Intraoperative Oxygen Consumption During Liver Transplantation.

BACKGROUND: The aim of this study was to investigate the changes in oxygen consumption during liver transplantation and to examine the relationship between intraoperatively elevated systemic oxygen consumption and postoperative liver function. METHODS: This study was performed in 33 adult patients undergoing liver transplantation between September 2011 and March 2014. We measured intraoperative oxygen consumption through the use of indirect calorimetry, preoperative and intraoperative data, liver function tests, and postoperative complications and outcomes. RESULTS: The mean age of patients was 52 ± 9.7 years; 14 (42%) of them were women. Average Model for End-Stage Liver Disease scores were 20 ± 8.9. Oxygen consumption significantly increased after reperfusion from 172 ± 30 mL/min during the anhepatic phase to 209 ± 30 mL/min (P < .0001). We divided patients into 2 groups according to the increase in oxygen consumption after reperfusion (oxygen consumption after reperfusion minus anhepatic phase oxygen consumption: 40 mL/min increase as cutoff). The higher consumption group had a longer cold ischemia time and higher postoperative aspartate aminotransferase and alanine aminotransferase levels as compared with the lower oxygen consumption group. There were no statistically significant differences in major postoperative complications, but the higher oxygen consumption group tended to have shorter hospital stays than the lower consumption group (58 versus 95 days). CONCLUSIONS: We have demonstrated that oxygen consumption significantly increased after reperfusion. Furthermore, this increased oxygen consumption was associated with a longer cold ischemia time and shorter hospital stays.

Increased heme oxygenase-1 gene expression in the livers of patients with portal hypertension due to severe hepatic cirrhosis.

Surgical bleeding associated with splanchnic hyperaemia due to portal hypertension complicates the anaesthetic management of hepatic transplantation. Although the mechanism(s) of portal hypertension are not fully understood, carbon monoxide, a product of the heme oxygenase (HO) reaction, is thought to be one of the endogenous vasodilators in the liver. In this study, the expression of mRNA encoding inducible HO isozyme (HO-1) in the livers of patients with portal hypertension undergoing hepatic transplantation was determined in comparison with those without portal hypertension. HO-1 mRNA levels were significantly greater in the portal hypertension group than in the group without portal hypertension. In contrast with HO-1, the gene expression of non-specific delta-amino-levulinate synthase (ALAS-N), which is down-regulated by heme in the liver, was the same in both groups. These results suggest that HO-1 is up-regulated through heme-independent stimuli according to the development of portal hypertension, and that induced HO-1 plays a pathophysiological role in portal hypertension through carbon monoxide production.

The effects of epidural block on the distribution of lymphocyte subsets and natural-killer cell activity in patients with and without pain.

Although epidural anesthesia prevents immune suppression during surgery, no reports have elucidated how epidural block affects immune response in nonsurgical patients. We examined changes in proportion of lymphocyte subsets and in natural-killer (NK) cell activity in patients with and without pain. Fifteen patients with pain (Pain group) and 15 preoperative patients without pain (Preoperative group) received three different treatments in random order: epidural block with 7 mL 1% lidocaine, epidural injection of an identical volume of normal saline, and IV injection of 1 mg/kg lidocaine. Blood samples were drawn before and after 30, 60, and 120 min of treatment. During epidural block at 30 and 60 min, both groups showed significantly decreased epinephrine, norepinephrine, and cortisol levels, and the proportion of NK cells decreased, whereas the CD4+/CD8+ ratio increased significantly. NK cell activity in both groups decreased significantly at 30 and 60 min. At 120 min, the variables had all returned to preblock values. During treatments with saline and IV lidocaine, neither group showed significant changes in any of the above variables. We conclude that epidural block causes a transient and significant alteration of lymphocyte subsets and NK cell activity regardless of pain status.

The path of kyosei.

Many global companies believe they have a moral duty to respond to the world's problems but are unsure how to do that and still pursue a reasonable profit for their shareholders. Ryuzaburo Kaku, honorary chairman of Canon, the Japanese technology company, suggests that companies consider kyosei, a business credo that he defines as a "spirit of cooperation" in which individuals and organizations work together for the common good. Kyosei, Kaku claims, has helped Canon make a significant and positive impact on many world problems as the company has grown to become one of the world's preeminent innovators and manufacturers of technology. The implementation of kyosei can be divided into five stages, with each stage building on the preceding one. In the first stage, companies must work to secure a predictable stream of profits and to establish strong market positions. From this foundation, they move on to the second stage, in which managers and workers resolve to cooperate with each other, recognizing that both groups are vital to the company's success. In the third stage, this sense of cooperation is extended beyond the company to encompass customers, suppliers, community groups, and even competitors. At the fourth stage, a company takes the cooperative spirit beyond national boundaries and addresses some of the global imbalances that plague the world. In the fifth stage, which companies rarely achieve, a company urges its national government to work toward rectifying global imbalances. For each stage, Kaku provides detailed examples from Cannon's own experience in putting the ideas of kyosei into practice.

