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Objective: Acute lung injury in Pseudomonas aeruginosa pneumonia depends primarily on ExoU toxin being delivered directly into the eukaryotic cell cytosol through the type III secretion system. The amino-acid sequence of ExoU has a potato patatin-like phospholipase domain, similar to the sequence of mammalian Ca2+-independent phospholipase A2. We examined whether the acute lung injury caused by cytotoxic P. aeruginosa was dependent on the patatin-like phospholipase domain of ExoU. Design: Laboratory investigation using an established mouse model for P. aeruginosa pneumonia with quantitative measurements of acute lung injury and mortality. Setting: University experimental research laboratory. Subjects: Balb/c mice. Interventions: First, a site-directional mutation was introduced in the predicted catalytically active site of the patatin-like phospholipase domain of recombinant ExoU protein. The effect of the mutation on the catalytic activity of ExoU was tested by the in vitro lysophospholipase A assay. Second, the same site-directional mutation was introduced into the exoU gene of P. aeruginosa PA103. Mice were intratracheally infected with either a wild-type P. aeruginosa strain PA103 or an isogenic mutant containing the mutation in exoU. Acute epithelial lung injury, lung edema, bacteremia, and mortality were evaluated quantitatively. Measurements and Main Results: Recombinant ExoU had lysophospholipase A activity. Site-directional mutations in the predicted catalytic site of ExoU caused a loss of the lysophospholipase A activity. Whereas the airspace instillation of PA103 caused acute lung injury and death of the infected mice, the airspace instillation of isogenic mutants secreting catalytically inactive ExoU were noncytotoxic and did not cause acute lung injury or death of the infected mice. Conclusion: Virulent P. aeruginosa causes acute lung injury and death by the cytotoxic activity derived from the patatin-like phospholipase domain of ExoU.

Ventilation with a small tidal volume (Vt) is associated with better clinical outcomes than with a large Vt, particularly in critical settings, including acute lung injury. To determine whether Vtinfluences the lipopolysaccaharide (LPS) recognition pathway, we studied CD14 expression in rabbit lungs and the release of TNF-α by cultured alveolar macrophages after 240 min of ventilation with a large (20 ml/kg) vs. a small (5 ml/kg) Vt. We also applied small or large Vtto lungs instilled with 50 μg/kg of LPS. The alveolar macrophages collected after large Vtventilation revealed a 20-fold increase in LPS-induced TNF-α release compared with those collected after small Vtventilation, whereas TNF-α was undetectable without LPS stimulation. In animals ventilated with a large Vt, the expression of CD14 mRNA in whole lung homogenates and the expression of CD14 protein on alveolar macrophages, assessed by immunohistochemistry, were both significantly increased in the absence of LPS stimulation. A large Vtapplied to LPS-instilled lungs increased the pulmonary albumin permeability and TNF-α release into the plasma. These results suggest that mechanical stress caused by a large Vtsensitizes the lungs to endotoxin, a phenomenon that may occur partially via the upregulation of CD14.

Acute lung injury in Pseudomonas aeruginosa pneumonia depends primarily on ExoU that is delivered directly into the eukaryotic cell via the type III secretion system. Recent studies demonstrated that ExoU has lipase activity, and that the cytotoxicity of ExoU is dependent on its patatin-like phospholipase domain. We investigated the phospholipase A (PLA) activity of ExoU. ExoU, but not non-catalytic ExoU- S142A , preincubated with the BEAS-2B cell lysate showed a weak increase of Ca 2+ -independent PLA 2 activity. When activated ExoU was mixed with secretory type PLA 2 , more phospholipase activity was observed, suggesting that ExoU has lysophospholipase A (lysoPLA) activity. A significant increase in lysoPLA activity was also observed. Glycerol enhanced this activity and inhibitors of iPLA 2 suppressed ExoU’s lysoPLA activity. Our results suggest that ExoU has a potent lysoPLA activity that requires the presence of the catalytically active site Ser 142 with an unknown eukaryotic cell factor(s) for its activation.

