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Enterocytozoon bieneusi is an emerging opportunistic pathogen infecting humans, and both domestic and wild pigs are known to harbour zoonotic genotypes. There remains a paucity of information on the prevalence and epidemiology of this enteropathogen in Southeast Asia. The present study was undertaken to determine the molecular prevalence and risk factors associated with E. bieneusi infection among commercially farmed pigs in Malaysia. Faecal samples were collected from 450 pigs from 15 different farms and subjected to nested PCR amplification of the ribosomal internal transcribed spacer (ITS) gene of E. bieneusi. Phylogenetic analysis involved 28 nucleotide sequences of the ITS region of E. bieneusi. An interviewer-administered questionnaire provided information on the animal hosts, farm management systems and environmental factors and was statistically analysed to determine the risk factors for infection. The prevalence of E. bieneusi infection was relatively high (40.7%). The highest prevalence (51.3%) was recorded among the piglets, while the adults showed the lowest level of infection (31.3%). Multivariate analysis indicated that age of the pigs, distance of the farm from human settlement and farm management system were significant risk factors of infection. Three genotypes (EbpA, EbpC and Henan-III) detected among the pigs are potentially zoonotic. The high prevalence of E. bieneusi among locally reared pigs, the presence of zoonotic genotypes and the spatial distribution of pig farms and human settlements warrant further investigation on the possibility of zoonotic transmission.

We evaluated the usefulness of the total myocardial uptake ratio (TMUR) of 15-(p-[ 123 I]iodophenyl)-3(R,S)-methyl-pentadecanoic acid ( 123 I-BMIPP) for predicting cardiac complications in patients with mitochondrial encephalomyopathy or myotonic dystrophy. Six patients with mitochondrial encephalomyopathy, four with myotonic dystrophy, and 10 control subjects were studied. Quantitative assessment of 123 I-BMIPP dynamic myocardial imaging was performed, and the TMUR of 123 I-BMIPP was calculated according to the Ishii-MacIntyre method. Then, the TMUR was compared in the 10 patients and 10 healthy controls, and all patients were followed for 56.1±22.1 months to evaluate cardiac complications. TMUR in patients (2.69±0.64) was significantly (P=0.01) lower than that in controls (3.28±0.25). Three patients in whom the TMUR value was above 3.00 had no cardiac complications. On the other hand, all patients in whom TMUR was below 3.00 had some kind of cardiac complication during the follow-up period. Two patients showed progressive conduction abnormality and underwent pacemaker implantation, one patient had sick sinus syndrome and underwent pacemaker implantation, another patient showed non-sustained ventricular tachycardia and paroxysmal atrial fibrillation, and four of seven patients, including one with a pacemaker, showed an increased cardiothoracic ratio value over 50%. In conclusion, measurement of the TMUR by the Ishii-MacIntyre method is useful for evaluating the development of cardiac complications in patients with mitochondrial encephalomyopathy or myotonic dystrophy.

It has been reported that cardiac function can be improved by implanting a DDD pacemaker (PM) and setting a short atrioventricular (AV) delay in patients with impaired cardiac function. A previous report found that the critical AV delay that induces diastolic mitral regurgitation (MR) may represent the upper limit of the optimal AV delay. The optimal AV delay can be predicted by a simple method: slightly prolonged AV delay minus the interval between the end of the atrial kick and complete closure of the mitral valve (duration of diastolic MR) at the AV delay setting. The patient was a 84-year-old man with an old myocardial infarction. He had repeated admissions to hospital for congestive heart failure. ECG showed prolongation of the PQ interval (0.28 s) and complete left bundle branch block. Cardiac function was improved by AV sequential pacing when the AV delay was set at 120 ms. After DDD-PM implantation, the cardiothoracic ratio decreased from 57 to 45% and cardiac function was improved from New York Heart Association class III to I. The AV delay was optimized during follow-up. Four years after PM implantation, the patient was in good condition without further hospital admission. (Jpn Circ J 2001; 65: 46 - 49)

QT interval may change when cardiac function is improved by optimizing the atrioventricular the (AV) delay. The relationship between AV delay, QT interval and cardiac function in patients with implanted DDD pacemakers was studied in 12 patients (aged 71&12 SD years) with complete or high degree AV block. Cardiac output (CO) was measured using a Swan‐Ganz catheter or by continuous Doppler echocardiography. The pacing rate was fixed at 70‐80/min to eliminate the influence of heart rate. The AV delay was prolonged stepwise by 30 ms starting from 90 ms. All measurements were performed after 5 min of pacing. When the AV delay was prolonged, the CO and QT interval gradually increased and reached a peak, and then decreased. When the CO was increased from the minimum to the maximum value by optimizing the AV delay, the QT interval was significantly prolonged from 440&40 to 456&39 ms (P

To clarify whether plasma somatostatin affects thyrotropin secretion in critical illness, plasma somatostatin and thyrotropin responses to thyrotropin-releasing hormone were studied in forty-three critically ill patients. High somatostatin levels were associated with blunted thyrotropin secretion in critically ill patients. There was an inverse correlation between plasma somatostatin levels and the maximum increment of thyrotropin after stimulation by thyrotropin-releasing hormone. Decreased somatostatin and increased thyrotropin secretion before discharge from the intensive care unit were demonstrated in survivors. On the other hand, non-survivors maintained high somatostatin levels and had blunted thyrotropin secretion during their intensive care admission. These results suggest that high plasma somatostatin levels may play a role in the blunted thyrotropin secretion observed in critical illness.

