Ulcerous gastrointestinal bleedings

On the basis of the study of 2388 patients with chronic gastric and duodenal ulcers complicated by acute bleeding, the most disputable organizational and tactical issues of ulcer bleeding (UB) treatment are discussed. It is reasonable to divide surgery for UB into urgent, delayed and elective. Indications for different surgeries in UB and basic surgical principles are discussed. Severe blood loss is the main factor of general lethality. Combined conservative therapy must provide correction of posthemorrhagic tissue hypoxia, functional disorders, hemostatic disturbances and immunosuppression. Artificial transmitters of oxygen and infusion of antihypoxants are promising in management of UB. Antisecretory drugs are a necessary component of conservative treatment in UB. Therapeutic endoscopy is important in the treatment of acute UB, but it is not alternative to surgical hemostasis. It may be regarded as a method of temporary hemostasis before delayed for more than 2 hours operation or as a method of final hemostasis in combined conservative treatment, first of all in patients of "surgical risk" group.     

Utilization of intravenous glucose and fructose in the postoperative period.

A comparison is made between the utilization of glucose and fructose given intravenously at the rates of 1 g kg-1 h-1 and 0.5 kg-1 h-1 to 6 and 10 patients, respectively, who had undergone stomach surgery. Each patient served as his own control. The maximum rise in the total blood sugar concentration during both the rapid and the slow glucose infusions (227 mg% and 171 mg%) was significantly larger than during the fructose infusions (86 mg% and 52 mg%). The maximum rise in blood glucose of an average 23 and 18 mg% during the administration of fructose seems to indicate that only a small percentage of fructose is converted directly to glucose. Hypoglycemia after the infusions was most pronounced after the use of glucose. During the rapid infusions the patients lost a significantly larger amount of the infused sugar in the urine when glucose was administered (12.9% vs 4.7%), and the greater loss of sugar was accompanied by a greater loss of water. During the slow infusions there was no difference in sugar excretion between the two carbohydrates. At the infusion rate of 0.5 g kg-1 h-1 6 times as much lactate was excreted during the fructose infusions as during the glucose infusions (1.8 mg as compared with 0.3 mg lactate kg-1 infusion h-1). The study seems to indicate that there is a renal threshold for lactate at blood concentrations of 10-15 mg%.     

Anesthetic management of a hemophilia A patient with HIV infection: a case report

A 40-year-old male with hemophilia A was scheduled for right total knee arthroplasty. He was HIV positive probably due to receiving infected blood products previously. We performed the pharmacokinetic study of factor VIII in advance, which showed the increased factor VIII activity 1.6% by an injection of one unit. kg-1 of factor VIII and the half-life of about 16 hours. To keep the factor VIII activity over 100% in the perioperative period, 3000 units of recombinant factor VIII was injected one hour before the induction of anesthesia followed by continuous infusion at 125 units per hour. The factor VIII activity before the induction was 110.6%. The operation was successful and there was no sign of bleeding tendency. The factor VIII activity after the operation, however, was unexpectedly low (73.1%), and it was necessary to increase the infusion rate to 150 units per hour. The factor VIII activity was kept over 80% until POD 7 with the continuous infusion and over 60% until POD 21 with intermittent administration. Factor VIII was discontinued on POD 21 without any sign of bleeding tendency after the postoperative rehabilitation. Although this patient was HIV positive, his immune system was well controlled with HAART and there was no difficulty in the anesthetic management. To prevent accidental infection to the medical staff, we again recognized the importance of standard precautions.     

Regulation of whole-body leucine metabolism with insulin during mixed-meal absorption in normal and diabetic humans

To determine the effects of insulin on dietary and endogenous leucine metabolism, five normal subjects, seven insulin-insufficient insulin-dependent (IDDM) diabetic patients, and five diabetic patients controlled with continuous subcutaneous insulin infusion (CSII) were studied before and for 8 h after ingestion of a chemically defined elemental test meal (10 cal/kg) containing crystalline amino acids. L-[1-14C]leucine was included in the meal to trace the entry and oxidation of the dietary leucine. Total (meal + endogenous) entry of leucine into the circulation was estimated with a constant infusion of [2H3]leucine. Postabsorptive and meal-related increases in the plasma leucine concentration were greater (P less than .05) in the insulin-insufficient IDDM than in the normal subjects but returned to near-normal values with CSII. Baseline leucine flux was approximately 40% greater in the insulin-insufficient IDDM than in normal subjects (2.17 +/- 0.17 vs. 1.55 +/- 0.15 mumol.kg-1.min-1, respectively; .05 less than P less than .01) but were near normal during CSII treatment (1.85 +/- 0.25 mumol.kg-1.min-1). Furthermore, total leucine entry during meal absorption was greater in the insulin-insufficient IDDM (1.41 +/- 0.10 mmol.kg-1.8 h-1) than in either normal (0.96 +/- 0.08 mmol.kg-1.8 h-1, P less than .01) or IDDM subjects during CSII treatment (1.09 +/- 0.11 mmol.kg-1.8 h-1, P less than .05). Fractional oxidation (approximately 40-50%) and entry of dietary leucine were similar in all three groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recovery after anesthesia with propofol in otorhinolaryngologic surgery of brief duration

