71.1% of cardiac arrests died in the operating room or within 7 days after surgery and only 19.8% survived without sequelae. The best prognoses were found in cardiac arrest cases due to AM: 69.4% survived without sequelae and 12.9% died. The mortality rate post-cardiac arrest was 3.44 per 10,000 anesthetics, of those 0.10 due to AM, 0.57 due to IP, 1.99 due to PC and 0.76 due to SG. The mortality rate after critical incidents other than cardiac arrest such as severe hypotension and severe hypoxemia was 3.75, of those 0.03 due to AM, 0.28 due to IP, 2.31 due to PC and 1.13 due to SG. The final mortality rate attributable to anesthesia/surgery including deaths post-cardiac arrest and after other critical incidents was 7.19 per 10,000 anesthetics and very close to 7.18 [6.22, 8.13], that of mean [95% C.I.] in 1994-1998. The final mortality rate totally attributable to anesthesia was 0.13 per 10,000 anesthetics, which was significantly improved from 0.21 [0.15, 0.27], that of mean [95% C.I.] in 1994-1998. IP, PC and SG showed the final mortality rate of 0.84, 4.30 and 1.89, respectively. Five major causes of all critical incidents were massive hemorrhage due to surgical procedures (20.8%), preoperative hemorrhagic shock (10.7%), surgical technique (8.0%), inappropriate airway management (5.2%) and intraoperative myocardial infarction and coronary ischemia (4.5%). Drug overdose or selection error (3.9%) and overdose of main anesthetic (2.9%) as a result of human error occupied the 7th and 10th places. As far as anesthetic management to reduce mortality and morbidity related to anesthesia is concerned, we should increase vigilance to avoid human errors in addition to improving preanesthetic preparations and assessment of cardiovascular status as well as intraoperative management of cardiovascular events.

Nonerythrodermic, leukemic variant of cutaneous T-cell lymphoma with indolent clinical course: Th2-type tumor cells lacking T-cell receptor/CD3 expression and coinfiltrating tumoricidal CD8 T cells.

As typically represented by Sézary syndrome, the leukemic form of cutaneous T-cell lymphoma (CTCL) mostly exhibits erythroderma. A patient with CTCL had slowly developing skin tumors as well as chronic leukemia. The tumor cell was CD4+ CD7- Th2 cells lacking T-cell receptor/CD3 complex and persistently occupied 27% to 48% of peripheral blood lymphocytes. In skin tumors, only 13% of tumor-infiltrating lymphocytes were malignant cells and substantial numbers of nonmalignant CD4+ or CD8+ T cells and B cells coinfiltrated. CD8+-infiltrating T cells had cytotoxic activity against the malignant T cell. Our case demonstrates the existence of the leukemic form of CTCL presenting with skin manifestation other than erythroderma and parapsoriatic patches. The nonerythrodermic feature and indolent course may be associated with the lack of T-cell receptor/CD3 expression and coinfiltration of a high percentage of nontumor lymphocytes, including tumoricidal CD8+ T cells.

[Utility of Ringer's acetate solution as an intraoperative fluid during cardiovascular surgery with cardiopulmonary bypass].

This study aimed to clarify the difference in the effects of Ringer's acetate (AR) and Ringer's lactate (LR) administration during cardiovascular surgery with cardiopulmonary bypass. We evaluated their effects on intra and postoperative metabolism, liver functions, blood gas and hemodynamic states. Twenty patients were divided into two groups; AR group (n = 10) and LR group (n = 10). Intraoperative serum D-lactate levels in LR group were significantly higher than those in AR group from the beginning of the operation to awakening. Serum acetate levels showed no increase in both groups. The arterial ketone body ratio (AKBR) in AR group was higher than that in LR group, but the difference was not significant. Serum glutamic pyruvic transaminase (GPT) and alkaline phosphatase (ALP) levels in LR group were significantly higher than those in AR group from the induction of the anesthesia. It has been reported that acetate has a greater vasodialatory effect than lactate. However, our findings indicate no significant difference in hemodynamics between the two groups. These results suggest that AR may be more useful than LR during cardiovascular surgery with cardiopulmonary bypass.