Anesthetic management for cesarean section in moyamoya disease: a report of five consecutive cases and a mini-review.

We report five consecutive cases of neuraxial anesthesia for cesarean section in women with moyamoya disease. Either epidural or combined spinal-epidural anesthesia was provided, with adequate sedation using intravenous diazepam and/or opioid(s). Hemodynamic stability and normocapnia were well maintained, except in one patient who exhibited transient hypertension and hypocapnia due to anxiety. None of the parturients suffered from neurological deficit in the intra- or postoperative period, although one patient complained of numbness in her fingers at the end of surgery, but she was not hypotensive or hypocapneic. The neonates were all in good health. The literature is reviewed on the anesthetic management for cesarean section in patients with moyamoya disease.

Relation between fentanyl dose and predicted EC50 of propofol for laryngeal mask insertion.

BACKGROUND: This study sought to determine the effective concentration for 50% of the attempts to secure laryngeal mask insertion (predicted EC(50LMA)) of propofol using a target-controlled infusion (Diprifusor) and investigated whether fentanyl influenced these required concentrations, respiratory rate (RR) and bispectral index (BIS). METHODS: Sixty-four elective unpremedicated patients were randomly assigned to four groups (n = 16 for each group) and given saline (control) or fentanyl 0.5, 1 or 2 micro g kg(-1). Propofol target concentration was determined by a modification of Dixon's up-and-down method. Laryngeal mask airway insertion was attempted without neuromuscular blocking drugs after equilibration had been established for >10 min. Movement was defined as presence of bucking or gross purposeful muscular movement within 1 min after insertion. EC(50LMA) values were obtained by calculating the mean of 16 patients in each group. RESULTS: Predicted EC(50LMA) of the control, fentanyl 0.5, 1 and 2 micro g kg(-1) groups were 3.25 (0.20), 2.06 (0.55), 1.69 (0.38) and 1.50 (0.54) micro g ml(-1) respectively; those of all fentanyl groups were significantly lower than that of control. RR was decreased in relation to the fentanyl dose up to 1 micro g kg(-1). BIS values after fentanyl 1 and 2 micro g kg(-1) were significantly greater than in the control and 0.5 micro g kg(-1) groups. CONCLUSIONS: A fentanyl dose of 0.5 micro g kg(-1) is sufficient to decrease predicted EC(50LMA) with minimum respiratory depression and without a high BIS value.

Predicted values of propofol EC50 and sevoflurane concentration for insertion of laryngeal mask Classic and ProSeal.

BACKGROUND: A new laryngeal mask airway, the ProSeal (PLMA), is said to be more difficult to insert than the laryngeal mask airway Classic (CLMA) using propofol anaesthesia. Therefore, we expected a greater dose of propofol and sevoflurane to be required to insert the PLMA compared with the CLMA. We determined the effective concentration 50% (EC(50)) of propofol and end-tidal sevoflurane to allow insertion of the PLMA and the CLMA. METHODS: Seventy-six elective female patients (aged 20-60 yr and ASA I-II) were randomly assigned to one of four groups. Either a PLMA or a CLMA was inserted using either propofol target controlled infusion or sevoflurane. Both propofol and sevoflurane targets were determined with a modified Dixon's up-and-down method. After equilibration between the predetermined blood and effect site concentrations, which had been held steady for more than 10 min, LMA insertion was attempted without neuromuscular block. RESULTS: The predicted EC(50CLMA) and EC(50PLMA) for propofol were 3.14 (0.33) and 4.32 (0.67) micro g ml(-1). E'(CLMA) and E'(PLMA) of sevoflurane (mean (SD)) were 2.36 (0.22) and 2.82 (0.45)% (P<0.01 and 0.05, respectively). CONCLUSIONS: The estimated concentration of propofol and the sevoflurane concentration needed to allow insertion of the ProSeal are respectively 38 and 20% greater than those needed for insertion of the Classic LMA.

Phase I/II study of daily carboplatin, 5-fluorouracil and concurrent radiation therapy for locally advanced non-small-cell lung cancer.