This study was designed to assess recovery from total intravenous anaesthesia with propofol for short ENT procedures. Twenty-six patients (ASA I and II) were assigned to two groups of thirteen: one breathed air (Laser laryngeal microsurgery), the second N2O-O2 (FIO2 : 0.5) (various ENT procedures). The induction sequence was exactly the same for both groups: oral premedication with 10 mg diazepam one hour before surgery, I mg pancuronium bromide, 2 micrograms X kg-1 fentanyl, denitrogenation within 3 min, after which propofol was delivered (2.5 mg X kg-1). When the eye-lash reflex had disappeared (time recorded), 1.5 mg X kg-1 suxamethonium was given and laryngotracheal intubation carried out. A continuous infusion of propofol (9 mg X kg-1 X h-1) was started. Surgery began 5 +/- 2 min after the start of propofol infusion. The durations of anaesthesia, surgery and propofol infusion were similar in both groups. To have good surgical conditions, it was necessary to give repeated doses of propofol for 15 patients. Thus, the total dose of propofol was significatively different between the two groups: 24.5 +/- 6.7 mg X kg-1 X h-1 in group "air" versus 16 +/- 3.6 mg X kg-1 X h-1 in group "N2O-O2" (p less than 0.001). Extubation occurred within 16 +/- 8 min in group "air", being more rapid in group "N2O-O2" (11 +/- 9 min; no significant difference). Recovery was assessed with two psychomotor tests: choice reaction time (CRT) and tracing test (TT).(ABSTRACT TRUNCATED AT 250 WORDS)     

Hemarthrosis in acquired hemophilia. Two case-reports

The many causes of hemarthrosis include acquired hemophilia due to production of autoantibodies to factor VIII. We report two very different cases. CASE 1: This woman experienced onset of juvenile idiopathic arthritis at 8 years of age. Her first child was born when she was 28-years-old. Three months after delivery, vaginal bleeding and recurrent hemarthrosis led to a diagnosis of acquired hemophilia (isolated APTT prolongation, 1% VIIIc activity, and 58 U of anti-factor VIII antibody). Treatment included glucocorticoid therapy, prothrombin complex, and intravenous immunoglobulins. She achieved a full recovery within a year. CASE 2: In this 84-year-old woman, spontaneous recurrent hemarthrosis with hematomas revealed idiopathic acquired hemophilia. Treatment included prothrombin complex, factor VIII concentrates, and intravenous immunoglobulins, followed by cyclophosphamide and glucocorticoid therapy. Recovery was complete within a year. The diagnosis, etiology, prognosis, and treatment of acquired hemophilia are discussed. CONCLUSION: Although rare, acquired hemophilia should be considered among the causes of hemarthrosis, particularly as a favorable outcome can be expected with early diagnosis and appropriate treatment.     

Perioperative management for hemicolectomy using propofol infusion in an elderly patient with a mechanical heart valve prosthesis

An 81-year-old female (145 cm, 39 kg) with a mechanical heart valve prosthesis underwent right hemicolectomy for cecal cancer under total intravenous anesthesia. She had received anticoagulation therapy [international normalized ratio (INR) 4.3] with warfarin for two years before surgery due to replaced aortic valve and atrial fibrillation. Three days before surgery warfarin was switched to heparin infusion (400 U.h-1) continued until 3 hours before the surgery. The activated partial thromboplastin time (APTT) was maintained above 1.5 times of the control (45 sec). Before induction of anesthesia, the activated clotting time (ACT) was 166 seconds. Following propofol infusion (50 ml.h-1; 38 mg) and vecuronium, anesthesia was maintained with propofol infusion (5.9 mg.kg-1.h-1), buprenorphine i.v. (0.08 mg) and appropriate doses of vecuronium. The total dose of propofol used was 950 mg. Heparin infusion (80 U.h-1) was restarted at the onset of surgery. Intraoperative ACT levels were between 148 and 156 seconds. However, at the end of surgery, APTT was prolonged (60.7 sec). Heparin infusion was reduced to 40 U.h-1 and APTT became normal 3 hours after the surgery. On the 4th postoperative day, heparin infusion was returned to 400 U.h-1 (APTT 32-38 sec). Two days after warfarin restoration on the 15th postoperative day, heparin was discontinued (INR 2.1-2.5). The thromboembolism and bleeding tendency did not occur. This case suggests that despite the suspected bleeding tendency via platelet inhibition under propofol infusion, the reduced heparin infusion can be continued with close coagulation monitoring.     

