Surgical removal of an isolated femoral metastasis of uterine cervical squamous cell carcinoma: a case report and review of the literature.

A bone metastasis from uterine cervical cancer normally indicates short life expectancy. Resection of the lesion is therefore palliative. The authors consider herein whether surgical resection can promote disease control while improving quality of life. A 33-year-old woman -presenting FIGO Stage IB 1 uterine cervical squamous cell carcinoma underwent a radical hysterectomy and pelvic irradiation. Twenty-two-months later, a solitary femoral metastasis was detected. Given the pain, imminent bone fracture, the patient's relative youth, absence of other metastases, and complete control of the primary lesion, wide excision of the lesion, and reconstruction were performed. Sixteen months later, she was disease-free and ambulatory using a cane. The findings of both the present case and the review showed that patients were disease-free for over one year after surgery, suggesting that resection may assist disease control as well as improve patients' quality of life.

A sensitive method for detecting Porphyromonas gingivalis by polymerase chain reaction and its possible clinical application.

BACKGROUND: It is useful for the clinical diagnosis of periodontitis to monitor the colonization of periodontopathic bacteria in periodontal pockets. In this study, we attempted to establish and possibly identify the clinical application of a sensitive method to detect Porphyromonas gingivalis (P.g.), one of the putative periodontopathic bacteria related to chronic periodontitis. METHODS: Genomic DNA extracted from cultured P.g. 381 and clinically isolated subgingival plaque samples were used as a template of polymerase chain reaction (PCR). We designed primers to amplify the genomic DNA coding 40 kDa outer membrane protein (OMP), one of the unique proteins to all strains of P.g. The efficiency and specificity of amplification were evaluated by agarose gel electrophoresis and subsequent Southern hybridization with a digoxygenin-labeled oligonucleotide probe. RESULTS: Fewer than 100 P.g. bacterial cells in the specimen were reproducibly detected by PCR-hybridization assay. This PCR-hybridization assay was at least 100 times more sensitive than the conventional indirect immunofluorescence assay (IIF). Furthermore, the imaging analysis showed that there is a linear correlation between the strength of the signal and the cell number of P.g. from which the template DNA was extracted semiquantitatively. It is noteworthy that the PCR assay could also be applied to detect P.g. from clinical plaque samples and that it was approximately 100 times more sensitive than a conventional IIF assay. CONCLUSION: The PCR assay established in this study can be a powerful tool to detect P.g. in periodontal pockets and monitor the colonization and/or recolonization of P.g. at the very early phase.

[Application of Internet technology in public health].

Recent advances in telecommunication technology have been enormous. Application of this technology in public health has the potential to markedly improve global health through better surveillance and information systems. With this assumption the GHNet was established in 1994 by representatives from academia, WHO, Pan American Health Organization, the World Bank, NASA, IBM, and AT & T. The GHNet consists of seven components: 1) promotion of networking with the Internet among people in public health; 2) disease tele-monitoring; 3) distance learning system with the internet; 4) connection of non-governmental health organizations; 5) training cyberdocs who are educated in both public health and telecommunications; 6) establishment of an electronic scientific research server; and 7) a home page on the World Wide Web (WWW). In order to effectively incorporate the Internet into the field, connectivity and knowing how to use it are of critical concern. More and more facilities are connected to the Internet in Japan. However, few courses teaching how to utilize the Internet are provided for people in this field. An Internet training course for people in public health was held as joint venture of the World Health Organization (WHO) and the Global Health Network (GHNet) on October 31, 1996, at the 55th Annual Meeting of Japanese Society of Public Health. Most of the participants for the course were from local public health departments and very few had previous experience with the Internet before the course. During this course participants learned how to use e-mail, how to find health resources on the WWW, how to construct a home page, and how the Internet could be utilized to improve public health, with their computers actually hooked to the Internet. From this experience, we found that this kind of course is feasible and beneficial and hope that this course would serve as a model for training people in public health.

[Effects of fructose on left ventricular function during hypoxia].