Development of ischemic stroke in normotensive and hypertensive diabetic patients with or without antihypertensive treatment: an 8-year followup study.

Although the impact of hypertension as a risk factor for brain infarction in diabetes mellitus is evident, the beneficial effect of antihypertensive therapy has not been demonstrated. Therefore, we designed a prospective cohort study to elucidate the effects of antihypertensive therapy on the development of ischemic stroke in diabetic outpatients. Two hundred forty patients, 219 non-insulin-dependent diabetes mellitus (NIDDM) and 21 insulin-dependent diabetes mellitus (IDDM), without history of cerebrovascular accident were followed for 8 years, from January 1981 until December 1988, in our diabetic clinic. Forty-eight of 88 hypertensive patients had received antihypertensive drugs. Among 40 untreated hypertensive and 152 initially normotensive diabetics, 14 hypertensives and 11 normotensives required antihypertensive therapy during followup period. Twenty-three patients were dropped out because of the unidentified reasons. Cerebrovascular accident occurred in 24 patients (10%): 18 brain infarctions, 4 transient ischemic attack (TIA), 1 subarachnoidal hemorrhage, and 1 brain hemorrhage. The percent incidence of ischemic strokes in the hypertension-treated patients was 8.9% which was similar to the 8.1% of the normotensives. In contrast, ischemic strokes developed in 29% of the untreated hypertensives, being significantly more frequent than in the former two groups. Multivariate analysis showed that serum total cholesterol and male gender were independent significant precursors of brain infarction in diabetic patients. In conclusion, antihypertensive treatment decreased the incidence of ischemic stroke in diabetics. Serum total cholesterol turned to independent risk factors for ischemic stroke in diabetic patients.

Invasive development of right atrial myxoma--a case report.

A thirty-nine-year-old man was admitted to the authors' department complaining of exertional dyspnea and high fever. An echocardiogram showed a mass in the right atrium, which was observed to move to the right atrium during the systolic phase and to the right ventricle during the diastolic phase. Magnetic resonance imaging showed that the mass developed from the right atrium to the superior vena cava. Intravenous digital subtraction angiography also showed a partial defect of the right atrium as well as obstructions of both the superior vena cava and the bilateral innominate veins. A pulmonary hemodynamic scintigram showed multiple defects at the mid and inferior areas of each lung, suggesting multiple pulmonary infarctions. The right atrial tumor was surgically removed. The superior vena cava and the innominate veins were found to be obstructed by organized thrombi, and the tumor had invasively grown into the right atrial wall. Histologic findings demonstrated that most of the tumor was composed of organized thrombi with scattered myxomatous tissue and was diagnosed as cardiac myxoma. These histologic findings suggest that the histogenesis of this right atrial myxoma might be thrombogenic.

Psychiatric disorders of pre-adolescence in Japan.

We have classified 200 pre-adolescent patients, with whom we have met during the last three years, into the following four types: school refusal and obsessive behavior, psychosomatic disorders, depressive reactions, and schizophrenic disorders. During our therapeutic process, we realized that even though their symptoms seemed varied and severe, they disappeared after comparatively short periods. The pre-adolescent period is a turning point at which the children depart from their earlier relationships with parents and start to form new ones with friends. We facilitated the patients' developmental process in this period so that they would recover naturally by themselves. However, when we looked at the social phenomena which influence the family and children, we noticed that some factors interfered with the pre-adolescents trying to get over the above-mentioned turning point.

Inhibition of leukocyte migration in agar by soluble extract from a human ovarian carcinoma cell line.