Maintenance of anaesthesia with propofol--a comparative study of a stepdown infusion of propofol and a low dose infusion supplemented by incremental doses.

Forty-four patients, ASA Grade I or II, had anaesthesia induced with propofol at 100 mg min-1 followed by a maintenance rate of 6 mg kg-1 h-1 or a stepdown regimen of 10 mg kg-1 h-1 for 10 min, 8 mg kg-1 h-1 for the next 10 min and at 6 mg kg-1 h-1 thereafter. Anaesthesia was maintained with propofol infused using an Ohmeda 9000 pump supplemented by nitrous oxide and oxygen (2:1) in a Bain circuit with spontaneous ventilation. Incremental doses of 20 mg of propofol were given to both groups as clinically indicated to maintain anaesthesia. Both methods provided satisfactory maintenance of anaesthesia but significantly more incremental doses were required in the group receiving the steady rate infusion. However, a lower cumulative dose was required up to 30 min in this group but not by 40 min. A comparable fall in systolic and diastolic blood pressure and heart rate was seen in both groups. There was no difference in the recovery times between the groups and the total dose did not correlate with time to recovery.     

Perioperative bleeding tendency in a hemodialysis patient during gastrectomy under total intravenous anesthesia using propofol infusion]

A 64-year-old female receiving hemodialysis (HD) underwent subtotal gastrectomy for gastric cancer under total intravenous anesthesia. Anesthesia was performed using continuous infusion of propofol (5-8 mg.kg-1.h-1), buprenorphine i.v. (2.5 micrograms.kg-1), 2% mepivacaine epidural infusion (7 ml.h-1) and appropriate doses of vecuronium. The blood pressure and heart rate were stable within 120% of the preoperative level. However, 3 and half hours after propofol anesthesia, increased bleeding from the surgical field was observed. The activated clotting time (ACT) was 144 seconds. Furthermore, at the end of the operation (5 hours after propofol anesthesia), the ACT (219 sec), PT (14.8 sec), PT-INR (1.94) and APTT (102.5 sec) were significantly prolonged. The platelet count was unchanged. The intraoperative total bleeding was 844 g. The total propofol infusion time and dose were 310 minutes and 1,580 mg, respectively. Immediate recovery with spontaneous ventilation was observed. Postoperative bleeding from the wound continued. Finally, 7 hours after the surgery, the bleeding ceased and the ACT (125 sec), PT (12.4 sec), PT-INR (1.34) and APTT (22.5 sec) were normalized. The total postoperative bleeding was 404 g. Despite the advantage of short-acting anesthetic agent, we suspect that propofol induced the bleeding tendency via platelet inhibition. This platelet inhibition may gradually increase with time and the dose of propofol. We should utilize propofol cautiously for patients receiving HD or with bleeding tendency.     

A rare hemostatic disorder: pseudo von Willebrand's disease

A case of pseudo von Willebrand's disease occurring in a 26 year old pregnant woman is reported. The diagnosis was made during the 33rd week of pregnancy. The patient had excessive bleeding of minor wounds, and biological tests revealed a bleeding time exceeding 20 min, a greatly reduced level of Rco fraction of von Willebrand's factor (27%), the absence of high molecular weight von Willebrand's factor multimers, and a greatly increased platelet aggregation in small doses of ristocetin. The patient was allowed to give birth by the vaginal route, receiving 30 IU.kg-1 highly purified concentrated factor VIII, once cervical dilatation was complete. Uterine revision was carried out for safety's sake because of prolonged post-partum bleeding. Two red cell packs were transfused as haemoglobin concentration decreased from 106 g.l-1 to 80 g.l-1. The newborn also presented with biological signs of pseudo von Willebrand's disease, with a bleeding time exceeding 15 min, hypothrombocytopaenia, and a level of Rco fraction of von Willebrand's factor of 9%. Preoperative assessment should always include an investigation of primary haemostatic mechanisms. In case of pseudo von Willebrand's disease, platelet transfusion combined or not with the transfusion of highly purified factor VIII seems to be useful. Investigation of other family members for a pseudo von Willebrand's disease trait is essential.     