Background In the partial CO(2) rebreathing method, monitored changes in CO(2) elimination and end-tidal CO(2) in response to a brief rebreathing period are used to estimate cardiac output. However, dynamic changes in CO(2) production during ischemia and reperfusion may affect the accuracy of these estimates. This study was designed to compare measurements of cardiac output as produced by the partial CO(2) rebreathing (NICO), bolus (BCO), and continuous thermodilution (CCO) methods of monitoring cardiac output. Methods Cardiac output was continuously monitored using both NICO and CCO in 28 patients undergoing aortic reconstruction. BCO measurements were taken at the following intervals when hemodynamic stability was achieved: (1) after anesthetic induction; (2) during aortic cross-clamp; (3) at reperfusion of the iliac artery; and, (4) during peritoneal closure. Results The bias and precision (1 SD) derived from all the measurements between NICO and BCO was -0.58 +/- 0.9 l/min, whereas for CCO and BCO it was 0.38 +/- 1.17 l/min. The bias between NICO and BCO was small after anesthetic induction and during cross-clamp, but increased following reperfusion. The bias between CCO and BCO was relatively small until reperfusion but increased significantly at peritoneal closure. Conclusions Results indicate that in aortic reconstruction surgery the performance of NICO monitoring is comparable with that of CCO; however, the direction of bias in these continuous measurement devices is the opposite.

Pseudomonas aeruginosa delivers the toxin ExoU to eukaryotic cells via a type III secretion system. Intoxication with ExoU is associated with lung injury, bacterial dissemination and sepsis in animal model and human infections. To search for ExoU targets in a genetically tractable system, we used controlled expression of the toxin in Saccharomyces cerevisiae. ExoU was cytotoxic for yeast and caused a vacuolar fragmentation phenotype. Inhibitors of human calcium-independent (iPLA(2)) and cytosolic phospholipase A(2) (cPLA(2)) lipase activity reduce the cytotoxicity of ExoU. The catalytic domains of patatin, iPLA(2) and cPLA(2) align or are similar to ExoU sequences. Site-specific mutagenesis of predicted catalytic residues (ExoUS142A or ExoUD344A) eliminated toxicity. ExoU expression in yeast resulted in an accumulation of free palmitic acid, changes in the phospholipid profiles and reduction of radiolabeled neutral lipids. ExoUS142A and ExoUD344A expressed in yeast failed to release palmitic acid. Recombinant ExoU demonstrated lipase activity in vitro, but only in the presence of a yeast extract. From these data we conclude that ExoU is a lipase that requires activation or modification by eukaryotic factors.

The perioperative management of pulmonary hypertension in a patient with Eisenmenger syndrome, the most advanced form of associated pulmonary artery hypertension (PAH), who required a sigmoidectomy is presented. The treatment for pulmonary hypertension was switched from oral sildenafil to intravenous epoprostenol to avoid the unexpected discontinuation of vasodilation during the perioperative period. The scheduled perioperative conversion should be considered for patients with severe PAH undergoing major abdominal surgery to ensure the stabilization of pulmonary and systemic hemodynamics.

Anaphylaxis associated with latex allergy is one of the fatal complications during anesthesia. To prevent this complication, we find out latex allergy and high-risk patients by preoperative interview and keep away not only latex allergic patients but high-risk patients from latex allergen in the operating room. In this study, we evaluated the cost-benefit efficiency of our guidelines.This is a prospective observational study for six month. We classified the patients undergoing elective operation into three categories: latex allergy (group LA), high-risk of latex allergy (group LH) and control (group C), and we compared the incidence of perioperative anaphylaxis and the cost of using products without latex allergen.A total of 1.291 patients were enrolled in the analysis. Five patients (0.4%) and 206 patients (16.0%) categorized into group LA, and LH respectively. There was no patient diagnosed with anaphylaxis associated with latex allergy during the observation period. We are able to save the cost of 3.5 million yen every year by our method than using products without latex allergen for all cases.Our guidelines for prevention of perioperative anaphylaxis associated with latex allergy might be efficient from the standpoint of cost-benefit

There are growing interests in perioperative preventation of surgical site infection, since the World Health Organization has published surgical safety checklist with the slogan "safe surgery saves lives" in 2008. According to the surgical safety checklist, the surgical team needs to check whether antibiotic prophylaxis has been given within 60 minutes of skin incision. In this study, we investigated whether anesthesiologists in our institution completed the administration of antibiotics before skin incision.Anesthetic records of patients who had undergone elective surgery between April to October 2011 were collected. The records were retrospectively analyzed to examine whether administration of antibiotics had been completed before skin incision or not.Although all the anesthesiologists were aware of the necessity of antibiotic prophylaxis, the administration of antibiotics before skin incision was not completed in 22.8% of 880 patients. The administration of antibiotics tended to delay patients receiving general surgery.Anesthesiologists should have knowledge on the preventation of surgical site infection especially on antibiotic prophylaxis, because it starts in the operating room.