To study whether the suppression of the thyrotropin (thyroid-stimulating hormone, TSH) response to thyrotropin-releasing hormone (TRH) correlates with severity of illness and death in patients with nonthyroidal critical illness.Prospective study.Intensive care unit (ICU) of a university hospital.Forty-one critically ill patients without thyroid disease with multiple organ failure who were admitted to the ICU.The TSH response to TRH was tested within 24 hrs of ICU admission. Blood samples were obtained just before, and at 15, 30, 60, 90, and 120 mins after 500-micrograms injection of synthetic TRH. Triiodothyronine, free-triiodothyronine, thyroxine, free-thyroxine and TSH concentrations were measured in the samples obtained just before TRH injection. Acute Physiology and Chronic Health Evaluation (APACHE II) scores and Sepsis scores were calculated based on the data obtained within 24 hrs of ICU admission. Individual variables were compared between survivors and nonsurvivors. The APACHE II scores and Sepsis scores of nonsurvivors were significantly higher than those scores of survivors. The overall occurrence of suppressed TSH response to TRH was 88%. Peak TSH concentration of the TSH response was significantly lower in nonsurvivors than in survivors. Serial measurement of the TSH response showed that nonsurvivors experienced a decrease in peak TSH concentration from 1.55 +/- 0.78 to 0.55 +/- 0.30 microIU/mL; in survivors, it increased from 2.10 +/- 0.26 to 7.38 +/- 1.83 microIU/mL. Conversely, the basal TSH concentration did not change in either survivors or nonsurvivors. The "severity" of illness of nonsurvivors remained high; their mean APACHE II score varied from 20.0 +/- 1.9 to 22.1 +/- 1.3 and the mean Sepsis score varied from 20.0 +/- 4.3 to 25.4 +/- 4.0, while the same scores for survivors decreased significantly (p.05): their APACHE II score decreased from 16.2 +/- 0.7 to 7.6 +/- 2.0 and the Sepsis score went from 14.0 +/- 1.9 to 6.0 +/- 1.6.In critically ill patients with multiple organ failure, suppression of the TSH response to TRH frequently occurs and correlates with severity of illness and outcome. Our data indicate that measurement of the TSH response is helpful in evaluating the severity of illness and prognosis for critically ill patients.

The purpose of this study was to evaluate whether or not cardiac sympathetic nerve activity, using (123)I-meta-iodobenzylguanidine ((123)I-MIBG) imaging, and cardiac natriuretic peptides (atrial and brain, ANP and BNP) were independent predictors of cardiac events, and, if so, which was the stronger predictor. Planar (123)I-MIBG images were obtained from 62 patients with heart disease. Plasma ANP and BNP levels, left ventricular ejection fraction (LVEF) by echocardiography, serum total cholesterol and triglyceride were measured. (123)I-MIBG was assessed as the heart-to-mediastinum (H/M) ratio of the delayed image and the washout rate (WoR) from the early to the delayed image. Patients were followed up for an average of 16.2 months, and 12 of 62 patients had cardiac events. Patients with events had significantly lower LVEF and H/M ratio compared with those without events. They had significantly higher WoR, ANP and BNP. By multivariate Cox proportional hazard analysis, (123)I-MIBG (H/M or WoR), ANP and BNP were independent predictors for cardiac events. Event-free survival using a Kaplan-Meier model, with a threshold value of 2.0 for H/M and 45% for WoR, showed that patients with H/M2.0 and/or WoR45% had a significantly poorer prognosis. These results suggest that (123)I-MIBG imaging and cardiac natriuretic peptides are useful tools for the evaluation of patients with heart disease, and that cardiac sympathetic nerve activity is a stronger predictor of cardiac events.

We evaluated the effects of continuous intra-articular and intra-bursal infusion of lidocaine on postoperative pain following shoulder arthroscopic surgery. Forty-one ASA I-II patients scheduled for shoulder arthroscopic surgery, were allocated into following four groups. The patients, after intra-articular arthroscopic surgery, either received intra-articular lidocaine (Group I, n = 10) or did not (Group III, n = 10). The patients after extra-articular arthroscopic surgery either received intra-bursal lidocaine (Group II, n = 11) or did not (Group IV, n = 10). Group I and Group II received 8 ml of 1% lidocaine intra-articularly and intra-bursally, respectively, at the end of surgery, followed by continuous infusion of 1% lidocaine at the rate of 2 ml.hr-1 for 24 hours. The intensities of postoperative pain were evaluated by Visual Analogue Scale (VAS), 2, 5, 8, 12, 18 and 24 hours after surgery, and by the number of patients' request for supplemental analgesic for 24 hours. The VAS scores and the number of analgesic requests were significantly lower (P0.05) in Group I than Group III, and in Group II than Group IV throughout the postoperative observation period. No adverse effects were observed during this study. We conclude that continuous intra-articular and intra-bursal infusion of lidocaine provides effective postoperative pain relief for shoulder arthroscopic surgery.