The effects of fructose on cardiac function and myocardial metabolism during hypoxia were compared with those of saline infusion in the anesthetized mongrel dogs. Hypoxia was induced with inhalation of low fraction of oxygen (PaO2 = 15 mmHg) for two hours. Fructose (N = 7) was infused intravenously at a rate of 1 g.kg-1.h-1 and saline (N = 7) was infused at 5 ml.kg-1.h-1, in the same volume as fructose infusion. Both infusions were started at the induction of hypoxia. In the fructose group, two of seven dogs died within 90 min, and other dogs within 120 min. After 120 min, only one dog survived. In saline group, three of seven dogs died within 60 min, another within 90 min, and three others died within 120 min. In both groups, the dogs with cardiac arrest at an early period tended to show low levels of blood glucose and high levels of lactic acid. Blood glucose levels were similar in both groups, but % increase of blood glucose from control and myocardial glucose uptake tended to be higher in fructose group than in saline group. Blood lactic acid (LA) levels increased significantly in both groups, but, in fructose group, LA levels were higher, and arterial pH decreased more than those in saline group. In fructose group maximum rate of rise of left ventricular pressure (LV dp/dt max) correlated with intramyocardial pH (r = 0.834, P < 0.01), but not with LA levels nor with difference of blood lactic acid from control (d-LA).(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of NaHCO3 on cardiac function and metabolism during hypoxic metabolic acidosis--1: Slow infusion of NaHCO3].

Effects of NaHCO3 on metabolic acidosis during hypoxia and after reoxygenation were studied in 18 anesthetized dogs. Metabolic acidosis was produced by inhalation of low fraction of oxygen (9%) for 2 hours. NaHCO3 1M was infused intravenously during hypoxia (n = 12) and 30 minutes after reoxygenation (n = 6) at the rate of 100 ml.min-1 (total 0.2 x body weight x base excess mEq). After reoxygenation, NaHCO3 significantly increased blood and intramyocardial pH and decreased blood lactate (LA) level. Maximal rate of rise of left ventricular pressure (LV dP/dt max) and cardiac index (CI) increased significantly, and left ventricular end-diastolic pressure (LVEDP) and LVEDP/left ventricular pressure (LVP) were unchanged. During hypoxia, NaHCO3 also significantly increased blood and intramyocardial pH but those changes were less than the values after reoxygenation, while blood LA level increased significantly. LVP and LV dP/dt max tended to decrease, while LVEDP and LVEDP/LVP increased significantly. In 8 of 12 dogs, myocardial glucose uptake increased but was not correlated with myocardial LA uptake and LV dP/dt max. Blood LA level correlated significantly with LV dP/dt max (r = 0.534, P < 0.01). It appears that during hypoxia, differing from reoxygenation, NaHCO3 may depress cardiac function due to intramyocardial acidosis.

[Effects of NaHCO3 on cardiac function and metabolism during hypoxic metabolic acidosis--2: Rapid infusion of NaHCO3].

The effects of 1M sodium bicarbonate (NaHCO3) on cardiac function and myocardial metabolism during hypoxia were compared with those of 1M sodium chloride (NaCl) in anesthetized dogs. Metabolic acidosis was induced with inhalation of low fraction of oxygen (9%) for 2 hours. NaHCO3 (n = 9) or NaCl (n = 10) was infused intravenously in a half dose of 0.2 x body weight x base excess mEq in 30 seconds. This treatment was repeated five minutes later. In NaHCO3 group; with first infusion, both blood and intramyocardial pH increased. Left ventricular pressure (LVP) and maximum rate of rise of LVP (LV dP/dt max) were unchanged. Cardiac index (CI) tended to increase, while left ventricular end-diastolic pressure (LVEDP) and LVEDP/LVP increased significantly. In five dogs in which myocardial glucose uptake increased, LV dP/dt max increased. With the second infusion, inspite of the increase of blood and intramyocardial pH, LVP and LV dP/dt max decreased significantly compared with the preceding values. In NaCl group, with first infusion, blood and intramyocardial pH decreased. CI increased significantly, while LVP and LV dP/dt max tended to decrease, and LVEDP and LVEDP/LVP increased significantly. After the second infusion, myocardial contractility was depressed significantly. In both groups, blood lactate (LA) level increased significantly, especially with NaHCO3 infusion. LV dP/dt max correlated significantly with LA in NaCl group (r = -0.614, P < 0.001). However, in NaHCO3 group, LV dP/dt max did not correlate with LA. Blood glucose level (r = 0.612, P < 0.001) and myocardial glucose uptake (r = 0.718, P < 0.001) correlated significantly with LV dP/dt max in NaHCO3 group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of deliberate hypotension on the ischemic heart during isoflurane anesthesia--a comparison of prostaglandin E1 and sodium nitroprusside].