A soluble membrane extract was prepared by a hypotonic extraction method from a cultured cell line, CKS, derived from serous cystadenocarcinoma of the ovary. The leukocyte migration inhibition assay in agar was used to determine the cell-mediated immune response with this extract in patients with ovarian carcinoma in comparison with patients with other benign or malignant tumors and normal healthy subjects. With 100 micrograms protein/ml of the extract, leukocytes from 15/25 patients with ovarian carcinoma showed positive response, whereas 5/30 patients with benign tumors, 2/23 patients with non-ovarian carcinomas, and 0/13 normal healthy controls did so. These findings suggested that the soluble membrane extract from the CKS cells specifically inhibited migration of leukocytes from patients with ovarian carcinoma. There was a tendency that the stage III or IV patients responded to the extract more frequently than the stage I patients irrespective of histological type of ovarian carcinoma. The migration inhibition assay with a basic encephalitogenic protein (100 micrograms protein/ml) from bovine brain was performed simultaneously with the ovarian cancer extract. One of 20 patients with ovarian carcinoma, 1/29 patients with benign tumors, 1/22 patients with non-ovarian carcinomas, and 0/13 normal healthy controls responded positively. Therefore, cross-reactivity between the basic protein and tumor-associated antigens could not be demonstrated in the present study.

[Experimental and clinical studies of cefmenoxime in the field of obstetrics and gynecology].

The study group was organized to evaluate the usefulness of cefmenoxime (CMX) injection, a new synthetic cephalosporin, for the treatment of infections in the field of obstetrics and gynecology. Fundamental and clinical studies were made by the society and the following results were obtained. 1. The peak distribution of CMX's MIC for E. coli, Klebsiella sp., Enterobacter sp., Bacteroides sp. and Peptococcus sp. isolated from obstetrical and gynecological infections with relatively high frequencies area 0.1, less than or equal to 0.05, 0.2, 3.13, 1.56 micrograms/ml, respectively, with an inoculation of 10(6) cells/ml. 2. When 1 g of CMX is administered by intravenous drip infusion for 1 hour, the maximum concentrations in various tissues of female genital organs were as follows: 14.2 and 13.2 micrograms/g in ovary and oviduct, respectively, at 1.20 hours after the start of administration, and 16.9 and 26.3 micrograms/g in corpus uteri and cervix uteri, respectively, after 1 hour. As for the transfer to the exudate in the pelvic dead cavity, the peak concentration was 15.6 micrograms/ml after 2.13 hours. 3. In the clinical studies, CMX was given to 258 cases with female genital organ infections and others. As for the clinical effects, with exclusion of 3 cases in which other antibiotics are concomitantly used, responses were excellent in 76 cases, good in 162 cases and poor in 17 cases, among 255 cases in total. The efficacy rate was 93.3%. The efficacy rates by diseases were 97.1% (68/70) for intrauterine infections, 88.8% (79/89) for intrapelvic infections, 98.4% (62/63) for adnexitis, and 100% (23/23) for infections of external genital organs. As for the clinical effects on causative bacteria, the efficacy rates were 100% (19/19) for single infections due to Gram-positive bacteria, 94.8% (55/58) for single infections due to Gram-negative bacteria, and 88.2% (15/17) for single infections due to anaerobic bacteria. And its efficacy rates were 89.6% (69/77) for mixed infection cases. Side effects were observed in 2 cases (0.8%); 1 case with eruption, and 1 case with diarrhea and vomiting. As for abnormal laboratory findings, lower white blood cell count was observed in 2 cases and elevation of the values regarding hepatic functions in 9 cases. All cases were returned to the normal after the completion of the administration. Cefmenoxime showed a satisfactory clinical efficacy and a potent bacteriological effect in treatment of the infections in the field of obstetrics and gynecology, and it has been concluded that cefmenoxime will be useful addition to the antibiotics for the therapy of these infections.

Interruption of pregnancy with vaginal suppositories containing 16,16-dimethyl-trans-delta 2-prostaglandin E1 methyl ester.

A new synthesized Prostaglandin E1 analogue, 16,16-dimethyl-trans-delta 2-Prostaglandin E1 methyl ester, has been shown to be effective in termination of 1st and second trimester pregnancy following vaginal administration. Suppositories, each containing 1 mg Prostaglandin E1 derivative, were administered five times to each of fifty pregnant women of five to twenty gestational weeks at three-hourly intervals. The procedure was clinically effective in 86% of the patients resulting in 56% complete and 30% incomplete abortions. The cervix of all patients was dilated up to 7 mm in diameter at the second insertion of the suppository. Vaginal bleeding and lower abdominal pain not requiring sedation were observed in all patients. Diarrhea (42%), vomiting (6%), and fever (4%) were the most common side effects. The Karyopyknotic Index of the vaginal smear increased significantly (p less than 0.01) twelve hours after the initial insertion. The superficial cells of the cervix gradually degenerated during the termination procedure.