Cardiac function is improved by optimizing the atrioventricular (AV) delay. An automatic optimizing function of AV delay may be necessary to achieve the most favourable haemodynamic state in paced patients. The QT interval may change when cardiac function is improved by optimizing the AV delay. The QT or stimulus-T interval is used as a sensor for rate-responsive pacemakers. Evoked (e) QT interval is measured as the time duration from the ventricular pace pulse (stimulus) and the T-sense point that is the steepest point of the intracardiac T wave (stimulus-T interval). The relationship between AV delay, eQT interval and cardiac function was studied in 10 patients (73 +/- 10 (SD) years old) with an implanted stimulus-T-driven DDDR pacemaker. Cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) were measured by Swan-Ganz catheter. The AV delay was prolonged stepwise by 30 ms. Electrocardiogram event markers which indicated ventricular spike and sensed T wave were recorded, and the interval between two event markers was measured as eQT interval. When AV delay was changed from 240 ms to the AV delay at which CO was maximal (172 +/- 33 ms), eQT interval prolonged from 346 +/- 60 to 353 +/- 62 ms (P < 0.01). There was a significant positive correlation between the optimal AV delay at which CO was maximal (172 +/- 33 ms) and the optimal AV delay which was predicted from the maximum eQT interval (179 +/- 37 ms, r = 0.92, P < 0.001). When AV delay was changed from 240 ms to the predicted optimal AV delay, CO increased from 4.2 +/- 0.7 to 4.5 +/- 0.81.min-1 (P < 0.001) and PCWP was decreased from 7.1 +/- 4.0 to 5.7 +/- 3.1 mmHg (P < 0.05). In conclusion, the optimal AV delay can be predicted from the eQT interval which is sensed by an implanted pacemaker. Automatic setting of the optimal AV delay may be achieved by the QT sensor of an implanted pacemaker.

Although sinus node recovery time (SNRT) assessment by the overdrive suppression test (ODST) is important in detecting sick sinus syndrome (SSS), its sensitivity is still inadequate. We have evaluated the effect of intravenous injection (i.v.) of disopyramide phosphate (DP) in ODST. The subjects were 30 SSS patients (64.9 +/- 10.0SDyears old). If SNRT was2,000 ms or the corrected SNRT (CSNRT) was1,000 ms, ODST was repeated after DP i.v. (2 mg. kg(-1),or = 100 mg in total). Eleven normal subjects (59.3 +/- 9.0 years old) were also studied. Although SNRT was2,000 ms or the CSNRT was1,000 ms in 13 of the 30 SSS patients (43%), SNRT was prolonged from 1,510 +/- 300ms to 3,400 +/- 1,160 ms (P0.01), and CSNRT from 510 +/- 190 to 2,470 +/- 1,470 ms (P0.01) after DP i.v. in these patients. Thus, SNRT wasor = 2,000 ms and the CSNRT wasor = 1,000 ms in 27 of 30 SSS patients (90%) after DP i.v. Using a combination of overdrive suppression and intravenous injection of disopyramide phosphate, the corrected sinus node recovery time was diagnostic (525 ms) in 29 of the 30 patients (97%). In contrast, SNRT and CSNRT were shortened in the normal subjects during ODST after DP i.v. (P0.01). The plasma concentration of DP estimated in nine patients was 4.1 +/- 1.0 microg.ml(-1). No serious side effect occurred. ODST employing DP i.v. is safe and seems to be highly effective in diagnosing SSS.

Visual interpretation of iodine-123-beta-15-(p-iodophenyl)-3(R,S)-methyl-pentadecanoic acid (123I-BMIPP) myocardial images cannot easily detect mild reduction in tracer uptake. Objective assessment of myocardial 123I-BMIPP maldistributions at rest was attempted using a bull's-eye map and its normal data file for detecting myocardial damage in patients with mitochondrial encephalomyopathy. Six patients, two with Kearns-Sayre syndrome and four with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), and 10 normal subjects were studied. Fractional myocardial uptake of 123I-BMIPP was also measured by dynamic static imaging to assess the global myocardial free fatty acid. These data were compared with the cardiothoracic ratio measured by chest radiography and left ventricular ejection fraction assessed by echocardiography. Abnormal cardiothoracic ratio and lower ejection fraction were detected in only one patient with Kearns-Sayre syndrome. Abnormal fractional myocardial uptake was detected in two patients (1.61%, 1.91%), whereas abnormal regional 123I-BMIPP uptake assessed by the bull's-eye map was detected in five patients (83%). All patients showed abnormal uptake in the anterior portion, and one showed progressive atrioventricular conduction abnormality and systolic dysfunction with extended 123I-BMIPP abnormal uptake. The results suggest that assessment based on the normal data file in a bull's-eye polar map is clinically useful for detection of myocardial damage in patients with mitochondrial encephalomyopathy.

