Bronchovascular cuff formation and lung lymph flow in edema formation of anesthetized sheep.

The relationship between bronchovascular cuff formation and lung lymph flow in hydrostatic edema was evaluated. After a balloon was inserted into the left atrium to increase left atrial pressure for 5 hrs, peripheral lung tissues were resected for analysis of the wet-dry ratio and cuff formation. The degree of cuff formation was expressed as the cuff ratio (outer diameter of cuff/outer diameter of microvessel or airway) in three size categories: 80-200, 200-400, and 400-750 microm in diameter. The amount of excess lung lymph (Ex LL) for 5 hrs was calculated from the recorded data for the whole lymph flow wave. The wet-dry ratio showed a significant correlation with ALAP and lung lymph flow increased significantly (flow rate, 0.67 +/- 0.46 ml/min (mean +/- SD); Ex LL, 56.4 +/- 47.6 ml). Cuff formation was found at all levels of the bronchovascular tree, with a larger cuff ratio (> 1.3) observed at arteries and veins of 80-200 microm in diameter, but a significant correlation with Ex LL was found only for arteries of 80-200 microm. Fluid accumulation in lung interstitium first occurred at smaller extra-alveolar arteries even under mild hydrostatic pressure elevation with a significant increase in lymph flow.

New method for evaluation of lung lymph flow rate with intact lymphatics in anaesthetized sheep.

AIM: Lung lymph has commonly been studied using a lymph fistula created by tube cannulation into the efferent duct of the caudal mediastinal node in sheep. In this method, the tail region of the caudal mediastinal node is resected and the diaphragm is cauterized to exclude systemic lymph contamination, and cannulation is performed into one of the multiple efferent ducts originating from the caudal mediastinal node. Moreover, the pumping activity of lymphatics might be diminished by cannulation. Therefore, the purpose of the study was to evaluate the flow rate of lung lymph with maintenance of intact lymphatic networks around the caudal mediastinal node to the thoracic duct in sheep. METHODS: An ultrasound transit-time flow meter was used to measure lung lymph flow. The thoracic duct was clamped just above the diaphragm and the flow probe was attached to the thoracic duct just after the last junction with an efferent duct from the caudal mediastinal node. The lung lymph flow rate was measured at baseline and under conditions of lung-oedema formation. RESULTS: The baseline lung lymph flow rate in our model was three- to sixfold greater than values obtained with the cannulation method. With oedema-formation, the lung lymph flow rate was the same as that measured using cannulation. CONCLUSION: The lung lymph flow was unexpectedly large under the conditions of the study, and our data suggest that the drainage effect of lymphatics is significant as a safety factor against pulmonary oedema formation.

Background values for evaluation of heavy metal contamination in sediments.

The contamination of sediments can be evaluated from comparison of the current concentration with the estimated background value. Although it is known that grain size affects background concentrations, there have been difficulties in evaluating this effect. The specific surface area of sediments, which can be calculated from the grain size distribution, is introduced as a property index for correlation of background values. The results show that for sandy-to-sandy silt sediments, the background values of metals are expressed in terms of fines content, which can be correlated with the corresponding specific surface area. However, for silty clay or clayey silt sediments, which would have a high metal retention capacity, the level of the background may be constrained by the relatively low concentrations of metals in seawater. Finally, background levels of Zn, Cu and Pb are presented.

Incarcerated paraesophageal hernia associated with perforation of the fundus of the stomach: report of a case.

We report herein a case of incarcerated paraesophageal hernia associated with perforation of the fundus of the stomach. A 71-year-old woman was transferred to our hospital after a diagnosis of gastrointestinal tract perforation had been made at a local hospital. Her history included an esophageal hiatal hernia. A laparotomy was performed which revealed that the antrum of stomach and the duodenal bulb had prolapsed into the esophageal hiatus and become incarcerated. This prolapse had caused stenosis in the corpus of the stomach, resulting in distension of the oral side of the stomach and thinning of the wall. A perforation, 15 mm long, was recognized in the major curvature of the fundus. The patient suffered respiratory failure postoperatively, necessitating respiratory support for 1 week. She was discharged on postoperative day 40. This case report serves to demonstrate that because of the very serious complications that may result from an untreated paraesophageal hernia, elective repair should be performed wherever possible even in asymptomatic patients.

[Cost accounting for gastrectomy under critical path--the usefulness of direct accounting of personnel expenses and a guide to shortening hospital stay].

In this study, cost accounting was made for a surgical case of gastrectomy according to critical path (path) and the economic contribution of the path was determined. In addition, changes in the cost percentage with changes in number of hospital days were simulated. Basically, cost accounting was done by means of cost accounting by departments, which meets the concept of direct cost accounting of administered accounts. Personnel expenses were calculated by means of both direct and indirect calculations. In the direct method, the total hours personnel participated were recorded for calculation. In the indirect method, personnel expenses were calculated from the ratio of the income of the surgical department to that of other departments. Purchase prices for all materials and drugs used were recorded to check buying costs. According to the direct calculating method, the personnel expenses came to approximately 300,000 yen, total cost was approximately 700,000 yen, and the cost percentage was 59%. According to the indirect method, the personnel expenses were approximately 540,000 yen and the total cost was approximately 940,000 yen, the cost percentage being 80%. A simulation study of changes in the cost with changes in hospital days revealed that the cost percentages were assessed to be approximately 53% in 19 hospital days and approximately 45% in 12 hospital days.