The effects of hypotension induced by prostaglandin E1 (PGE1) or sodium nitroprusside (SNP) on regional myocardial function and metabolism were studied in a canine heart with coronary artery stenosis. Ultrasonic dimension technique was used to assess left ventricular performance. Fourteen open-chest mongrel dogs were anesthetized with isoflurane and mean aortic pressure was maintained at approximately 80 mmHg. The left circumflex coronary artery blood flow was reduced by 40% using a screw flow regulator without affecting global and regional myocardial function. The severity of stenosis was considered almost critical. PGE1 (n = 7) or SNP (n = 7) was administered to reduce mean aortic pressure to 50 mmHg. There were no significant differences between PGE1 and SNP regarding their effect on systemic hemodynamics. Nevertheless SNP decreased percent segment shortening in the stenosed area from the pre-hypotension value more significantly than PGE1 (55.0 +/- 10.8% versus 24.2 +/- 7.3%). This suggests that regional myocardial ischemia is more deteriorated during SNP-induced hypotension. It seems that PGE1-induced hypotension is safer when it is applied to patients with coronary artery disease.

[Effect of cardiopulmonary bypass on the renal tubular cell--the importance of the changes in the ratio of creatinine to blood urea nitrogen].

We examined the effect of cardiopulmonary bypass on the renal tubular cell in 19 adult patients undergoing cardiac surgery. The ratio of creatinine to blood urea nitrogen (BUN/Cr) decreased in the early period of cardiopulmonary bypass, because of increased serum creatinine and unchanged blood urea nitrogen. N-acetyl-beta-D-glucosaminidase (NAG) index in the intra- and postbypass period was higher than that in the preoperative period. Creatinine clearance (CCr) on the 7th postoperative day and the difference of BUN/Cr between preoperative period and 30 min after initiation of cardiopulmonary bypass (delta BUN/Cr 30 min) correlated significantly with the postoperative NAG index. The results suggest that cardiopulmonary bypass impaired the renal tubular cell, and renal tubular injury deteriorated the glomerular filtration in the postbypass period, and that creatinine production increased in the early period of cardiopulmonary bypass. delta BUN/Cr 30 min may predict the intraoperative renal tubular injury.

[Bronchospasm during anesthesia in a patient with Prader-Willi syndrome].

A patient with Prader-Willi syndrome developed bronchospasm during anesthesia. The patient was a 9-year-old boy and was scheduled for orchiopexy. His psychomotor development was delayed, and at 12 months of age he was diagnosed as Prader-Willi syndrome by chromosomal examination. The patient weighed 17 kg, was 111 cm tall, and had no symptom of upper respiratory infection preoperatively. Preoperative examinations were normal except supraventricular extrasystole in electrocardiogram. Following administration of scopolamine 0.15 mg intramuscularly as preanesthetic medication, anesthesia was induced smoothly by slow induction using N2O-O2-sevoflurane. However, right after endotracheal intubation with vecuronium 2 mg, remarkable stridor was noticed. Despite hyperventilation, the patient exhibited hypercapnia, and the diagnosis of bronchospasm was made. Aminophylline and steroid were administered intravenously and halothane was inhaled instead of sevoflurane. The bronchospasm was improved gradually and surgery was finished. Prader-Willi syndrome is an uncommon disease first reported by Prader in 1956 and characterized by hypotonia, hypomentia, hypogonadism and obesity. In the perioperative management for a patient with Prader-Willi syndrome, special attention must be paid to the abnormalities in the upper and lower respiratory systems.