A 42-year-old woman with diabetes mellitus lost consciousness and was transferred to the Yokohama City University Hospital. Blood chemistry findings indicated low blood sugar levels and chest X-ray examination revealed cardiomegaly and bilateral pleural effusions. These clinical abnormalities were corrected by treatment with glucose, diuretics, angiotensin converting enzyme inhibitor and digitalis. Cardiological laboratory examinations were performed after admission. Electrocardiography revealed first degree atrioventricular block and incomplete right bundle branch block. Ultrasonography showed lower grade of ejection fraction and diffuse hypokinesis of the cardiac wall. After admission, sinus arrest suddenly occurred. The diagnosis was sick sinus syndrome. Scintigraphy using iodine-123 betamethyl-p-iodophenyl-pentadecanoic acid showed abnormal mottled defects. Coronary angiography found no significant stenosis of the coronary artery. Electron microscopy showed abnormally shaped mitochondrial accumulations in an endomyocardial biopsy specimen. Mitochondrial DNA amplification by polymerase chain reaction followed by restriction enzyme Apa I digestion revealed adenine-to-guanine transition at 3243 of the mitochondrial tRNA(LEU)(UUR) gene.

Evoked spinal cord potential (ESCP) elicited by direct spinal cord stimulation has been applied to monitor the spinal cord function during spinal surgery. We report here two patients who showed excessive muscle contraction and developed severe metabolic acidosis as a result of the stimulation of spinal cord to measure ESCP. These changes were prevented by vecuronium administration prior to ESCP monitoring. These results suggest that excessive muscle contraction by direct spinal cord stimulation may lead to metabolic acidosis. In conclusion, the use of a non-depolarizing muscle relaxant is recommended to prevent the adverse effects of ESCP monitoring.

The effects of right ventricular outflow pacing were studied in 13 patients (mean [+/-SD] 69.8 +/- 8.2 years old). All patients received DDD pacemakers except two patients with implanted VVI pacemakers who had chronic atrial fibrillation. Cardiac output and pulmonary capillary wedge pressure were measured by Swan-Ganz catheter. Pacing rate was fixed at 70-80/min and atrioventricular delay was fixed at 165 msec. When the pacing site was changed from the right ventricular apex to the right ventricular outflow during right ventricular pacing in 11 patients, cardiac output increased from 3.3 +/- 0.6 to 3.4 +/- 0.5 l/min (p0.001), and wedge pressure decreased from 9.3 +/- 1.9 to 8.8 +/- 2.0 mmHg (p0.05). When the pacing site was changed from the right ventricular apex to the right ventricular outflow during atrioventricular pacing in eight patients, cardiac output increased from 3.9 +/- 0.4 to 4.0 +/- 0.4 l/min (p0.05), and wedge pressure decreased from 7.1 +/- 2.3 to 6.6 +/- 2.1 mmHg (p0.05). When the pacing site was changed from the right ventricular apex to the right ventricular outflow in seven patients with ejection fraction (EF) greater than 55%, cardiac output increased from 3.6 +/- 0.5 to 3.7 +/- 0.4 l/min (p0.05), and in four patients with EF less than 55%, it increased from 2.9 +/- 0.4 to 3.0 +/- 0.4 l/min (p0.01). Cardiac function was improved by right ventricular outflow pacing compared to right ventricular apex pacing regardless of the pacing mode or cardiac function.

We reported two patients who developed skin eruptions and severe hypotension immediately after scrubbing their wound in the leg using 4% chlorhexidine solution. Both patients were successfully treated by epinephrine administration. Patient-1 (a 42-year-old man) had his wound scrubbed using this antiseptic several times before the operation. He showed a positive skin scratch test for chlorhexidine. Patient-2 (a 74-year-old man) had no prior treatment with chlorhexidine. Positive lymphocyte transformation test was not demonstrated in these patients. It has been reported that more than 10% of patients with anaphylactic shock induced by chlorhexidine use had previous exposure to it and 80% of them had it used for mucosa or wound washing. From these results, we should keep it in mind that chlorhexidine is not likely to be a safe antiseptic and can possibly induce anaphylactic shock.

A 13-day-old infant with multiple teratisms of the oral cavity was scheduled for resection of the epignathus. Her oral cavity was occupied by large epignathus, submandibular tumor, congenital bifid tongue and cleft palate, but she had no other congenital abnormalities. We anticipated that an endotracheal intubation would be difficult because of the large size of the tumor in relation to the oral cavity. Initially, awake intubation using a standard laryngoscope was attempted. Although a large elastic epignathus did not interrupt the insertion of the curved laryngoscope blade, the hard submandibular tumors protruded from the submaxillary ramport interfered with mid-line management of the laryngoscope. After several attempts of intubation, a better exposure was obtained and she was successfully intubated using a stylet under deep sedation. We recognized that a careful observation of anatomical abnormalities in the oral cavity is important to keep airway in an infant with multiple abnormalities of the oral cavity.

The accuracy of auscultatory blood pressure (BP) determination was assessed in patients with chronic atrial fibrillation by performing simultaneous auscultatory BP determination on the upper arm and a direct BP determination on the contralateral arm. The subjects were three hospitalized patients, aged from 52 to 75 years. A Teflon catheter was introduced into the radial artery which was connected to a pressure transducer, and a cuff was twisted around the contralateral upper arm in the supine position. Simultaneous recording of directly determined BP and cuff pressure enabled the comparison of direct BP with auscultatory BP. The appearance of the Korotkoff I sound (systolic BP) and V sound (diastolic BP) was marked on the cuff pressure curve. This maneuver was repeated five times in each patient. The method of Bland and Altman was employed to assess the agreement between auscultatory and direct determinations. The auscultatory method estimated BP with differences of -14.3 to +27.3 mmHg in systolic BP and -12.1 to +11.9 mmHg (+/-2SD) in diastolic BP compared with the direct method. The difference in systolic BP between the auscultatory and the direct methods was greater than that in diastolic BP. Thus, there are unacceptable differences in systolic BP between auscultatory and direct methods that can be attributed to BP fluctuations. The auscultatory method in diastolic BP is more accurate than that in systolic BP and may be more useful in the clinical setting.

