Aldehyde dehydrogenase 2 as a potential protective factor for renal insufficiency in Japanese subjects with heart failure: a pilot study.

The association between the aldehyde dehydrogenase 2 (ALDH2, rs671) genotypes and the estimated glomerular filtration rate (eGFR) was investigated in Japanese hypertensive patients with/without coronary artery disease or with ischemic heart failure (HF), and age/sex-matched normotensive healthy controls. The eGFRs were significantly lower in the HF subjects with the ALDH2 *2/*2 genotype than in those with the other genotypes. Multiple regression analyses adjusted by the potentially confounding factors showed the *2/*2 genotype to be significantly associated with the decreased eGFR, compared to the *1/*1 genotype (ß = 31.99 ml min1 per 1.73 m2, P < 0.01).

Occurrence of parasympathetic vasodilator fibers in the lower lip of the guinea-pig.

The present study was designed to examine whether there are parasympathetic vasodilator fibers in the lower lip of the guinea-pig. Electrical stimulation of the central cut end of the lingual nerve of guinea-pigs evoked intensity- and frequency-dependent decreases in lower lip blood flow and systemic arterial blood pressure (SABP). Pretreatment with guanethidine, a postganglionic sympathetic nerve blocker and antihypertensive drug (30 mg kg(-1), s.c., 24 h prior to experiments), reduced the magnitude of the decrease in SABP while the intensity- and frequency-dependent increases of the lip blood flow occurred by the lingual nerve stimulation only on the side ipsilateral to stimulation. Increases in the lip blood flow evoked by lingual nerve stimulation in guanethidine pretreated guinea-pigs were reduced by hexamethonium (an autonomic ganglion cholinergic blocker) in a dose-dependent manner. When fluoro-gold (a retrograde neural tracer) was injected into the lower lip, labeled neurons were observed in the ipsilateral otic ganglion. The present study indicates the presence of parasympathetic vasodilator fibers originating from the otic parasympathetic ganglion in the guinea-pig lower lip, similar to those reported previously in rats, cats, rabbits and humans.

Unusual presentations of spilled gallstones.

Perforation of the gallbladder with resultant spillage of gallstones is not an uncommon occurrence. Spillage is reported to occur in 6% to 40% of laparoscopic cholecystectomies. Although not generally considered a significant problem, retained gallstones may cause serious complications years after the operation, with a clinical presentation that often is confusing. We report two cases of unusual complications from spilled gallstones. The first patient presented with clinical and radiologic findings of acute appendicitis 8 years after the laparoscopic cholecystectomy. The second patient presented with spontaneous erosion of spilled gallstones through the back 2 years and 9 months after the laparoscopic cholecystectomy. The literature is reviewed, and the management of spilled gallstones is discussed briefly. Although the complication rate is low, every effort should be made to retrieve spilled gallstones, and the event should be recorded in detail in the operative record. Obligatory conversion to an open procedure is not necessary.

delta15N of seagrass leaves for monitoring anthropogenic nutrient increases in coral reef ecosystems.

In a coral reef environment, a slight increase in dissolved inorganic nitrogen (DIN;> or =1.0 micro M) can alter the ecosystem via macroalgal blooms. We collected seagrass leaves from the tropical and subtropical Pacific Ocean in five countries and examined the interactions between nutrient concentrations (C, N, P), molar ratios of nutrients, and delta15N to find a possible indicator of the DIN conditions. Within most sites, the concentrations of nutrients and their molar ratios showed large variations owing to species-specific values. On the other hand, almost identical delta15N values were found in seagrass leaves of several species at each site. The correlations between delta15N and nutrient concentrations and between delta15N and molar ratios of nutrients suggested that nutrient availability did not affect the delta15N value of seagrass leaves by altering the physiological condition of the plants. Increases in delta15N of seagrass leaves mostly matched increases in DIN concentrations in the bottom water. We suggest that delta15N in seagrass leaves can be a good tool to monitor time-integrated decrease/increase of DIN concentrations at a site, both in the water column and the interstitial water.

[Strong opioids].

Oral route morphine should be first choice for moderate or strong cancer pain. Morphine must be administered essentially at fixed interval. It is important to keep effective plasma morphine concentration. When a patient can not take morphine via oral route, morphine must be administered by intravenous or subcutaneous infusion. Respiratory rate per minute of patients always must be measured during administration of morphine. Patients taking morphine have to take laxatives and antiemetics simultaneously. It is crucial to establish the cause of pain and choose other proper treatment when morphine is not effective.

[Giant epidermal cyst in the perineum extending into the pelvic space in the patient with polycystic kidney disease: a case report].