A 75-year-old woman with primary pulmonary hypertension was on medical therapy and ambulatory oxygen inhalation therapy for 7 years. The patient had right femoral fracture and was admitted to our hospital. She had also suffered from asthma for 2 years, and her vital capacity was 1.35 l with forced expiratory volume in 1 second 0.79 l, and with her mean pulmonary artery pressure 60 mmHg. Open reduction and internal fixation were performed under spinal anesthesia using isobaric bupivacaine 6 mg with fentanyl 10 microg, and the patient was discharged on postoperative 31 day with no major complications. One year after the surgery, she had left femoral fracture, and surgery was performed under spinal anesthesia using isobaric bupivacaine 6 mg with fentanyl 10 microg. With its minimal effects on hemodynamics, we speculate that spinal anesthesia using a low dose of isobaric bupivacaine can be a choice for patients with pulmonary hypertension.

We hypothesized that pre-operative BNP levels predict postoperative morbidity and mortality in patients undergoing non-emergent cardiac surgery.We retrospectively assessed patients who underwent non-emergent cardiac surgery at our institution regarding major morbidity (prolonged ventilation48 hours and prolonged ICU stay7 days), and all-cause mortality within 30 days. The cutoff value of BNP for prolonged ventilation was also evaluated.A total of 62 patients with a mean age of 68.7 +/- 12.4 and preoperative BNP value of 391+/- 324 pg x ml(-1) were included. Risk factors for prolonged ventilation were high preoperative BNP and combined procedures. The risk factor for prolonged ICU stay was high preoperative BNP alone. All-cause mortality within 30 days were associated with high preoperative BNP and low intraoperative urine output. A preoperative BNP value (259 pg x ml(-1)) provided the optimal BNP cutoff point for prolonged ventilation, and predicted postoperative hemodynamic instability.Preoperative BNP predicted postoperative morbidity and mortality.

A 62-year-old woman with Wolff-Parkinson-White syndrome was with recent worsening of dyspnea to New York Heart Association functional status Class III. The patient was diagnosed as having central type chronic thromboembolic pulmonary hypertension. By cardiac catheterization, her mean pulmonary artery pressure was 53 mmHg with total pulmonary resistance 2238 dynes·sec·cm−5. After medical therapies with tadalafil, furosemide, ambrisentan, beraprost, and warfarin were initiated, percutaneous transluminal pulmonary angioplasty (PTPA) was performed. Following PTPA, life-threating hypoxemia resulting from postoperative reperfusion pulmonary edema developed. High-flow nasal cannula therapy (HFNC) was applied, and 100% oxygen at 50 L/min of flow was required to keep oxygenation. HFNC was continued for 3 days, and the patient was discharged on 8th postoperative day with SpO2of 97% on 3 L/min of oxygen inhalation. Because of the simplicity of the technique, the lower cost of equipment, and remarkable patient tolerance to the treatment, we speculate that HFNC can take over the post of noninvasive ventilation as first-line therapy for patients with acute respiratory failure.

To the Editor: A recent clinical trial from Austria recommended ‘‘the 20/22 cm rule’’ to determine the insertion depth of an endotracheal tube (ETT) to 20 cm in women and 22 cm in men, measured at the corner of the mouth [1]. In this study, we determined the insertion depth of ETT using the vocal cord marker, measured the distance between the distal tip of ETT and carina (T–C length), and compared the actual distance with the calculated distance if the insertion depth of ETT was determined by the 20/22 cm rule. This retrospective study was approved by the research ethics committee of Kyorin University Hospital, which granted a waiver of written informed consent. In 69 Japanese patients undergoing general anesthesia requiring oral endotracheal intubation, we decided the depth of ETT using the vocal cord marker during tracheal intubation. We measured the T–C length on a portable chest radiograph taken at the end of surgery (the T–C length by the vocal cord marker). In the same patients, we calculated the T–C length if the depth of ETT was determined by the 20/22 cm rule (the T–C length by the 20/22 cm rule). According to the T–C length, the insertion depth of ETT was defined as ‘‘appropriate’’ (2–6 cm), ‘‘shallow’’ ([6 cm), and ‘‘deep’’ (\2 cm). Figure 1 shows the T–C length by the vocal cord marker and by the 20/22 cm rule. No statistical difference in the T–C length was detected by paired t test, although these nonsignificant differences can be false negatives because of the limited sample size. However, three females shorter than 150 cm in height were supposed to get endobronchial intubation when the depth of ETT was determined by the 20/22 cm rule. In conclusion, when we apply the 20/22 cm rule to Japanese patients, caution is needed for females shorter than 150 cm.