Plasma levels of cyclic GMP, immune parameters and depressive status during interferon therapy. A prospective study in Japan.

In this report, we investigated the relationship between depressive symptoms and plasma interferon (IFN)-alpha-like immunoreactivity, cyclic GMP (cGMP) and soluble interleukin-2 receptor (sIL-2R) levels during IFN therapy. An altered mood state was observed in 5 of 26 patients. IFN-alpha-like immunoreactivity in the depressed group tended to be elevated. cGMP levels of depressed patients were significantly greater than those of control subjects before and 6 weeks after IFN therapy. However, sIL-2R levels were not different between the two groups. These results suggest that a number of patients suffered from depression during IFN therapy and that patients had greater concentrations of cGMP levels.

Usage of haloperidol for delirium in cancer patients.

Although haloperidol is mainly used for the medical treatment of delirium in cancer patients, there are no universally accepted guidelines for its usage. We accordingly assessed the usefulness in managing delirium of a haloperidol treatment regimen in ten delirious cancer patients. The results of this preliminary study suggest that, in the management of delirium, appropriate usage of haloperidol on the first day is important as it affects the dosage thereafter.

Bronchial vascular reabsorption of low-protein interstitial edema liquid in perfused sheep lungs.

Previously, we quantified reabsorption of interstitial pulmonary edema liquid into the pulmonary circulation during recovery from hydrostatic edema. To determine whether the bronchial circulation also reabsorbs edema liquid, we induced very-low-protein interstitial edema in seven sheep lungs by perfusion of the pulmonary circulation with diluted blood and 1% albumin in Krebs-Henseleit buffer containing 125I-labeled albumin for 70 +/- 40 min. In eight control sheep we perfused the lungs with diluted blood and 5% albumin in Krebs-Henseleit buffer containing 125I-albumin without causing significant edema formation. Subsequently, we washed the intravascular tracer from the pulmonary circulation with buffered saline and then perfused the bronchial vessels via the bronchoesophageal artery with whole or diluted blood (normal protein osmotic pressure). We measured flow, hematocrit, and 125I-albumin concentration in the venous outflow into the left atrium and into the azygos vein for 2 h. We calculated the volume of liquid reabsorbed on the basis of the change in hematocrit and 12I-albumin concentration in the outflow. On the basis of hematocrit dilution, the net clearance of interstitial liquid (edema minus control) averaged 21 ml (15% of the induced edema). One the basis of 125I-albumin reabsorption, the net clearance of interstitial liquid was 12 ml. We conclude that the bronchial circulation may be a clearance route for interstitial liquid and protein during recovery from low-protein hydrostatic edema.

A survey of Japanese physicians' attitudes and practice in caring for terminally ill cancer patients.

To clarify the psychiatric liaison issues in cancer care, questionnaires were distributed to physicians at 31 teaching hospitals in Japan, including cancer centers and psychiatrists at 197 teaching hospitals. Data from 329 physicians and 156 psychiatrists showed that the majority of the physicians felt troubled by the psychiatric problems of terminally ill patients. However, actual psychiatric referrals were infrequent. An important factor that interferes with appropriate psychiatric referrals for cancer patients is that most physicians do not usually inform patients of a cancer diagnosis. This, it seems that close communication between physicians and psychiatrists is essential in caring for terminally ill cancer patients in the context of Japanese culture, when the psychiatric consultations are offered.

Psychiatric liaison issues in cancer care in Japan.

To clarify the psychiatric liaison issues in Japan, this paper briefly introduces a survey of physician attitudes and practices regarding cancer care in Japan and preliminarily reports on an "active" liaison program developed at one Japanese general hospital. The survey of physicians from 31 teaching hospitals, including all cancer centers, revealed that 56% of physicians do not inform patients of a diagnosis of cancer. Thus, actual psychiatric consultation referrals were very few due to the physician's fear of harming his relationship with the cancer patient. One medical unit, in which about one-quarter of the cancer patients were told their diagnoses by the unit chief physician, showed significantly higher rates of psychiatric consultation after the introduction of an "active" liaison program in that hospital. These results suggest that the liaison program can positively influence the rate of psychiatric consultation referrals for cancer patients when the physician discloses the diagnosis to the patient. Consultation-liaison psychiatry in cancer care is expected to develop in Japan, because most physicians report a trend toward informing patients of their cancer diagnosis.

Recovery from increased pressure or increased leakiness edema in perfused sheep lungs.