A 75-year-old man with autosomal dominant polycystic kidney disease was admitted to our hospital with the chief complaint of a giant mass in the left side of the perineum that had gradually developed in size during the previous 20 years. Palpation revealed a neonatal head-sized cystic mass with no tenderness. Magnetic resonance imaging (MRI) demonstrated a well-circumscribed homogeneous mass extended to the dorsal side of the bladder. It was excised surgically without any injury of rectum or urinary tract. The resected specimen was 23 x 18 x 12 cm in size and 1.2 kg in weight. The pathological diagnosis was epidermal cyst. Cases with an epidermal cyst extending into the pelvic space are extremely rare with few cases having been reported in the world.

Identifying sources and mass balance of dioxin pollution in Lake Shinji Basin, Japan.

On the basis of congener-specific analysis of dioxins in a dated sediment core, the sources and behavior of dioxins in Lake Shinji Basin, Japan, were estimated. The dioxins in the core showed that their deposition in the lake increased rapidly during the 1960s, peaked in the early 1970s, and then decreased gradually. Principal component analysis of the congener-specific data showed that three major sources existed: pentachlorophenol (PCP), chloronitrophen (CNP), and combustion. PCP and CNP are paddy field herbicides used extensively in the basin. The time trends of source contributions were estimated by multiple regression analysis using the source profiles. The results revealed that dioxin emission from PCP and CNP herbicides was high in the 1960s and the early 1970s, respectively. The contributions from PCP, CNP, and combustion in recent surface sediment were about 68, 16, and 16% in terms of total amount of dioxins. From the decreasing trend of dioxin deposition in the lake after extensive herbicide use, the amount of dioxins that accumulated in the agricultural soil in the basin was estimated to have decreased by about 2%/yr or a half-life of about 35 yr, indicating that dioxin runoff from agricultural fields would continue for a long time.

Power spectral analysis of the electroencephalogram during induced total spinal block.

PURPOSE: To evaluate the effects of total spinal block (TSB) on brain function, TSB-induced changes in cortical electrical activities were analyzed using power spectral analysis of an electroencephalogram (EEG). METHODS: Six patients suffering from chronic pain who were undergoing TSB therapy were studied. TSB was established with intrathecal 1% lidocaine (0.3 ml.kg(-1)) injected through the C1-2 lateral intervertebral space. Mechanical ventilation was continued via a laryngeal mask until the recovery of respiration. The EEG recording was started before TSB induction and continued until 10 min after extubation. The following processed EEG parameters were monitored: spectral edge frequency-90% (SEF90), spectral median frequency (SMF), and relative power in the frequency bands of delta, theta, alpha, beta, and the delta ratio [(alpha + beta)/delta]. RESULTS: TSB induced an unconscious state more than 40 min in all patients. During TSB, 12-13 Hz in SEF90 and 6-7 Hz in SMF were observed. These values are consistent with the previously reported prearousal threshold from general anesthesia. The other EEG descriptors did not change during the TSB-induced unconscious state. CONCLUSION: The dissociation of cortical electrical activities and the clinical coma-like condition may be characteristic of the TSB-induced unconscious state.

Comparison of the responses of global tests of coagulation with molecular markers of neutrophil, endothelial, and hemostatic system perturbation in the baboon model of E. colisepsis--toward a distinction between uncompensated overt DIC and compensated non-overt DIC.

This study correlates changes in neutrophilic activity and endothelial injury with markers of hemostatic activity following the infusion of increasing concentrations of E. coli organisms. It focuses on the hemostatic response as a marker of microvascular injury and uses the response to increasing concentrations of E. coli to refine our definition of disseminated intravascular coagulation (DIC) and distinguish between a compensated (non-overt DIC) and uncompensated (overt DIC) response. We observed that the global coagulation tests reflected activation of the hemostatic system in a dose dependent manner (overt DIC) in the early phases (T+2 to 6 h) of the response to increasing concentrations of E. coli, but that they failed to do so in the late phases (T+ 24 to 48 h). We observed that molecular markers, soluble thrombomodulin and elastase, unlike thrombin/antithrombin and plasmin/antiplasmin complexes, remained elevated out to T+24 to 48 h indicating endothelial injury that persists beyond the initial inflammatory insult in compensated as well as uncompensated DIC.

Celiac plexus block in cancer pain management.