PIP: 16,16-dimethyl-trans-delta2-prostaglandin El methyl ester, a newly synthesized prostaglandin E1 analogue (PGE), was evaluated to determine the clinical and cytological characteristics and efficacy of vaginally administered PGE for termination of 1st and 2nd trimester pregnancies. 50 16-45 year-old, 5-20 week pregnant, women were studied. Suppositories, each containing 1 mg of PGE derivative, were administered 5 times to each woman at 3-hour intervals. The procedure was clinically effective in 86% of the patients, resulting in 56% complete and 30% incomplete abortions. Cervix of all patients was dilated up to 7 mm in diameter at the 2nd insertion. Vaginal bleeding and lower abdominal pain, not requiring sedation, were observed in all patients. Vaginal smear karyopyknotic index increased significantly (P .01) 12 hours after the initial insertion. Superficial cells of the cervix gradually degenerated during the termination procedure. No significant difference in cervical dilatation was observed between parous and nonparous study participants.

Hemodynamic assessment of the new aortic Carpentier-Edwards bioprosthesis.

Although glutaraldehyde-preserved porcine aortic Hancock heterografts have lower thromboembolism incidence than mechanical aortic valves, Hancock xenografts provide less functional aortic outflow orifices and thereby greater transvalvular gradients than mechanical prostheses. The newly developed aortic Carpentier-Edwards porcine heterografts comprise a thin-walled Elgiloy flexible metal stent covered with Teflon which provides somewhat wider internal orifices than aortic Hancock valves of the same external annulus diameter. Since aortic Carpentier-Edwards xenografts have not been clinically evaluated previously, the present study assessed cardiac function and heterograft performance (1.7 months postoperation) and clinical status (4.2 months postoperation) of 19 patients with severe aortic stenosis and/or regurgitation prior to surgery. Left ventricular end-diastolic pressures decreased (17 to 9 mm Hg), cardiac index remained normal, and clinical symptomatology diminished markedly. Mean peak transxenograft systolic pressure was only 16 mm Hg (valve area 1.73 cm2), without meaningful regurgitation. Thus aortic Carpentier-Edwards bioprostheses provide generally excellent heterograft function which appears more favorable than previous reports of Hancock xenografts.

End-to-side anastomosis of the mesenteric vein to the inferior vena cava in the treatment of glycogen storage disease: case report.

A 2-year-old boy with Type I glycogen storage disease received an end-to-side anastomosis of the mesenteric vein to the inferior vena cava with marked improvement in his biochemical factors and nutritional status and with shrinkage of the liver. The efficacy and simplicity of this technique and its lack of complications, as evidenced by follow-up studies over a 4 year period, suggest that its further use is warranted.

Reevaluation of parasternal lymph node dissection in the treatment of mammary cancer.

One hundred and forty one patients with mammary cancer underwent the extended radical mastectomy with parasternal lymph nodes dissection between January, 1966 and December, 1974. From the basis of the present report involvement of parasternaly lymph node chain was evaluated retrospectively with respect to the stage, location, size, histological type of cancer, metastasis to axillary and subclavicular lymph nodes, and the five-year survival rate. The parasternal as well as subclavicular and axillary lymph node involvements were not found in non-infiltrating cancer. The more the stage of cancer advanced, the more frequently the parasternal lymph nodes were involved regardless of the location of cancer in the breast. The parasternal lymph node chain alone was rarely involved, but frequently affected along with the axillary lymph nodes. When the parasternal lymph nodes were involved, the five-year survival rate was extremely poor, even after their surgical removal. Subsequently, addition of parasternal lymph node dissection does not seem to be beneficial.

Private school activities and psychosomatic problems in Japanese children.

This paper investigates the relation between private school activities and psychosomatic problems in Japanese elementary school children. Of 1,073 children studied, 67.3 percent attended private schools to study such subjects as calligraphy, abacus, and music. Of these children, 25.3 percent attended three to four times per week, and 18.1 percent five times and more. Statistical analysis showed that frequently attending children exhibited symptoms of dizziness, sleep disturbance, and other psycholphsiological problems. The results may warn educators as well as parents of some of the unfavorable effects of these extracurricular activities.

Mitral insufficiency in an incomplete form of Marfan syndrome corrected with valve replacement.

A 14-year-old boy with an incomplete form of the Marfan syndrome developed an acute episode of severe congestive heart failure following exertion. The preoperative studies indicated a mitral insufficiency, and a floppy, thickened mitral valve was removed and replaced with a Starr-Edwards prosthesis. Microscopically, the valve showed increase in collagen with central myxomatous transformation. Seven months postoperatively the patient is doing well and has no symptoms of heart failure.