Two routes by which interstitial pulmonary edema liquid may leave the lung during recovery are reabsorption into the pulmonary circulation and clearance by lung lymphatics. We hypothesized that reabsorption of edema liquid of low protein concentration into the pulmonary circulation would be greater than reabsorption of edema liquid of high protein concentration because of the greater protein osmotic gradient in the former. On the basis of previous studies, lymph flow should contribute minimally to the recovery. In 22 in situ perfused sheep lungs with lymph fistulas, we produced approximately 100 g of osmotic or hydrostatic edema (low protein) or increased leakiness edema by calcium depletion (high protein). To induce reabsorption, we changed the perfusate from low- (1% albumin, osmotic pressure = 4 cmH2O) to high-protein (7% albumin, osmotic pressure = 22 cmH2O) solution in the osmotic group, decreased capillary pressure from 29 +/- 9 to 11 +/- 6 cmH2O in the hydrostatic group, or reversed leakiness by adding CaCl2 to the perfusate in the increased leakiness group. Reabsorption occurred only during recovery from osmotic (40 +/- 22% of filtered liquid) and hydrostatic (15 +/- 11%) edema. Total lung lymph flow during recovery from osmotic, hydrostatic, or increased leakiness edema was 4.9 +/- 3.4, 4.3 +/- 3.4, or 3.5 +/- 1.9 g, respectively. We conclude that during recovery from pulmonary edema interstitial liquid is reabsorbed into the circulation in inverse proportion to its protein concentration. We confirm that only a small fraction of the interstitial edema liquid is cleared by the lymphatics during recovery from any type of edema.

Effects of endothelin-1 and conversion of big endothelin-1 in the isolated perfused rabbit lung.

We examined the effects of endothelin-1 (ET-1) on pulmonary hemodynamic and transvascular fluid filtration and the conversion of big endothelin-1 (big ET-1), a precursor of ET-1, in isolated perfused rabbit lungs at constant vascular and airway pressures. Furthermore we examined whether ET-1 contributes to cyclooxygenase metabolism. The perfusate flow decreased significantly after bolus administration of 1 or 0.1 nmol of ET-1. Lung weight did not increase throughout the experimental period. Big ET-1- (1 nmol) induced decrease in the flow was slow in developing, although the maximum response was comparable to that induced by the same dose of ET-1. The concentration of bit ET-1 in the perfusate progressively decreased, while that of ET-1 increased in a time-dependent manner. Phosphoramidon, an inhibitor of metalloproteinase, suppressed the pressor effect of big ET-1 (P less than 0.01) and the increase in the concentration of ET-1 in the perfusate (P less than 0.05). The present findings provide the first evidence suggesting that the potent vasocontractile effect of big ET-1 in pulmonary circulation can be attributed to the production of ET-1 by the conversion from big ET-1 in the vascular bed. ET-1-induced perfusate flow changes were not affected by indomethacin, and the concentration of 6-ketoprostaglandin F1 alpha, a metabolite of prostacyclin, did not increase after ET-1 administration.

[Evaluation of postoperative pulmonary complications and remaining pulmonary arterial flow of lobectomized lung cancer patients using pulmonary digital subtraction angiography].

Postoperative pulmonary complications cause the decrease of the flow of remaining pulmonary circulation. We examined the effects of the difference of resected lobes on the postoperative course and remaining pulmonary circulation of the lobectomized lung cancer patients using a pulmonary digital subtraction angiography. In all cases with preoperative pulmonary complications, circulatory flow of the remaining lung on the operated side significantly decreased. In the cases without preoperative pulmonary complications, only the cases performed left upper lobectomy developed the decrease of the circulatory flow on the operated side. This seemed to be chiefly caused by a postoperative continual atelectasis of the remaining lower lobe due to kinking of the bronchus. On the other hand, the postoperative decrease of the residual pulmonary circulatory flow on the operated side was not developed in the cases undergoing a segmentectomy, even with pulmonary complications. Therefore, for any case requiring a left upper lobectomy or the case with an impaired lung requiring any type of lobectomy, contralateral pulmonary function should be exactly evaluated preoperatively.

[Bronchopleural fistula after pulmonary resection of lung cancer].

From 1977 to 1988, 390 cases of lung cancer were resected in our hospital. In 12 patients (3.1%) a postoperative bronchopleural fistula developed. This complication occurred more commonly after right pulmonary resection than left and most common after right pneumonectomy. Moreover, that had occurred following right pneumonectomy was most fatal. After right middle and lower lobectomy, this complication occurred at the same rate as after pneumonectomy and also caused a fatal result. On the other hand, after the resection of single lobe, the rate of the occurrence of a bronchopleural fistula was lower. And, even if it had developed, the fistula sometimes could be healed by a conservative treatment only. In one of our cases the fistula was successfully treated by intra-bronchial gluing through a bronchofiberscope.

Hypoproteinemia related with chronic lithium therapy in two patients.

We present here two cases of reversible hypoproteinemia which could have occurred as an adverse effect of chronic lithium administration. In the present cases, protein losing a renal dysfunction, liver dysfunction and malabsorption syndrome were not observed, and the relationship between their dietary volume and serum protein levels was poor. The mechanism of hypoproteinemia in these cases was not identified from previously obtained data. We suggested that this type of hypoproteinemia might be a new adverse effect of lithium.