A study was undertaken to determine the maximum tolerated dose, the dose-limiting toxicities and the response rate of carboplatin and 5-fluorouracil administered daily with concurrent thoracic radiation therapy in patients with locally advanced non-small-cell lung cancer. In a phase I/II clinical trial, patients with histologically documented, unresectable stage IIIA or IIIB non-small-cell lung cancer (NSCLC) were enrolled. Carboplatin (20-40 mg m(-2) 2-h infusion, daily) and 5-fluorouracil (200 mg m(-2) 24-h continuous infusion, daily) were administered concurrently with radiotherapy on days 1-33. Radiotherapy, with a total dose of 60 Gy, was delivered in 30 fractions on days 1-40. In the phase I portion, the daily dose of carboplatin was escalated from 20 to 40 mg m(-2). Once the maximum tolerated dose (MTD) and recommended dose (RD) of carboplatin was determined, the study entered the phase II portion. In the phase I portion, the daily MTD and RD of carboplatin were 40 and 35 mg m(-2), respectively. The dose-limiting toxicity was neutropenia. In the following phase II study, 30 patients were entered and the objective response rate was 76.7% (95% CI, 62-92%) and the local control rate was 85.7%. The median survival time was 19.8 months, with a survival rate of 70% at 1 year, 36.7% at 2 years. The major toxicities of treatment were neutropenia (>or=grade 3, 87.9%) and thrombocytopenia (>or=grade 3, 23.3%). This combined therapy for locally advanced non-small-cell lung cancer is promising and shows acceptable toxicity.

Cp50 of propofol for laryngeal mask airway insertion using predicted concentrations with and without nitrous oxide.

This study sought to determine the predicted Cp50 of propofol required for laryngeal mask airway insertion (Cp50LMA) and to investigate whether nitrous oxide reduces these required concentrations. Using target-controlled infusion and incorporating the standard Diprifusor pharmacokinetic model, 46 unpremedicated patients were randomly assigned to one of two groups. The patients received either 40% oxygen in air (control group: n = 23), or 60% nitrous oxide in oxygen (nitrous oxide group: n = 23). The target concentration for each patient was determined using the up and down method. Following equilibration between the predetermined blood and effect site concentrations, had been established for > 10 min, laryngeal mask airway insertion was attempted without neuromuscular relaxants. The data were analysed using a probit analysis to obtain Cp50LMA levels. The values for Cp50LMA were 3.24 micro g.ml-1 in the control group and 1.93 microg.ml-1 in the nitrous oxide group.

Substitution of Dmo1 with normal alleles results in decreased manifestation of diabetes in OLETF rats.

AIM: Dmo1 (Diabetes Mellitus OLETF type I) is a major quantitative trait locus for dyslipidaemia, obesity and diabetes phenotypes in the Otsuka Long Evans Tokushima Fatty (OLETF) rat strain. To evaluate possible metabolic and pathological improvements generated by correction of the Dmo1 genetic pathway, we produced congenic lines, in which both OLETF Dmo1 alleles are replaced by the F344-derived genome. METHODS: Congenic animals were produced by introgressing F344-derived Dmo1 alleles into the OLETF rat. Congenic animals of the fourth generation (BC4) were intercrossed to obtain F1 animals (BC4:F1). Animals of the next generation, BC4:F2, were used for this study. We used 23 BC4:F2 males harbouring homozygous replacement of the OLETF Dmo1 region with the F344-derived genome. Seven animals with OLETF-derived Dmo1 alleles were used as controls. RESULTS: Dmo1-F344/F344 congenic rats showed significant decreases in body weight, abdominal fat weight, serum triacylglycerols, total cholesterol, food consumption and blood glucose after glucose loading (13%, 39%, 45%, 27%, 18% and 27% respectively; p < 0.05) compared with Dmo1-OLETF/OLETF animals. Furthermore, histopathological analysis of the kidney showed that mesangial sclerosis, hyalin deposits and deposition of PAS-positive substance were significantly lower in Dmo1-F344/F344 animals (p < 0.05). CONCLUSION: Improvements in metabolic parameters and histopathological scores show that correction of the Dmo1 genetic pathway in the diabetic and mildly obese OLETF rat strain produces wide-ranging therapeutic effects. Thus, this pathway might represent a new drug target also applicable to humans.

[Serological diagnosis of pulmonary tuberculosis and nontuberculous pulmonary mycobacteriosis].