A 38-year-old woman on medical therapy for Basedow disease and hypertension with a history of recent heart failure became pregnant. At the 13th week of gestation, her echocardiography showed pulmonary hypertension with 63 mmHg of estimated systolic pulmonary arterial pressure. At the 26th week of gestation, she was admitted to our hospital with dyspnea and uncontrolled hypertension. After medical treatments, elective caesarean section was scheduled at the 30th week of gestation. While monitoring continuously arterial blood pressure and central venous pressure, continuous infusion of prostaglandin E1 was initiated. After epidural anesthesia had been established, surgical procedure was safely performed. The patient was discharged 9 days after surgery, and her estimated systolic pulmonary arterial pressure dropped to 35 mmHg on echocardiography 2 months after the operation. We speculate that pregnancy induced her severe pulmonary hypertension.

A 51-year-old Japanese male underwent on-pump coronary artery bypass grafting surgery. After weaning from cardiopulmonary bypass (348 min), sudden bradycardia and hypotension occurred, followed by ventricular fibrillation. Although defibrillation and infusion of catecholamine restored sinus rhythm, transesophageal echocardiography demonstrated severely reduced contraction of both ventricles, and perioperative vascular spasm was suspected. As vascular spasm was refractory to medications, percutaneous cardiopulmonary support (PCPS) system was quickly instituted under cardiac massage. Coronary angiography revealed vascular spasm of not only the native coronary arteries but also the implanted left internal thoracic artery. After 3 days of full hemodynamic assist, PCPS was withdrawn with no obvious abnormalities in regional wall motion by transesophageal echocardiography. The patient was extubated on postoperative day 6 with no impaired brain function. In this case, the immediate diagnosis of refractory vascular spasm by transesophageal echocardiography and full cardiocirculatory assistance by PCPS helped to save the life of the patient.

We evaluated the dual immuno-regulatory effects of Y-40138, inhibiting tumor necrosis factor (TNF)-α production and augmenting interleukin (IL)-10 productions, in animal models of organ dysfunction related to systemic inflammatory response syndrome. Male Sprague-Dawley rats received Y-40138 (1, 10 and 30 mg/kg) or saline subcutaneously, and were subjected to cecal ligation and puncture (CLP) surgery 15 min later. Male C57Bl/6 mice received Y-40138 (30 mg/kg) or saline intravenously and were subjected to intratracheal instillation of hydrochloric acid (0.1 N, pH = 1.0) 30 min later. Survival after CLP surgery was monitored for 10 days and compared by Kaplan-Meier analysis and log rank statistics. Neutrophil count and cytokine concentrations in bronchoalveolar lavage (BAL) fluid at 12 h after intratracheal instillation were analyzed by one-way ANOVA. After CLP surgery, while 1 mg/kg of Y-40138 increased survival, 30 mg/kg of Y-40138 decreased survival (p < 0.01). After acid aspiration, Y-40138 significantly inhibited neutrophil recruitment by decreasing TNF-α / IL-10 ratio in BAL fluid (p < 0.05). Although the down regulation of pro-inflammatory cytokines and augmentation of anti-inflammatory cytokines seems a rational approach for SIRS-related multiple organ failure, further studies are needed for future clinical application of Y-40138, especially in situations compromised with microorganisms infection. Key words: Immunomodulators, sepsis, aspiration pneumonitis.

A 61-year-old woman with pulmonary lymphangioleiomyomatosis was scheduled for video-assisted thoracoscopic surgery for partial resection of the lung. The patient had micrognathism and a recent history of difficult airway management [difficult mask ventilation and intubation (Cormak grade III)]. On induction, mask ventilation was accomplished with the use of nasal airway. We initially inserted Airtraq laryngoscope and gained a view of Cormak grade III. Therefore, a 32 Fr left-sided Blue Line endobroncheal tube was nasotracheally intubated using a fiberscope (3.1-mm diameter). Nasotracheal intubation with a 32F Blue Line endobroncheal tube can be a choice for patients with difficult airway when one lung ventilation is required.

A 69-year-old man with chronic thromboembolic pulmonary hypertension (CTEPH) was on amblatory oxygen inhalation therapy (3 L/min) and scheduled for percutaneous transluminal pulmonary angioplasty (PTPA). The patient's New York Heart Association functional status was class III with recent worsening of dyspnea and apparent leg edema. Transthoracic echocardiography revealed right ventricular enlargement with mean pulmonary artery pressure of 42 mmHg. After PTPA, he was complicated with postoperative reperfusion pulmonary edema, and noninvasive positive pressure ventilation (NPPV) was applied immediately. Hypoxemia was successfully treated with 15 days of NPPV. Although mean pulmonary artery pressure was unchanged, his brain natriuretic peptide level decreased from preoperative 390.3 to postoperative 44.3 pg/dL. In addition, total pulmonary resistance decreased from preoperative 18 to postoperative 9.6 wood unit·m2. The patient was discharged on day 25 with SpO2of 95% on 5 L/min of oxygen inhalation. Because pulmonary edema is a postsurgical life-threatening complication following PTPA, application of NPPV should be considered.