The neurolytic celiac plexus block (NCPB) has been recommended for pain relief in patients with upper abdominal cancer by the WHO Cancer Pain Relief Program. In this article, we review the indications, techniques, and adverse effects of NCPB based on the previous findings in the literature and our own experience of 142 NCPBs during the past 11 years. No well-validated indication criteria for the NCPB have been available from invasive trials or non-invasive pain evaluations. Thus, the procedure has been employed using comprehensive pain assessment. Several modified approaches have been described for NCPB with differences in the target space where the alcohol is injected (precrural and retrocrural) and the insertion route of the needle (posterolateral and transdiscal). We have used the retrocrural transdiscal approach because of its simplicity and safety. The efficacy of the resultant pain relief does not differ among these techniques. Therefore, whether a distinction exists between blocks of the celiac plexus and those of the splanchnic nerves is controversial. The term "peri-aortic nerve block" may better describe the feature of this neurolytic intervention. The noteworthy adverse effects of alcoholic neurolysis include regional pain, hypotension, diarrhea, hypoxemia, and acute alcoholic intoxication. Most of them are transient and controllable. The diarrhea may counteract the morphine-induced constipation. NCPB relieves visceral pain in upper abdominal cancer with no serious adverse effects. We recommend this procedure to improve the quality of life of the patients suffering from abdominal cancer pain.

Hepatic portal venous gas: report of a case.

Hepatic portal venous gas is easily diagnosed radiographically by the appearance of tubular lucencies branching horizontally from the porta hepatis and extending to within 2cm of the liver capsule. Associated conditions vary from benign to potentially lethal diseases which require emergency operations. A case of hepatic portal venous gas secondary to small bowel obstruction is presented and a review of the literature is also provided.

Hemostatic abnormalities in patients with thrombotic complications on maintenance hemodialysis.

Before hemodialysis (HD), plasma levels of tissue factor (TF), free-TF pathway inhibitor (TFPI) and thrombomodulin (TM) were significantly higher in patients with HD than in healthy volunteers. Plasma levels of (T-F) TFPI and plasmin plasmin inhibitor complex (PPIC) were significantly higher in patients with HD than in healthy volunteers. During HD, plasma levels of TF and (T-F) TFPI were not significantly increased, but plasma levels of total TFPI and free TFPI at 1 hour after and at the end of HD were significantly increased, compared with levels before start of HD. Plasma level of PPIC 1 hour after start of HD was significantly higher than before start of HD, and plasma levels of thrombin antithrombin complex (TAT), PPIC, D-dimer, TM, and protein C (PC) at the end of HD were significantly higher than before start of HD. In patients with thrombosis complications, plasma TF levels were significantly higher than in patients without thrombotic complications during HD. Plasma levels of PC were significantly lower in patients with thrombotic complications than in patients without thrombotic complications. There was no significant difference between both groups during HD in hemostatic parameters, with the exception of TF and PC. Hemostatic abnormalities existed in patients with HD; especially, increased TF and decreased PC might cause thrombotic complications.

Risk factors and outcomes after coronary reoperation in 739 elderly patients.

BACKGROUND: As second coronary artery bypass graft (CABG) operations are becoming more common in elderly patients, we conducted a retrospective analysis of risk factors for in-hospital and late outcome in patients aged 70 and over. METHODS: We reviewed records of 739 patients who underwent second CABG at age 70 or older at our institution between 1983 and 1993. Preoperative, operative, and postoperative variables were analyzed to identify predictors of in-hospital and long-term mortality. RESULTS: The mean age (+/- standard deviation) at reoperation was 74 +/- 3 years and the mean interval after primary operation was 130 +/- 55 months. In-hospital mortality was 7.6% (n = 56). Preoperative factors associated with increased in-hospital mortality were preoperative creatinine greater than 1.6 mg/dL (p < 0.001), emergency operation (p < 0.001), female sex (p = 0.012), moderate or severe left ventricular dysfunction (p = 0.049), and left main coronary disease (p = 0.045). In-hospital, actuarial survival was 75% at 5 years and 49% at 10 years. Cardiac event-free survival was 60% at 5 years and 27% at 10 years. The factors independently associated with increased late death were hematocrit (p = 0.046), diabetes (p = 0.011), peripheral vascular disease (p < 0.001), left ventricular function (p < 0.001), history of cancer (p = 0.016), preoperative nonsinus rhythm (p = 0.003), anticoagulation or antiplatelet therapy (p = 0.018), postoperative encephalopathy (p = 0.001), and postoperative stroke (p = 0.014). CONCLUSIONS: CABG reoperation can have excellent results for many elderly patients, but mortality is markedly higher when elderly patients have certain risk factors and comorbidities, alone or in combination. This information should be helpful in educating patients before they decide whether to choose reoperation.