[Epidural fentanyl provide sufficient analgesia for extracorporeal shock wave lithotripsy (ESWL)].

Epidural fentanyl (0.2 mg in 10 ml normal saline) was administrated in 10 unpremedicated patients undergoing extracorporeal shock wave lithotripsy (ESWL). No test dose of local anesthetics was administrated and accessory drugs such as narcotics or analgesics were not used. Painful procedures except for shock wave such as insertion of urethral catheter were not applied. We observed analgesic effect using original score (grade 0-3) and monitored heart rate, blood pressure, respiratory rate and Spo2 during ESWL. At 1, 2, 3, 4 and 24 hours after ESWL, patients were questioned regarding the presence of postoperative nausea, vomiting, and motor disturbance. At the start of ESWL, nine patients experienced mild pain, although no patient requested additional analgesic treatment. Until the end of ESWL, local anesthetics were administered through the epidural catheter in three patients because of increase of pain, while the others completed ESWL with epidural fentanyl alone. No remarkable change in blood pressure and heart rate were observed. Respiratory rate and Spo2 slightly decreased during ESWL. Postoperative side effects were mild especially in the patients treated with epidural fentanyl alone. Epidural fentanyl is considered to be useful analgesic technique for ESWL.

[Is thoracic epidural anesthesia beneficial to myocardial ischemia?--Influence of hemodynamics].

The effects of thoracic epidural anesthesia (TEA) on regional myocardial blood flow (RMBF) and hemodynamics were evaluated in open-chest dogs with coronary artery stenosis. In the 6 dogs with pressure-rate quotients (PRQ) of greater than 0.8, TEA caused a significant increase of the ratio of endocardial to epicardial RMBF in the ischemic region and tended to increase the ratio of RMBF in the ischemic to normal area, resulting in improved myocardial ischemia. There was no reduction of myocardial ischemia in the 11 dogs with PRQ of less than 0.8. The hemodynamic effects determine whether TEA is favorable for the ischemic heart or not. It appears that PRQ is useful as an indicator of myocardial oxygen balance during TEA.

[Hypoxemia during cesarean section--evaluation of venous air embolism by transesophageal echocardiography].

We studied the incidence and cause of hypoxemia during Cesarean section under general anesthesia. Arterial oxygen desaturation (< or = 95%) occurred in 6 of 28 patients (21%). Venous air embolism (VAE) was detected in 7 of 28 subjects (25%), but the severity of which was mild and was not associated with oxygen desaturation. While, there were significant differences in obesity index, preoperative respiratory function, and PaO2 after the induction of anesthesia between the patients with and without oxygen desaturation. Our results suggest that hypoxemia may occur frequently during Cesarean section under general anesthesia, but is not caused by VAE, and is related with the physiological changes associated with pregnancy.

[Blood coagulation-fibrinolysis system during transurethral resection evaluated by thrombelastography].

Intraoperative changes in blood coagulation-fibrinolysis system were evaluated in 21 patients under epidural anesthesia by thrombelastography. Ten patients received transurethral resection of prostate (TUR-P) and 11 patients received transurethral resection of bladder tumor (TUR-Bt). Thrombelastographic variables: reaction time (R), coagulation time (K), maximum amplitude (MA), and amplitude 60 min after MA (A 60) were measured. The coagulability was evaluated by R + K, the absolute strength of clot by MA, and fibrinolysis using MA-A60. There was no significant change of these indices in TUR-Bt group. On the other hand, in TUR-P group, R + K was significantly shortened and MA-A60 had a tendency to increase it, but MA caused no change. Resected prostatic weight correlated significantly with the decrease of MA, and had a tendency to correlate with the increase of MA-A60 in TUR-P group. Both coagulation and fibrinolysis were activated in TUR-P group. When the resected prostatic weight is large, the risk of coagulopathy may increase.

[Delayed hypoxia after the surgical correction of femoral neck fracture].