The quinone profiling technique was used to investigate the effects of zinc stress on the bacterial population structure of sewage activated sludge in laboratory-scale reactors. The quinone composition of sludges cultivated under different conditions with respect to the sludge retention time and zinc concentrations was determined by thin-layer chromatography, ultraviolet spectroscopy, reverse-phase high-performance liquid chromatography, and mass spectrometry. Numerical analysis of the quinone profiles showed that there were significant differences in the community structure between sludges cultivated with Zn2+ and without Zn2+. When the sludge was loaded with Zn2+, the sludge retention time was also an important factor affecting the quinone composition. The changes in the quinone composition from the normal sludge to the zin-stressed sludges resulted mainly from an increase in bacterial populations with ubiquinone-8 and a decrease in those with partially hydrogenated menaquinones.

Preoperative evaluation of infectious diseases in patients for elective and non-elective surgery is important for the anesthesiologists not only to rule out the patient's state of illness, but also to prevent transmission of infectious diseases in healthcare settings. To prevent transmission of infectious diseases in healthcare settings, Center for Disease Control published guidelines that consist of standard precaution and transmission-based precautions. In the face of exposure to known infectious diseases, certain post exposure prophylaxis has been established, especially against exposure to human immunodeficiency virus and hepatitis B virus. There are also growing interests in perioperative prevention of surgical site infection, since World Health Organization has published surgical safety checklist with the slogan "Safe surgery saves life". Anesthesiologists need to have knowledge on the prevention of surgical site infection especially on antibiotic prophylaxis, because it starts in the operating room.

A 48-year-old woman was diagnosed with cavernous hemangioma of hypopharynx and larynx, which extended to the trachea and mediastinum. She was scheduled for tracheostomy and open surgical excision of hypopharynx hemangioma under general anesthesia. On induction of anesthesia, we planned awake fiberoptic intubation according to the difficult airway algorithm of the American Society of Anesthesiologists. Under continuous infusion of remifentanil at 0.1-0.2 microg x kg(-1) x min(-1), the patient became sedated while spontaneously breathing, and her pain and laryngeal reflexes were reduced. Although tracheal intubation was successfully accomplished without injuring the hypopharynx hemangioma, tracheostomy was difficult because of bleeding from the surgical site. After 3 hr of surgery with 1880 g of blood loss, the surgeons quitted tracheostomy and the patient was transferred to the intensive care unit. Her airway was managed with endotracheal tube for 7 days, and open surgical excision of hypopharynx hemangioma was performed on day 7. The patient was successfully extubated on day 9 with the support of non-invansive positive pressure ventilation. Awake fiberoptic intubation under remifentanil infusion is safe and useful approach for patients with airway hemangioma.

A 22-year-old muscular karate player was diagnosed to have a tracheal tumor with a diameter of 2.8 cm that existed 2 cm under the glottis and occupied 60% of his trachea. He was scheduled for trachea resection and construction surgery. After awake-fiber intubation, anesthesia was maintained by continuous infusion of propofol and remifentanil, together with thoracic epidural anesthesia (T4-5). After 431 minutes of surgery, 50 mm of trachea was rejected. To prevent him from extending his neck, the surgeon placed stay-sutures between the patient's chin and chest wall. Twenty minutes after the termination of propofol and remifentanil infusion, the patient became awake and was extubated. Subsequently, although the body temperature was 37.6 degrees C, excessive shivering occurred and his neck was nearly extended. We immediately injected 0.8 mEq of magnesium sulfate and 70 mg of pethidine. It took almost 10 minutes to stop shivering completely, and the patient became too sedated and required noninvasive positive pressure ventilation overnight. We speculate that intraoperative remifentanil infusion induced severe shivering in this case. Shivering after remifentanil infusion can be a fatal complication in tracheal resection and construction surgery, especially in muscular patients.

The highest zinc concentration in activated sludge occurred at 15 days SRT in a laboratory simulation of the batch activated sludge process. It is possible to maintain a low concentration of zinc in composted sewage sludge, which is derived from excess activated sludge, by keeping the SRT short.