During cardiac surgery, esophageal, rectal, or bladder temperature is usually monitored as an index of core temperature; however, these methods are invasive, and often inconsistently reflect the central body temperature, especially in pediatric patients. The purpose of this study was to evaluate the utility of tracheal temperature monitoring during cardiac surgery in pediatric patients. Fifteen children (ages; 8 m.-7 yr.) undergoing cardiac surgery with cardio-pulmonary bypass (CPB) were studied. Anesthesia was induced and maintained with high doses of fentanyl and intermittent doses of midazolam. After anesthetic induction, esophageal, rectal, bladder, tympanic, and forehead deep temperatures were monitored with a Core Temp Monitor (CTM-205, Terumo Co.). Simultaneously, the tracheal temperature was monitored with a specially made tracheal tube. A thermistor was attached by medical glue (Loctite Prism, Loctite Co.) at the anterior surface of a tracheal tube (Trachelon, Terumo Co.) without cuff (inside diameter 4.0-6.0 mm) where the tracheal tube tightly fits against the trachea. The inspired gas was warmed to 35 degrees C and humidified. During CPB, the blood temperature at the inlet to the patients was also recorded simultaneously. All indicated temperatures (Y) during CPB were analyzed for correlation with the blood temperature to the patients (X). The tracheal temperature had the highest correlation with the blood temperature from the patients (Y = 0.68X + 10.60, r = 0.89). There were also good correlations of the esophageal as well as bladder temperatures with blood temperature. There were no patients who suffered tracheal inflammation or laryngeal edema from the thermistor. Monitoring tracheal temperature is not only valuable for monitoring the core temperature, but also is convenient for pediatric patients in cardiac surgery.

Although the incidence of pulmonary tuberculosis had been rapidly decreased in Japan, it is pointed out that the rate of decrease in annual incidence became smaller in recent years. This slowing down of the rate of decrease is considered to be resulted from an increase in number of individuals who are more susceptible to tuberculous infection; such as the elderly, young people who are not exposed to TB bacilli previously and therefore not immunized, patients with malignant disease or with organ transplantation and HIV-infected persons. Pulmonary tuberculosis still remained as a pulmonary infectious disease of highly ranked importance. Especially, miliary tuberculosis is life-threatening and occasionally fatal unless early intensive antituberculosis chemotherapy was started on the basis of a rapid and definite diagnosis. We made a retrospective survey to clarify the characteristic clinical features of miliary tuberculosis. For this purpose, we compared the characteristics and clinical features of 10 patients with miliary tuberculosis and those of 18 patients with severe pulmonary tuberculosis, not due to hematogenous dissemination. The mean ages of miliary tuberculosis group and that of severe pulmonary tuberculosis group were 62.6 and 63.8 years old, respectively, with no significant difference. Nine out of ten patients with miliary tuberculosis had fever as one of initial symptoms, whereas, all the patients with severe pulmonary tuberculosis had cough and sputa but they seldom developed fever (high fever) at the initial stage of their diseases. Duration from onset of symptom to the admission was 1.2 months on average in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical effectiveness of erythromycin for patients with diffuse panbronchiolitis (DPB) was previously recognized. However, it remains unknown what kind of airway lesions change with the clinical effectiveness induced by erythromycin. We performed the present study to clarify this unknown. We devised a method for scoring findings on high-resolution computed tomography (HRCT) to aid in the objective evaluation of the airway lesions in patients with DPB. The 18 patients with DPB were treated with oral erythromycin, 600 mg/d. All patients were evaluated by pulmonary function tests and HRCT before and after 3 months of therapy. Characteristic HRCT findings in patients with DPB pretherapy were small nodules, airway ectasia, periairway thickening, and mucus plugging. After erythromycin therapy, there was significant reduction in scores for the extent of small nodular opacities, the severity of periairway thickening, and the extent of mucus plugging with a corresponding significant improvement in results of the pulmonary function test parameters. The present study demonstrated reversible airway lesions in patients with DPB in response to erythromycin therapy.

Diastolic mitral regurgitation (MR) may be induced by prolonging atrioventricular (AV) delay, and a significant negative correhtion has been described between tbe critical PQ interval for the appearance of diastolic MR and pulmonary capillary wedge pressure (PCWP) in patients with DDD pacemakers. We report the relationship between the critical PQ interval for the appearance of diastolic MR and the optimal PQ interval in 11 patients (69.1 ± 12.6 years). Cardiac output (CO) and PCWP were measured by Swan-Ganz catheter and transmitral blood flow was recorded by pulsed-Doppler echocardiography. AV delay was prolonged stepwise by 0.025 seconds starting from 0.065 seconds. The pacing rate was fixed at 70 beats/min. CO was highest when the PQ interval was 0.18 ± 0.04 seconds. There was a significant positive correlation between the critical PQ interval for the appearance of diastolic MR and the PQ interval at which CO was the highest (r = 0.91, P < 0.01). The PQ interval at which CO was the highest was 0.02 ± 0.02 seconds shorter than the critical PQ interval for the appearance of diastolic MR (P < 0.05). When the PQ interval was increased by 0.025 seconds from the critical PQ interval for the appearance of diastolic MR, CO decreased from 4.3 ± 0.6 L/min to 4.1 ± 0.6 L/min and PCWP increased from 7.5 ± 6.4 mmHg to 8.5 ± 7.3 mmHg (P < 0.05). In conclusion, the critical PQ interval for the appearance of diastolic MR may represent the upper limit of the optimal PQ interval and the AV delay should be set to not exceed the critical PQ interval for the appearance of diastolic MR.