We investigated perioperative blood gas changes in 26 patients scheduled for surgical correction of femoral neck fracture under epidural anesthesia. Arterial blood gases during spontaneous air respiration were measured eight times during the femoral neck prosthetic replacements (n = 16), and four times during osteosynthesis (n = 10). In the patients who received femoral neck replacements using bone cement (n = 8), arterial oxygen tension decreased significantly four hours after insertion of prosthesis, and did not recover during two postoperative days. In contrast, in the patients who received cementless femoral neck replacements (n = 8), arterial oxygen tension tended to decrease but not significantly, and returned to normal on the second postoperative day. In the patients who received osteosynthesis, arterial oxygen tension did not change. We suspected that the causes of delayed hypoxia in the femoral neck replacements were vascular endothelial cell injury in the lung by free fatty acid originating from fat embolism, and/or microthrombosis resulting from activated coagulation system. Bone cement was thought to intensify fat embolism because of elevated intramedullary pressure in the femur.

[Isoflurane and sevoflurane impair left ventricular relaxation in dogs with fixed heart rate].

The effects of isoflurane (Iso) and sevoflurane (Sev) on left ventricular relaxation were evaluated in 22 open-chest dogs with fixed heart rate (130 beats.min-1) using atrial pacing. Fentanyl was injected intravenously to maintain anesthesia during the preliminary preparation. In both Iso and Sev groups (n = 11), left ventricular systolic pressure, mean aortic pressure and dp/dt max were significantly decreased at 0.5 MAC, but there was no significant change in left ventricular end-diastolic pressure. Left ventricular systolic function was depressed to the similar extent in both groups. In Sev group, -dp/dt max and time constant of isovolumic left ventricular pressure fall (T) increased significantly at 0.5 MAC but it increased at 1.5 MAC in Iso group. T at 0.5 MAC Sev was also significantly longer compared with T at equipotent Iso. These findings suggest that Sev may impair isovolumic left ventricular relaxation more strongly than Iso, and this may result from the difference of the effect of each agent on intracellular Ca2+ homeostasis in the myocardium.

[Recovery from cardiac arrest by prostaglandin E1 infusion during emergency open heart surgery].

A 21 day old infant, diagnosed as ASD, VSD, and PDA, was scheduled for an emergency radical operation. After admission, she fell into cardiac failure and was treated with artificial ventilation and infusion of inotropic agents. Anesthesia was induced with fentanyl and maintained with continuous fentanyl infusion and chlorpromazine. Dopamine and dobutamine were administered before she underwent a cor-pulmonary by-pass. At the time of release of aortic clamping, her blood pressure went down and dopamine, dobutamine and isoproterenol were administered. After completion of the cor-pulmonary by-pass, tachy-arrhythmia and hypotension occurred. Digitalis and calcium did not reverse the condition. The thorax was reopened and BP rose. After 15 min, ventricular fibrillation occurred. Defibrillation was carried out, but the heart was arrested. Even with pacing and cardiac massage, cardiac contraction did not resume. However immediately on intravenous administration of PGE1, 40 ng.kg-1.min-1, the heart started to beat. The cause of recovery from cardiac arrest was speculated to be due to reuptake of intracellular Ca2+ by PGE1. We stress therefore, that during and after cor-pulmonary by-pass procedures, PGE1 infusion may be beneficial.

[Effects of diltiazem hydrochloride on blood gases].

The effects of diltiazem, Ca ion channel blocker, on arterial blood gases were evaluated in 50 patients (G-I: 24 patients undergoing abdominal surgery, G-II: 26 patients undergoing non-abdominal surgery). Diltiazem hydrochloride was administered to prevent intraoperative hypertension as a bolus (5 mg) followed by a continuous infusion (5-10 micrograms.kg-1.min-1). Arterial blood gases were analyzed just before, as well as 5 and 15 min after the administration of diltiazem. In G-I, arterial blood oxygen tension decreased significantly (P < 0.001) from 210.8 +/- 42.4 to 197.7 +/- 50.2 mmHg 5 min after infusion, and to 193.2 +/- 53.4 mmHg 15 min after; while there was no significant difference in G-II. Diltiazem infusion may deteriorate oxygenation in patients undergoing abdominal surgery, and therefore oxygenation should be carefully monitored.