Virulent P. aeruginosa strains express PcrV, one of the translocational components of the type III secretion system. PcrV has been reported to be a protective antigen against lethal P. aeruginosa infection. The PcrV region, which contributes to protective immunity against P. aeruginosa infection, was investigated by using genetically engineered, truncated PcrV proteins and affinity-purified anti-PcrV antibodies against the truncated PcrV proteins. The efficacy of active and passive immunization against PcrV was tested in mice with cyclophosphamide-induced immunosuppression by intraabdominal challenge of P. aeruginosa. Active immunization with either full-length PcrV1-294 or PcrV139-294 significantly improved the survival of mice infected with P. aeruginosa, while PcrV139-258, PcrV139-234, PcrV197-294, and PcrV261-294 were not protective. These results suggest that an effective PcrV vaccine needs to contain not only the Mab166 epitope (PcrV144-257) but also the carboxyl terminal tail of PcrV. In the case of passive immunization, administration of affinity-purified anti-PcrV IgG against either PcrV1-294 or PcrV139-258 showed significantly higher efficacy against lethal P. aeruginosa infection than did original anti-PcrV IgG and Mab166. The increased efficacy of affinity-purified anti-PcrV IgG implies that more potent anti-PcrV strategies are possible. The results of this study are crucial to the development of an effective PcrV vaccine for active immunization and to an appropriate blocking anti-PcrV antibody against P. aeruginosa infection in humans.

Toll-like receptor 4 (TLR4) plays important roles in the recognition of lipopolysaccharide (LPS) and the activation of inflammatory cascade. In this study, we evaluated the effect of TAK-242, a selective TLR4 signal transduction inhibitor, on acute lung injury (ALI).C57BL/6J mice were intravenously treated with TAK-242 15 min before the intratracheal administration of LPS or Pam3CSK4, a synthetic lipopeptide. Six hours after the challenge, bronchoalveolar lavage fluid was obtained for a differential cell count and the measurement of cytokine and myeloperoxidase levels. Lung permeability and nuclear factor-kappaB (NF-kappaB) DNA binding activity were also evaluated.TAK-242 effectively attenuated the neutrophil accumulation and activation in the lungs, the increase in lung permeability, production of inflammatory mediators, and NF-kappaB DNA-binding activity induced by the LPS challenge. In contrast, TAK-242 did not suppress inflammatory changes induced by Pam3CSK4.TAK-242 may be a promising therapeutic agent for ALI, especially injuries associated with pneumonia caused by Gram-negative bacteria.

The amount of heavy metals discharged from daily life was estimated in order to know the origin of the metals contained in the sewage sludge which is produced in the wastewater treatment plant treating only domestic wastewater. The amounts of the metals discharged from our daily life were estimated to be in the range of 0.2 to 0.3 for Cd, 1.6 to 1.9 for Ni, 3.5 to 6.8 for Pb, 0.8 to 1.4 for Cr, 8.2 to 19.3 for Mn 9.4 to 55.8 for Cu, 44.3 to 62.7 for Zn and 111 to 293 for Fe in mg.d−1 per person, Using these data, the cycle of the metals in our daily life was discussed in relation to land application of sewage sludge.

Proinflammatory cytokines play an important role in ventilator-induced lung injury (VILI). High-mobility group box-1 (HMGB1) is a macrophage-derived proinflammatory cytokine that can cause lung injury.This study tested the hypothesis that HMGB1 is released in intact lungs ventilated with large Vt. A second objective was to identify the source of HMGB1. A third objective was to examine the effects of blocking HMGB1 on the subsequent development of VILI.Bronchoalveolar lavage fluid (BALF) and lung tissues were obtained from rabbits mechanically ventilated for 4 h with a small (8 ml/kg) versus a large (30 ml/kg) Vt. BALF was also obtained from rabbits with intratracheal instillation of anti-HMGB1 antibody before the initiation of large Vt ventilation.The concentrations of HMGB1 in BALF were fivefold higher in the large than in the small Vt group. Immunohistochemistry and immunofluorescence studies revealed expression of HMGB1 in the cytoplasm of macrophages and neutrophils in lungs ventilated with large Vt. Blocking HMGB1 improved oxygenation, limited microvascular permeability and neutrophil influx into the alveolar lumen, and decreased concentrations of tumor necrosis factor-alpha in BALF.These observations suggest that HMGB1 could be one of the deteriorating factors in the development of VILI.

Overnight polysomnography (PSG) is indispensable for diagnosis of obstructive sleep apnea hypopnea syndrome. However, studies on interscorer agreement on PSG scoring between laboratories are few. The purpose of this study was to examine the reliability of interscorer agreement on PSG scoring among 16 sleep laboratories in Japan. We found a relatively moderate interscorer reliability of the index of oxygen desaturation and arousal during sleep, but a relatively low reliability of the index of transient reduction in and complete cessation of breathing (apnea hypopnea index). The median rate of interscorer coincidence of sleep staging was the lowest for slow wave (deep) sleep (23.5%), followed by those for Stage 1 (59.8%), Wake (73.2%) and Stage 2 (74.2%) in this order, and rapid eye movement was the most reliably identified stage (91.3%). The median rate of interscorer coincidence for all stages was 71.8%. The present study demonstrates that scorers tend to analyze PSG data according to a relatively empirical decision as opposed to a rule-dependent decision. Further detailed scoring manuals are required to decrease the interscorer discrepancy in PSG scoring.