We investigated the correlation between the endogenous hormonal changes of pituitary-adrenal and pituitary-thyroid hormones and the prognosis of patients in multiple organ failure, and elucidated the mechanism of blunted thyrotropin (TSH) secretion by histological and immunocytochemical studies of anterior pituitary glands.Forty-three patients were studied who had been admitted to the intensive care unit of Sapporo Medical University Hospital and had been diagnosed as having multiple organ failure.Pituitary adrenal hormones [corticotropin (ACTH), cortisol] and pituitary thyroid hormones [TSH, triiodothyronin (T3), free-T3, thyroxine (T4), free-T4, thyroxine-binding globulin (TBG)] were measured, and TSH and prolactin (PRL) responses thyrotropin-releasing hormone (TRH) were examined within 24 hours of admission to the ICU. Individual variables were compared between survivors (n = 19) and nonsurvivors (n = 24). Thirteen patients (five survivors, eight nonsurvivors) were investigated again before discharge from the ICU or death. Morphology was examined by hematoxilin-eosin staining, and avidin-biotin-peroxidase complex immunostaining was used to demonstrate the spectrum of TSH in 14 nonsurvivors.(1) ACTH levels remained within the normal range, while cortisol levels increased to above normal levels. Neither hormone showed significant differences between survivors and nonsurvivors. In nonsurvivors, cortisol levels decreased before death despite the increased ACTH levels. (2) T3 and free-T3 levels decreased markedly to below normal values, and reverse-T3 levels increased markedly to above normal values. Nonsurvivors showed significant differences in TSH, T4 and reverse-T3 levels compared with survivors. (3) TSH response to TRH was blunted in both groups but PRL response to TRH was normal. Nonsurvivors showed severely depressed TSH response. Nonsurvivors continued to show blunted TSH response to TRH, while this improved in survivors. (4) The histological study did not show very serious damages to anterior pituitary glands as TSH secretion was depressed. Many TSH immunoreactive cells were also observed by immunocytochemical study.Decreased cortisol, low T4 levels and blunted TSH response to TRH correlated with mortality in MOF patients. Histological and immunocytological studies suggest that blunted TSH secretion is not caused by pituitary damages or TSH exhaustion but by disturbances in TSH secretion. This blunted TSH secretion is reversible and its improvement is an indicator of survival.

A 67-year-old man was scheduled for left upper lobectomy under epidural and general anesthesia. About 1 hour after the beginning of operation, he developed cardiac arrest due to sudden massive bleeding from the pulmonary artery. In spite of open chest cardiac massage and intravenous administration of epinephrine, we could not resuscitate him successfully. More than 30 minutes after the cardiac arrest, cardiopulmonary bypass (CPB) was started and mean arterial blood pressure was maintained at 50-60 mmHg. His pulmonary artery was repaired under CPB. One hour after CPB, the weaning from artificial circulation was attempted and the spontaneous beating was observed. However, he developed low cardiac output syndrome due to long time ischemia resulting in hemorrhagic infarction. Therefore, the intra-aortic balloon pumping was started and his hemodynamics was immediately restored. We presume that CPB is useful for intraoperative resuscitation and this gives us new application of advanced life support for the patient in whom the conventional technique is ineffective.

The effects of an angiotensin II receptor (AT1) antagonist on sympathetic nervous responses to a mental arithmetic task and a cold pressor test were investigated using a placebo-controlled, single-blind design in 8 patients with essential hypertension (53 +/- 3 years). All patients received a placebo for 2 weeks (placebo run-in period), after which the control group (P; n = 4) continued to receive the placebo, while the experimental group (TCV; n = 4) received TCV-116 at 4 mg/day for 4 weeks (treatment period). After basal measurements were carried out, an arithmetic task and a cold pressor test were conducted on the last day of each period. Blood pressure (BP), heart rate (HR) and electrocardiogram (ECG) were continuously monitored. Muscle sympathetic nerve activity (MSNA) was assessed by determining the burst rate of the mean voltage neurogram obtained from the tibial nerve. Sympathovagal balance was also assessed, by determining the area ratio of the low frequency (LF: 0.05-0.15 Hz) to high frequency bands (HF: 0.16-0.5 Hz) of a power spectral analysis of HR variability (maximum entropy method). During the placebo run-in period, there were no significant differences in basal BP, HR, LF/HF or MSNA between the two groups. During the treatment period, basal mean BP in the TCV group was significantly lower (p0.05) than that in the P group, but there were no significant differences in basal HR, LF/HF or MSNA between the two groups. Although the arithmetic stress significantly increased BP, HR and LF/HF in both groups, MSNA was not significantly altered in either group.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary dysfunction often follows cardiopulmonary bypass (CPB). In the present study, we examined (1) the effects of the human urinary tripsin inhibitor ulinastatin on the extravascular lung water volume (EVLW), and (2) A-aDO2 as an indicator of pulmonary function, in 30 adult patients undergoing CPB. We administered 600,000 U of ulinastatin intravenously immediately before start of CPB in 15 patients (U group). In the control group without ulinastatin, remarkable transient increases in EVLW and A-aDO2 occurred after CPB. In contrast, in the U group extravascular lung water volume level was maintained within the normal range and an inhibited transient increase in A-aDO2 after CPB was observed. We conclude that the administration of ulinastatin in patients undergoing CPB may be useful to prevent pulmonary dysfunction following CPB.