OBJECTIVE: The present study was undertaken to evaluate the utility of the serodiagnosis of pulmonary tuberculosis and nontuberculous pulmonary mycobacteriosis by ELISA using a Pathozyme-Myco kit (Myco kit) and a Pathozyme-TB complex kit (TB kit) (OMEGA Diagnostics Ltd.). STUDY POPULATION: The subjects comprised 256 healthy volunteers (HV, healthy hospital employees), 66 patients with sputum-positive active pulmonary tuberculosis (apTB), 14 patients with healed pulmonary tuberculosis (hpTB), 24 patients with nontuberculous pulmonary mycobacteriosis (NTM) and 32 patients with pulmonary diseases other than mycobacteriosis. RESULTS: 1) The serum IgG antibody titers determined with the Myco kit were significantly higher in the apTB group (p < 0.01), the hpTB group (p < 0.01), and the NTM group (p < 0.01) than those in the HV and the other pulmonary disease group. At a cut-off value of the mean + 2SD of the values obtained in the HV, the positive rate was 47.0% in patients with apTB, 50.0% in those with NTM, 21.4% in those with hpTB, 3.1% in those with other pulmonary diseases, and 1.6% in the HV. Analysis of ROC curves showed that the HV and the pulmonary mycobacteriosis group (apTB and NTM) were best distinguished by a cut-off value of -0.280 OD (log), with the sensitivity and the specificity being 83.3% and 78.5%, respectively. It was impossible to distinguish apTB from NTM. 2) The serum IgG antibody titers determined with the TB kit were significantly higher in the apTB group than those in the HV (p < 0.01), the NTM group (p < 0.05) and the other pulmonary disease group (p < 0.01). No significant difference was observed between the HV and the patients with NTM or those with other pulmonary diseases. Although the positive rate of the test was low in the apTB group (42.4%), there was a significant difference between apTB and NTM (12.5%) (p < 0.05), suggesting that apTB could be distinguished from NTM. 3) Since the serum antibody titers determined by the Myco kit showed no significant difference between apTB and NTM, and there was also no difference in the positivity between the two diseases, we performed serologic examination using the Myco kit to detect both diseases as pulmonary mycobacteriosis. After diagnosing pulmonary mycobacteriosis by the Myco kit, we then used the TB kit to separate apTB from NTM. In this case, the sensitivity and specificity of the test were 55.6% and 85.7%, respectively. Better methods should be developed to distinguish apTB from nontuberculous mycobacteriosis.

[Severe pulmonary edema in a preeclamptic patient with peripartum cardiomyopathy].

We report a preeclamptic patient who revealed severe pulmonary edema. A 37-year-old woman, at 32-week gestation, underwent emergency cesarean section under general anesthesia. She had no particular past medical history. SpO2 was 84% (room air) on the arrival at the operating room, and a chest X-ray showed pulmonary edema. She was managed in the intensive care unit postoperatively, she received an intensive treatment (positive pressure ventilation, furosemide, and inotropic support), and was extubated successfully on the third postoperative day. From clinical course and echocardiographic findings, we consider that this pulmonary edema was caused by peripartum cardiomyopathy.

[Endotoxin adsorption and continuous hemodiafiltration in three septic patients].

We report 3 patients in septic shock with panperitonitis. Endotoxin adsorption by polymixin B affinity column (PMX) and continuous hemodiafiltration (CHDF) were performed immediately after the surgery. Septic shock was not improved in patient 1 and 2 despite intensive care. Multimodal approach, including complete surgical repair, cardiovascular support and blood purification methods, is essential in treating septic patients.

Effects of Dmo1 on obesity, dyslipidaemia and hyperglycaemia in the Otsuka Long Evans Tokushima Fatty strain.

Whole-genome scans have identified Dmo1 as a major quantitative trait locus (QTL) for obesity and dyslipidaemia in the Otsuka Long Evans Tokushima Fatty (OLETF) rat. We have produced congenic rats for the Dmo1 locus, using marker-assisted speed congenic protocols, enforced by selective removal of other QTL regions (QTL-marker-assisted counterselection), to efficiently transfer chromosomal segments from non-diabetic Fischer 344 (F344) rats into the OLETF background. In the third generation of congenic animals, we observed a substantial therapeutic effect of the Dmo1 locus on lipid metabolism, obesity control and plasma glucose homeostasis. We conclude that single-allele correction of an impaired genetic pathway can generate a substantial therapeutic effect, despite the complex polygenic nature of type II diabetic syndromes.

Single-allele correction of the Dmo1 locus in congenic animals substantially attenuates obesity, dyslipidaemia and diabetes phenotypes of the OLETF rat.

1. Whole-genome scans have identified Dmo1 as a major quantitative trait locus for dyslipidaemia and obesity in the Otsuka Long Evans Tokushima Fatty (OLETF) rat. 2. We have produced congenic rats for the Dmo1 locus through successive back-cross breeding with diabetic OLETF rats. Marker-assisted speed congenic protocols were applied to efficiently transfer chromosomal segments from non-diabetic Brown Norway (BN) rats into the OLETF background. 3. In the fourth generation of congenic animals, we observed a substantial therapeutic effect of the Dmo1 locus on lipid metabolism, obesity control and plasma glucose homeostasis. 4. We have concluded that Dmo1 primarily affects lipid homeostasis, obesity control and/or glucose homeostasis at fasting and is secondarily involved in glucose homeostasis after loading. 5. The results of the present study show that single-allele correction of a genetic defect of the Dmo1 locus can generate a substantial therapeutic effect, despite the complex polygenic nature of type II diabetic syndromes.