The pcrV genotype was analyzed in clinical isolates of Pseudomonas aeruginosa which showed a negative phenotype for secretion of V-antigen PcrV. The suppression of PcrV secretion in these isolates was due not to a lack of the pcrV gene but rather to suppression of PcrV expression.

Objective: Acute lung injury induced by lung overstretch is associated with neutrophil influx, but the pathogenic role of neutrophils in overstretch-induced lung injury remains unclear. Design: To assess the contribution of neutrophils, we compared the effects of noninjurious large tidal volume (VT) ventilation on lungs in normal and neutrophil-depleted animals. Setting: Research animal laboratory. Subjects: Twenty-six male Japanese white rabbits. Interventions: Animals were mechanically ventilated for 4 hrs with one of the three following protocols: large VT (20 mL/kg), small VT (8 mL/kg), and large VT (20 mL/kg) with neutrophil depletion achieved by a single dose of vinblastine injection (0.75 mg/kg) intravenously 4 days before the experiment. Measurements and Main Results: Large VT ventilation produced alveolar neutrophil influx compared with low VT (p .002) without evidence of edema or increased epithelial permeability. The neutrophil influx was accompanied by increases in interleukin-8 in bronchoalveolar lavage fluid (p .04). Immunohistochemistry of large VT lungs showed increased interleukin-8 staining in bronchial epithelial cells, alveolar epithelium, alveolar macrophages, and smooth muscles of pulmonary vessels. Neutrophil depletion attenuated the interleukin-8 increase in the lung. Large VT did not increase plasma interleukin-8 or tumor necrosis factor- in plasma and bronchoalveolar lavage fluid. No expression of p-selectin or intercellular adhesion molecule-1 was observed. Conclusions: Cyclic overstretching of normal rabbit lungs with noninjurious large VT produced neutrophil influx and interleukin-8 increase in bronchoalveolar lavage fluid. Production of pulmonary interleukin-8 by lung overstretch might require the interaction between resident lung cells and migrated neutrophils. This study suggests that large VT ventilation potentiates the predisposed, subclinical lung injury, such as nosocomial pneumonia or aspiration of gastric contents. (Crit Care Med 2004; 32:514 ‐519)

Background The relative contributions of the cytotoxic phenotype of P. aeruginosa expressing type III secretory toxins and an immunocompromised condition lacking normal Toll-like receptor 4 (TLR4) signaling in the pathogenesis of acute lung injury and sepsis were evaluated in a mouse model for Pseudomonas aeruginosa pneumonia. By using lipopolysaccharide-resistant C3H/HeJ mice missing normal TLR4 signaling due to a mutation on the tlr4 gene, we evaluated how TLR4 signaling modulates the pneumonia caused by cytotoxic P. aeruginosa expressing type III secretory toxins. Methods We infected C3H/HeJ or C3H/FeJ mice with three different doses of either a cytotoxic P. aeruginosa strain (wild type PA103) or its non-cytotoxic isogenic mutant missing the type III secretory toxins (PA103ΔUT). Survival of the infected mice was evaluated, and the severity of acute lung injury quantified by measuring alveolar epithelial permeability as an index of acute epithelial injury and the water to dry weight ratios of lung homogenates as an index of lung edema. Bacteriological analysis and cytokine assays were performed in the infected mice. Results Development of acute lung injury and sepsis was observed in all mouse strains when the cytotoxic P. aeruginosa strain but not the non-cytotoxic strain was instilled in the airspaces of the mice. Only C3H/HeJ mice had severe bacteremia and high mortality when a low dose of the cytotoxic P. aeruginosa strain was instilled in their lungs. Conclusion The cytotoxic phenotype of P. aeruginosa is the critical factor causing acute lung injury and sepsis in infected hosts. When the P. aeruginosa is a cytotoxic strain, the TLR4 signaling system is essential to clear the batcteria to prevent lethal lung injury and bacteremia.