We reported a case of type II cryoglobulinemia involving glomerulopathy associated with HCV-induced liver cirrhosis. The patient was a 57-year-old woman. Her past history included chronic hepatitis at 51 years and rheumatoid arthritis at 53 years of age. At 46 years, an erythematous lesion appeared on her legs, which was diagnosed as allergic vasculitis by skin biopsy. At 50 years, proteinuria, hematuria and hypertension were recognized. The next year, the first renal biopsy was performed and showed membranoproliferative glomerulonephritis (MPGN). Recently, the edema of her legs has progressed, and the laboratory data showed proteinuria, hematuria, hypocomplementemia, rheumatoid factor positivity, and increase of monoclonal IgG kappa chain. The second renal biopsy revealed an endocapillary proliferative glomerulonephritis-like lesion with marked infiltration of monocytes and macrophages. The subendothelial deposit showed a fine fibril-like pattern. She was treated with steroids and double filtration plasmapheresis (DFPP) therapy, but the treatment was not very effective. She died of liver cirrhosis, which was probably induced by hepatitis C virus (HCV), and sepsis. Generally, the patients of type II cryoglobulinemia often showed HCV antibody positivity, pointing to HCV as an etiological factor. In this case, renal biopsy was performed twice in the same patient, and the histologic findings suggest the clinicopathological course of cryoglobulinemia.

Continuous thoracic epidural anesthesia (T4/5) using 4-5 ml.h-1 of 1.5% lidocaine with 1:200,000 epinephrine and inhaled anesthesia using nitrous oxide, oxygen and sevoflurane were performed in two patients, (40 and 22 yr-old females) with myasthenia gravis. This combined anesthetic technique provided muscle relaxation for endotracheal intubation and optimal operating conditions, including muscle relaxation and stability of hemodynamics during transsternal thymectomy. Further, continuous epidural anesthesia using 4 ml.h-1 of 0.25% bupivacaine provided postoperative pain relief without other analgesics and stable postoperative respiratory conditions. In conclusion, we confirm the benefits of this technique which provides not only safe and stable conditions during the surgery, but also an improved comfort for patients in the postoperative period following transsternal thymectomy for myasthenia gravis.

Pain relief following thoracotomy and arterial concentration profiles after interpleural administration of lidocaine were studied in 23 adult patients. They were allocated to three groups and given interpleural injection of 20 ml each of 1.0% (group 1, N = 9, non-pneumonectomy patients), 1.5% (group 2, N = 10, non-pneumonectomy patients), and 1.5% (group 3, N = 4, pneumonectomy patients) lidocaine with epinephrine (5 micrograms.ml-1). Complete pain relief was obtained within 20 min after injection in all patients. The mean duration of analgesia was 2.8 hr, 3.1 hr, and 5.1 hr in group 1, 2, and 3, respectively. The maximum plasma concentrations of lidocaine (Cmax) were 1.7 +/- 1.0 (mean +/- SD) microgram.ml-1, 2.2 +/- 0.6 micrograms.ml-1, and 0.7 +/- 0.2 micrograms.ml-1 in group 1, 2, and 3, respectively. The mean duration of analgesia was significantly longer in group 3 than in group 2 (P less than 0.01). Cmax was significantly lower in group 3 than in group 2 (P less than 0.01). In conclusion, we consider interpleural injection of lidocaine with epinephrine to be an effective method of providing postoperative analgesia after thoracotomy. Our data also suggest that the duration of analgesia may increase and the plasma levels of lidocaine may remain quite low in total pneumonectomy patients, because local anesthetic solution is not absorbed through the visceral pleura but absorbed only through the parietal pleura alone in these patients.

A case of pulmonary embolism associated with diabetes insipidus is reported in an 18-year-old male. The patient, who had been treated with DDAVP for diabetes insipidus and hydrocortisone for hypocorticism for two years after first operation for the removal of craniopharyngioma, was admitted with recurrence of that tumor. Diabetes insipidus immediately after second operation was controlled with intermittent drip infusion of a small amount of aqueous pitressin under monitorings of body weight hourly using a patient weighing system to keep the weight changes within +/- one kilogram. Serum and urine electrolytes levels, osmolarity, and free water clearance were also monitored every three hours to maintain water-electrolytes balances appropriately. Postoperative course had been uneventful except that CSF rhinorrhea occurred 7 days after operation. The patient was, then, kept in bed with horizontal plane to avoid further leakage of CSF. Two days later, he developed chest pain suddenly with tachypnea, tachycardia, and general cyanosis. The arterial-BGA showed PaO2 of 53.5mmHg and PaCO2 of 35.3mmHg in room air. The definite diagnosis of pulmonary embolism was made by technetium microaggregate lung perfusion scans and by pulmonary angiograms. The patient was treated with heparin, 15000IU/day, and urokinase, 720000IU/day. The symptoms due to pulmonary embolism had improved gradually within a couple of weeks. Recent articles have shown an unexpected high incidence of deep vein thrombosis and pulmonary embolism in neurosurgical patients associated with the elevation of blood coagulability. Brain tumors, especially suprasellar mass with hypothalamic dysfunction have been suggested to cause thromboembolic disorders frequently. The clinical course was described and factors causing pulmonary embolism on this patient was discussed.