Quantitative trait loci for lipid metabolism in the study of OLETF x (OLETF x Fischer 344) backcross rats.

1. The Otsuka Long-Evans Tokushima Fatty (OLETF) rat is a model of type II diabetes with accompanying dyslipidaemia and obesity. 2. To define chromosomal intervals associated with obesity (abdominal fat weight and plasma leptin levels), dyslipidaemia (plasma triglyceride, cholesterol and free fatty acids) and hyperglycaemia (plasma glucose levels), we have performed genome-wide quantitative traits loci (QTL) analyses of 115 male OLETF x (OLETF x Fischer 344) backcross animals at 16 weeks of age. 3. The Diabetes Mellitus OLETF type I (Dmo1) locus on rat chromosome 1 showed statistically significant involvement in elevations of plasma levels of triglycerides (P = 4.87 x 10(-6) at D1Rat90) and total cholesterol (P = 1.16 x 10(-5) at D1Rat306). 4. No other loci produced significant linkage to these observed phenotypes. 5. These analyses have confirmed the importance of Dmo1 in lipid homeostasis at younger ages as well as during overt diabetes, which appears later. Thus, alterations at the Dmo1 locus are a major risk factor for pathogenesis in the strain, a finding that agrees with physiological studies that indicate a role for dyslipidaemia in the type II diabetic syndrome of OLETF rats.

[Anesthesia for emergency surgery in 2 extremely low birth weight infants with ileus].

Two extremely-low-birth-weight infants, weighing each 684 and 975 g at birth, underwent emergency surgery because of ileus. Our previous experience with an extremely low birth weight infant, whose hemodynamic control during the surgery had been difficult without administering extra preoperative fluid and transfusion, made us administer enough fluid and transfusion during operation although their urine output was more than 2 ml.kg-1.hr-1. We gave intravenous volume to the present 2 cases before the operations despite the level of preoperative urine output and made their hemodynamic situation more stable during surgeries. We conclude it is very important to administer some amounts of intravenous volume (approximately 8-12 ml.kg-1.hr-1) in extremely low birth weight infants for emergency surgery with ileus regardless of their preoperative urine output.

[A review of correlation between transfusion rate of irradiated blood and potassium load].

Transfusion of the irradiated blood has become popular in Japan to prevent the graft-versus-host disease. Case reports, however, of hyperkalemic death or lethal ECG change have been increasing since the irradiated blood was introduced nation-wide. The potassium concentration of the supernatant of irradiated blood becomes about 60 mEq.l-1 by the end of storage period. If the potassium concentration is 60 mEq.l-1, the estimated safe transfusion rate would be 6 ml.min-1 and this can not be agreed with by clinicians who transfuse daily in cases of massive bleeding. The calculated safe transfusion rate (10 mEq.hr-1 of potassium load) ranges from 6 to 72 ml.min-1 considering the storage period from the day of gathering and irradiation. This difference could affect the survival rate. On the other hand, only the difference of the potassium concentration in the supernatant between the irradiated blood and the non-irradiated blood could not explain the increasing number of hyperkalemic case report. The mechanical factors may be related to hemolysis that causes extreme hyperkalemia. Control studies of proper transfusion rate of irradiated blood should be performed to establish a safety guideline for rapid transfusion of irradiated blood.

[Antimicrobial susceptibility testing for Mycobacterium tuberculosis by measuring mycobacterial adenosine triphosphate].

The antimicrobial susceptibility test for Mycobacterium tuberculosis H37Rv and 43 clinical isolates was performed using a bioluminescence assay by measuring the content of adenosine triphosphate (ATP) derived from mycobacteria. The drugs tested were isoniazid (INH), rifampicin (RFP), ethambutol (EB), streptomycin (SM), and kanamycin (KM). The ATP contents of M. tuberculosis incubated in the Middle-brook 7H9 broth medium containing antituberculous agents were measured at days of 0, 1, 3, 5, 7 and 10. A reduction of ATP content, indicating growth inhibition, was observed in susceptible strains within 5 to 10 days of incubation. Optimal concentrations to distinguish between susceptible and resistant strains were determined as being INH 0.20, RFP 0.50, EB 5.0, SM 4.0, KM 6.0 g/ml. The agreements of ATP method (evaluated at 10 days) with Vite Spectrum and MIC determinations were 81.4% and 100%, respectively. Susceptibilities to most drugs, except for EB, could be determined within 7 days. This method is simple, rapid, nonradiometric, and can be used for drug susceptibility.