Changes of plasma hemostatic markers during percutaneous transluminal coronary angioplasty in patients with chronic coronary artery disease.

Changes of hemostatic parameters during percutaneous transluminal coronary angioplasty (PTCA) in 75 patients with chronic coronary artery disease were evaluated. Plasma levels of D-dimer, soluble fibrin monomer, plasmin-alpha2 antiplasmin inhibitor complex, and tissue factor (TF) were significantly increased in all patients with chronic coronary artery disease. The activity of antithrombin and protein C and the levels of protein C antigen were significantly decreased 1 hr after PTCA, but they returned to normal range 1 day after PTCA. There was no significant difference in the level of plasma APC-PCI complex before and 1 hr after PTCA. The plasma levels of D-dimer, soluble fibrin monomer, thrombomodulin, TF and PPIC were significantly decreased 1 hr, and the plasma levels of plasmin-alpha2 antiplasmin inhibitor complex 1 day after PTCA. These findings suggest that the decrease of protein C and antithrombin resulted in activation of the coagulation system. One hour after PTCA, the plasma levels of (total-free) TF pathway inhibitor (TFPI) were significantly decreased, but the plasma levels of total and free-TFPI were significantly increased, suggesting that consumption of (total-free) TFPI occurs during PTCA. Overall, these findings suggest that the hypercoagulable state improves during PTCA and that transient decrease of antithrombin, protein C, (total-free) TFPI or plasmin-alpha2 antiplasmin inhibitor complex may cause restenosis of coronary artery.

Comparison between in vivo and in vitro pharmacokinetics of succinylcholine in humans.

PURPOSE: To compare the in vivo and in vitro pharmacokinetics of succinylcholine (SCh) in humans. METHODS: A bolus of SCh 1 mg.kg(-1) (n = 7) or 2 mg.kg(-1) (n = 11) was given to 18 patients anesthetized with thiopental. Arterial blood samples for determination of in vivo SCh concentrations were collected every 30 s for 5 min. Another 20-ml blood sample was obtained before induction of anesthesia for determination of in vitro SCh. Concentrations of SCh were measured by high-performance liquid chromatography. In vivo and in vitro concentrations of SCh vs time data were analyzed by the one-compartment model. RESULTS: The respective in vivo and in vitro pharmacokinetic parameters (SCh 1 mg.kg(-1) vs SCh 2 mg.kg(-1)) were as follows: Plasma clearance was 4.17 +/- 2.37 and 1.85 +/- 0.28 l.min(-1), P < 0.05, vs 2.91 +/- 2.01 and 1.27 +/- 0.43 l.min(-1), P < 0.05. Elimination half-life was 25.4 +/- 10.6 and 47.4 +/- 5.4 s, P < 0.002 vs 26.3 +/- 10.0 and 75.2 +/- 21.8 s, P < 0.00005. CONCLUSION: These results suggest that the rapid disappearance of SCh from the circulation is due to diffusion out of the blood vessels rather than to enzymatic hydrolysis.

Changes in plasma tissue factor pathway inhibitor levels during the clinical course of disseminated intravascular coagulation.

In healthy volunteers, the plasma total tissue factor pathway inhibitor (TFPI) level was 68.7+/-14.1 ng/ml; the plasma free TFPI level, 17.7+/-5.4 ng/ml; the lipoprotein-associated TFPI (LP-TFPI), 51.1+/-12.0 ng/ml; the free TFPI/total TFPI ratio 0.26+/-0.07; and the plasma tissue factor levels were 149+/-46 pg/ml. Plasma tissue factor levels in patients with disseminated intravascular coagulation (DIC) were significantly higher than those in pre-DIC patients or in non-DIC patients. Plasma total-TFPI, free-TFPI and LP-TFPI levels were significantly higher in DIC patients than those in pre-DIC patients or in non-DIC patients. Before the onset of DIC, the plasma levels of tissue factor gradually increased, and 3 days before the onset of DIC they were significantly higher than those in non-DIC patients. The plasma levels of tissue factor reached their highest level 1 day before the onset of DIC and gradually decreased after the onset of DIC. Plasma levels of total-TFPI, free-TFPI, and LP-TFPI gradually increased before the onset of DIC, and the total-TFPI and LP-TFPI reached their highest levels at the onset of DIC. Plasma free-TFPI reached highest level one day after the onset of DIC. During the clinical course of DIC, the plasma level of tissue factor was the first to increase, then that of LP-TFPI and finally the free-TFPI plasma levels. These differences in the peak plasma levels of tissue factor, free-TFPI, and LP-TFPI might be related to the clinical course of DIC.