The authors present a rare case of a 58-year-old female who had cardiac arrest due to massive abdominal hemorrhage because of the rupture of pancreatic pseudocyst during an emergency operation. We succeeded in resuscitation by performing emergency thoracotomy and internal cardiac compression. Thoracic aortic cross clamping was employed to control bleeding, and we could perform the operation. She recovered without any neurological deficits. Thoracic descending aortic cross clamping should be always considered both before and during operation for the control of massive abdominal hemorrhage to avoid circulatory collapse.

A rapid selective method for measuring the activity of lactate dehydrogenase isoenzyme LD-1 in serum by using 1,6-hexanediol as an inhibitor of the M-subunit was developed. Hexanediol was added to serum at a final concentration of 0.7 mol/l. After incubation at 30 degrees C for 15 min, the activity was measured with an automatic analyser. The inter-assay coefficient of variation was 6.9% for the lactate dehydrogenase isoenzyme LD-1 measurement. The results obtained from the sera of 100 patients analysed by the proposed selective method and by the conventional electrophoretic method, respectively, showed an excellent correlation. This selective method was used to determine the lactate dehydrogenase isoenzyme LD-1 activity of sera from patients with acute myocardial infarction, and the results were correlated well with those obtained by the immunological, Roch Isomune method. Addition of 1,6-hexanediol did not affect the measurement of activities of other enzymes such as alkaline phosphatase, gamma-glutamyltransferase, aspartate aminotransferase and alanine aminotransferase.

In the present report we described two cases of malignant hyperthermia under halothane anesthesia. Case 1; A 54-year-old, 58 kg-male was scheduled for the operation of giant arterio-venous malformation. Anesthesia was induced with thiamylal, fentanyl and pancuronium, and maintained with oxygen, nitrous oxide and halothane. The patient was subjected to halothane inhalation for 26 hours prior to the development of the malignant hyperthermia. Although body temperature rose to 41 degrees C, it returned to normal with the administration of 280 mg of dantrolene and systemic cooling. Case 2; A 31-year-old, 68 kg-female was scheduled for tonsillectomy. Anesthesia was induced with thiamylal, oxygen, nitrous oxide and halothane. After the administration of 70 mg of SCC, marked muscular rigidity occurred and endotracheal intubation was impossible. The operation was postponed. Two months after the first anesthesia, operation was successfully performed under NLA with droperidol and fentanyl. Caffeine contracture test was performed in each case by skinned fiber method and the result showed that the sensitivity to caffeine increased in the isolated skeletal muscle fiber bundles from these patients. Thresholds of caffeine contracture of these skinned fiber bundles were all lower than 5mM caffeine.

Five hundred and thirty-three patients have been treated after thoracic and cardiovascular surgery in our ICU during the last four years. Cardiac failure was shown in 150 cases, respiratory failure in 132 cases, renal failure in 76 cases, and hepatic failure in 84 cases. The appropriate mechanical organ-supports (MOS) were applied in the following cases: intra-aortic balloon pumping (IABP) in 48 cases, veno-arterial bypass (VAB) in 18 cases, left ventricular assist device (LVAD) in 1 case, respirator in 132 cases, continuous hemofiltration (CHF) in 44 cases, hemodialysis (HD) in 13 cases, peritoneal dialysis (PD) in 21 cases, Continuous intensive peritoneal dialysis (CIPD) in 7 cases, and plasma exchange (PEx) in 22 cases. The results of MOS6 which required exocorporeal circulation were not satisfactory, especially CHF (mortality rate 75.0%), HD (76.9%), and VAB (100%). Though, the results of IABP (35.4%) and CIPD (14.3%) were significantly better. The main cause of early death (within 6 post-operative days) was low output syndrome (LOS) (63.6%). However, that of late death (beyond 14 post-operative days) was sepsis (66.7%). Therefore, it is important for the survival of these patients to control LOS during the early post operative period and then to concentrate on the prevention of infection.

We analysed the clinical significance of ANCA in patients with ulcerative colitis. On either an indirect immunofluorescence assay or an ELISA with fixed neutrophils, 71% (25/35) of the patients were positive for ANCA. However, only half of them reacted with either cathepsin G or lactoferrin. Western blot assays revealed positive bands in 40% (10/25) of the antibody-positive patients. The sizes of the bands detected were ≈58, 47, 44, 40, and 28 kD. No significant correlation was found between the ANCA positivity and various variables, i.e. disease activity, extent of lesion, or treatment of the disease. The anti-cathepsin G and 28-kD positivity, however, significantly correlated with a refractory type of ulcerative colitis.