Genetic determinants of plasma triglyceride levels in (OLETF x BN) x OLETF backcross rats.

Altered lipid metabolism is closely associated with diabetes in humans, although predisposing genetic factors that affect hyperlipidemia have not yet been clarified. Our previously established OLETF strain is an obese rat model of type II diabetes, exhibiting hypertriglycemia as well as hyperinsulinemia, hyperglycemia, insulin resistance, and abundant abdominal fat. To identify genetic factors responsible for dyslipidemic phenotypes in OLETF rats, we performed a whole-genome scan using 293 male (OLETF x BN) x OLETF backcross rats. Our analysis identified two significant quantitative trait loci (QTLs), on rat chromosomes 1 and 8, that are related to fasting triglyceride levels. The chromosome 1 QTL colocalized with Dmo1 (diabetes mellitus, OLETF type 1), a locus previously shown to associate strongly with both fat levels and body weight. The other significant QTL localizes to the chromosome 8 marker D8Mit2, in a region where several apo-lipoprotein genes are clustered.

[Significance of serum surfactant protein-D (SP-D) level in patients with pulmonary tuberculosis].

Elevated levels of serum surfactant protein-D (SP-D) have been previously reported in patients with idiopathic pulmonary fibrosis (IPF) and pulmonary alveolar proteinosis. To determine whether the same change is seen in other pulmonary diseases, especially pulmonary tuberculosis (TB), we measured the serum SP-D levels in active pulmonary TB (smear and/or culture: positive), acute interstitial pneumonia (AIP), IPF, acute exacerbation of IPF, hypersensitivity pneumonitis (HP), pneumoconiosis, bronchiectasis, and bacterial pneumonia by an enzyme-linked immunosorbent assay using monoclonal antibodies to human lung SP-D, and compared them with those of healthy elderly subjects over 50 years of age. The SP-D level in the healthy elderly subjects was 57.6 +/- 38.4 ng/ml (mean +/- SD, n = 287). The levels in patients with active pulmonary TB (140.6 +/- 18.2 ng/ml, n = 49), AIP (1,021 ng/ml, n = 1), IPF (307.0 +/- 180.7 ng/ml, n = 42), acute exacerbation of IPF (817.7 +/- 283.6 ng/ml, n = 3), and HP (716.6 +/- 548.8 ng/ml, n = 4) were significantly higher than those in the healthy elderly controls (p < 0.05), whereas those of pneumoconiosis, bronchiectasis, and bacterial pneumonia, 121.9 +/- 92.8 ng/ml (n = 8), 93.9 +/- 72.9 ng/ml (n = 11), and 72.7 +/- 3.4 ng/ml (n = 4), respectively, showed no significant difference with the controls. In active pulmonary TB, the percentage of patients whose serum SP-D levels were over 134.6 ng/ml (mean + 2SD of healthy elderly controls) was 34.7%, and therefore we considered the serum SP-D level was not useful for the diagnosis of pulmonary TB. However, it was significantly higher in the patients with cavity formation than in those without (p < 0.05), and there was a significant positive correlation between the serum SP-D level and the number of tubercle bacilli in the sputum (r = 0.416, p = 0.00165), erythrocyte sedimentation rate at 1 hr (r = 0.489, p < 0.01), and CRP level (r = 0.383, p = 0.003). These findings suggest that the serum SP-D level is a useful indicator of the disease activity in pulmonary TB.

Kaikasaponin III and soyasaponin I, major triterpene saponins of Abrus cantoniensis, act on GOT and GPT: influence on transaminase elevation of rat liver cells concomitantly exposed to CCl4 for one hour.

The antihepatotoxic activities of soyasaponin I and kaikasaponin III, triterpenoidal saponins isolated from Abri Herba, the whole plant of Abrus cantoniensis, were studied on liver injury induced by CCl4 in primary cultured rat hepatocytes. The antihepatotoxic activities of these saponins and glycyrrhizin (positive control) were demonstrated by measuring the levels of glutamic pyruvic transaminase (GPT) and glutamic oxaloacetic transaminase (GOT). Soyasaponin I inhibited the elevation of GOT and GPT activities. The activities were comparable to those of glycyrrhizin. On the other hand, kaikasaponin III was more effective than soyasaponin I and glycyrrhizin. Kaikasaponin III showed the antihepatotoxic activity at less than 100 micrograms/ml. Furthermore, the highest activity was observed even in the lower doses (50, 100 micrograms/ml). However, soyasaponin I and kaikasaponin III showed some toxicity at the highest dose (500 micrograms/ml), though glycyrrhizin did not show toxicity at any dose.