Background: The effects of the murine monoclonal anti-PcrV antibody Mab166 on acute lung injury induced by Pseudomonas aeruginosa were analyzed in a rat model. Methods: Lung injury was induced by the instillation of P. aeruginosa strain PA103 directly into the left lungs of anesthetized rats. One hour after the bacterial instillation, rabbit polyclonal anti-PcrV IgG, murine monoclonal anti-PcrV IgG Mab166 or Mab166 Fab-fragments were administered intratracheally directly into the lungs. The degree of alveolar epithelial injury, amount of lung edema, decrease in oxygenation and extent of lung inflammation by histology were evaluated as independent parameters of acute lung injury. Results: These parameters improved in rats that had received intratracheal instillation of either rabbit polyclonal anti-PcrV IgG, murine monoclonal anti-PcrV IgG Mab166 or Mab166 Fabfragments in comparison with the control group. Conclusion: Mab166 and its Fab fragments have potential as adjuvant therapy for acute lung injury due to P. aeruginosa pneumonia.

The purpose of this research is the estimation of the amount of heavy metals discharged to domestic wastewater from our daily life.

横須賀, 八戸および函館市においてそれぞれ4～5名のモニターを選択し, それぞれの家庭から下水へ排出される, いわゆる生活由来の重金属の原単位を求めた。その結果, 横須賀市においては1日1人当たり, Cd192μg, Ni1.66, Pb6.75, CrO.78, Mn8.19, Cu55.8, Zn44.3およびFe111.1mgであった。家庭下水のみの処理場における重金属収支から求めた原単位はFeとCu以外の重金属は家庭排水から求めた重金属量とほぼ一致した。八戸市および函館市において求めた生活由来の重金属原単位は, 2市間ではPb以外の重金属はほとんど同程度の値であった。全般的に横須賀市の原単位より低かった。その値は, それぞれCd72, 88.6μg・day-1・person-1, Ni405,444, Pb2,832,506, Cr392,230, Mn7.33, 6.45, Cu4.09, 3.12, Zn21.5, 24.4およびFe24.3, 30.5mg・day-1・person-1であった。八戸市, 函館市の家庭下水のみの処理場から得られた重金属量は, 生活排水から求めた値とよい一致を示した。

The heavy metal (Cd, Ni, Pb, Zn and Cu) contents of soils and of reed, Phragmites australis (Cav.) Trin. ex Steudel, sampled from freshwater and brackish-water reed stands in the lower reaches of the Nanakita River, Miyagi Prefecture, Japan, were measured. The heavy metal contents of soils showed a positive correlation with organic contents, and were higher in the brackish-water stand than in the freshwater stand, even when the levels of organic contents were equal. In the brackish-water stand, heavy metals are probably accumulated as sulfides. Heavy metal concentrations in reed roots showed higher values than those in leaves, stems and rhizomes. The ratio of the concentration in reed roots to that in soils (availability of heavy metals) was high in the freshwater stand as compared with the brackish-water stand.

Microbial silver toxicity is found in situations of industrial pollution, especially those associated with the use of photographic film. In hospitals, silver salts are the preferred antimicrobial agents for burns. It is well known that silver-resistant bacteria with plasmids (extrachromosomal DNA molecules) encoded for silver resistance can be isolated from polluted industrial sites and hospitals. The silver resistance of five strains of Enterobactercloacae isolated from contaminated sewage was investigated. In one of these strains, a high frequency of inactivation of silver resistance was achieved by treatment with ethidium bromide and acriflavine (inactivation frequencies of 23.3% and 17.7%, respectively). The maximum concentration of AgNO3 at which plasmid-less Ag-sensitive strains could be grown was 20 mg/l. The maximum concentration of AgNO3 at which Ag-resistant strains were able to grow was 10 000 mg/l, i.e., 500 times that for silver-sensitive strains. Agarose gel electrophoresis profiles showed that the DNA with higher mobility, i.e., plasmids, present in the silver-resistant cells was inactivated by the treatment with ethidium bromide and acriflavine. Viable organisms of Ag-resistant and Ag-sensitive strains at about 108 colony-forming units (CFU) per ml were inoculated into broth containing AgNO3. The concentrations of AgNO3 in the supernatants were measured by atomic absorption spectrophotometry. A decrease in the concentration of AgNO3 was observed. The concentrations decreased to below 50% of the initial value after 24 h, and to almost 0% (trace) after 1 week.

The biomass of newborn snails was higher in paddy soil without rice plants than in the soil with rice plants. There was an inverse correlation between shell width and concentratins of Zn and Cu in snail flesh. The Zn and Cu concentrations in snail flesh were extremely high compared with those in the paddy soil surrounding the snails, possibly because snails ingest sludge, one of the main components of the composts. These results suggest that this type of snail may be used to eliminate Zn and Cu from paddy soil when composted sewage sludge has been applied.

The purpose of this research is the estimation of the amount of heavy metals discharged to domestic wastewater from our daily life.