[Severe hypoxemia during cesarean section].

We describe three cases in which severe hypoxemia occurred during cesarean section. The first and second patients showed low oxygen saturation (91, 90%, respectively) on their arrival at the operation room, and hypoxemia deteriorated rapidly after the induction of anesthesia. During surgery low oxygen saturation, ranging from 90 to 95%, persisted until the beginning of spontaneous respiration. In the third patient, oxygen saturation fell suddenly to 93% after the delivery of a neonate, and the arterial blood gas analysis revealed Pao2 68.5 mmHg with 38% oxygen. Hypoxemia was transient and resolved at the end of operation. Parturients have been reported to be likely to develop hypoxemia physiologically. Apnea for a short interval during tracheal intubation may cause severe hypoxemia in parturients compared with normal subjects. Ritodrine, a beta 2 stimulator, which was administered in the first and second patients just prior to operation, may be one of the factors leading to hypoxemia because of its inhibition of hypoxic pulmonary vasoconstriction. Venous air embolism (VAE) may occur frequently during cesarean section, especially during repair of the uterus. VAE may have caused hypoxemia in the third patient. In conclusion, parturients should be monitored carefully with pulse oximetry during cesarean section.

[Left ventricular function during hypoxia. 1: Effect of blood glucose level].

We investigated the effects of blood glucose levels and myocardial glucose uptake on cardiac function during hypoxia in mongrel dogs (N = 50). During hypoxia (PaO2 = 20 mmHg) caused by inhalation of low concentration of oxygen for 2 hours, left ventricular (LV) function including LV pressure, maximum rate of rise of LV pressure, and cardiac index decreased significantly following initial enhancement. There were significant correlations between these hemodynamic parameters and blood glucose levels. The blood glucose levels correlated significantly with myocardial glucose uptake and blood lactic acid levels (r = 0.660: P = 0.000, r = 0.380: P = 0.000, respectively). Eight of nine dogs which died within 90 minutes during hypoxia showed low blood glucose levels and high lactic acid levels. During hypoxia, myocardial glucose uptake increased to more than five times of control value. On the other hand myocardial lactic acid uptake decreased and turned to production. At the same degree of blood lactic acid levels, LV function was maintained better with high blood glucose levels than with low levels. With low blood glucose levels, myocardial lactic acid uptake and production tended to cease. The pronounced change in LV function during hypoxia could be partially explained by decreased production of ATP due to decrease in myocardial glucose uptake and high lactic acid levels. It seems that high blood glucose levels are preferable to maintain cardiac performance under such a condition.

[Left ventricular function during hypoxia--II: Effects of intramyocardial pH].

We investigated the effects of intramyocardial acidosis on cardiac function during hypoxia in mongrel dogs (n = 50). Intramyocardial pH in subendocardium of left ventricle was measured continuously using a pH electrode. During hypoxia (PaO2 = 20 mmHg) caused by inhalation of low oxygen fraction, intramyocardial pH decreased significantly following initial enhancement. Intramyocardial pH correlated significantly with arterial pH, base excess, lactic acid (LA) levels, coronary venous PcO2, and coronary venous-arterial PcO2 difference. There were significant correlations between intramyocardial pH with maximum rate of rise of left ventricular pressure (LV dp/dt max), left ventricular end-diastolic pressure (LVEDP), LVEDP/LVP and the time constant of exponential isovolumic left ventricular pressure fall. High arterial LA levels tended to cease myocardial LA uptake and production, turning LA balance into zero. LV dp/dt max was low in such a condition. Myocardial LA production decreased intramyocardial pH, but LV dp/dt max was maintained at high levels of LA production. These observations suggest that myocardial LA production maintains left ventricular function with the increase of ATP by acceleration of anaerobic glycolysis. In conclusion, during hypoxia, intramyocardial acidosis was caused by the increase of arterial LA level, myocardial anaerobic glycolysis and ATP breakdown, and it worsened left ventricular contractile function and relaxation. Arterial LA levels can play a major part in intramyocardial acidosis, but the increase in myocardial LA production might be beneficial to left ventricular contractile function.