Branched chain amino acids as the protein component of parenteral nutrition in cancer cachexia

A prospective randomized trial was conducted to determine the effects of branched chain amino acids (BCAA) as the protein component of total parenteral nutrition (TPN) on protein kinetics in patients with intraabdominal adenocarcinoma. Nine malnourished patients were given both conventional TPN containing 19 per cent BCAA (AA) and isocaloric, isonitrogenous TPN containing 50 per cent BCAA (BCAA-TPN), in random order. Both [13C]leucine and [14C]tyrosine were employed as tracers to avoid the potential bias due to the different amino acid composition of the two TPN solutions. With BCAA-TPN, leucine and tyrosine flux increased significantly from (mean +/- s.d.) 158.0 +/- 37.2 to 243.5 +/- 75.8 mumol kg-1 h-1 (P less than 0.025) and from 35.0 +/- 8.4 to 42.6 +/- 11.0 mumol kg-1 h-1 (P less than 0.05) respectively. Leucine oxidation was significantly higher on BCAA-TPN (24.1 +/- 6.3 on AA versus 68.3 +/- 37.1 mumol kg-1 h-1, P less than 0.025) while tyrosine oxidation was significantly lower (3.7 +/- 1.8 mumol kg-1 h-1 on AA versus 2.5 +/- 2.0 mumol kg-1 h-1 on BCAA-TPN, P less than 0.05). Whole body protein synthesis and breakdown was significantly higher on BCAA-TPN by the tyrosine tracer (31.3 +/- 7.3 on AA versus 40.1 +/- 9.3 mumol kg-1 h-1, P less than 0.025 and 33.0 +/- 8.4 on AA versus 41.3 +/- 11.1 mumol kg-1 h-1, P less than 0.05) respectively. Using the leucine tracers both synthesis and breakdown were increased, but not significantly, from 133.8 +/- 40.0 to 175.3 +/- 65.1 mumol kg-1 h-1 and from 127.9 +/- 33.6 to 167.7 +/- 71.2 mumol kg-1 h-1 respectively. The fractional albumin synthetic rate increased significantly on BCAA-TPN from 4.3 +/- 2.9 on AA to 8.0 +/- 5.1 per cent per day (P less than 0.05). The reduction in tyrosine oxidation, suggesting improved protein utilization, coupled with an increase in protein and albumin synthesis, strongly support a positive benefit from BCAA-TPN in cancer cachexia.     

Continuous epidural infusion of bupivacaine and morphine for postoperative pain relief

Forty-five patients admitted to the intensive care unit following thoracic or abdominal surgery received continuous epidural infusion of bupivacaine and morphine for 48 hours. During the first 10 hours, the patients received 0.25% bupivacaine solution with 0.005% morphine at the rate of 4 ml.h-1, and bupivacaine concentration was decreased to 0.125% with the same morphine concentration. The mean infusion rate of bupivacaine during 48 hours was 0.12 +/- 0.03 (SD) mg.kg-1.h-1 and that of morphine was 4.0 +/- 1.0 micrograms.kg-1.h-1. Thirty-one patients (69%) complained no pain on deep breathing at 24 hours and 33 patients (74%) required no other type of analgesics during this study. The mean plasma bupivacaine concentration was 0.6 +/- 0.3 microgram.ml-1 at 48 hours. Hypotension defined as systolic arterial pressure below 90 mmHg and itching were observed in 15 patients (33%), but no other severe side effects were noted. Continuous epidural infusion of bupivacaine and morphine mixture for 48 hours postoperatively provided effective pain relief with a low incidence of side effects.     

Slipped upper femoral epiphysis with hemophilia A

A 13-year-old boy who had hemophilia A was reported with pain in the left thigh and hip on walking. He had no history of trauma. Severe hemophilia A is diagnosed with a Factor VIII level of <1 iu/dl. The presumptive diagnosis was that of a spontaneous bleed into the hip joint. Factor VIII mutational analysis revealed a C to G substitution at nucleotide 6683 which results in a cystine change at codon 2194. However, the symptoms persisted and an X-ray demonstrated the presence of an acute on chronic slip of the upper femoral epiphysis. The patient was transferred to the center treating his hemophilia where the hip was pinned in situ under cover with Factor VIII. This case demonstrates the need to be aware of a possible traumatic diagnosis of hip pain in a hemophiliac child with a longstanding history of spontaneous bleeding into joints.     

Spontaneously acquired anti-factor VIII antibodies: report of a patient with adenocarcinoma of the prostate

Anti-factor VIII antibodies, inherited or acquired inhibitors of the factor VIII molecule, have not been reported previously in the urological literature. Although more common in hemophiliac patients who have received multiple transfusions, this anticoagulant may be the cause of severe hemorrhage in nonhemophiliac patients. We describe a patient with carcinoma of the prostate and an unsuspected anti-factor VIII antibody, who experienced excessive postoperative bleeding and prolonged hospitalization following a vesicolithotomy and bilateral orchiectomy. A prolonged partial thromboplastin time and a significant decrease in measurable factor VIII clotting activity in a patient with no history of bleeding problems are essential clues in making the diagnosis of a factor VIII inhibitor. This coagulation defect is treated best with prothrombin complex concentrates, which contain vitamin K dependent clotting factors.     

Sustained factor VIII expression after in utero gene therapy

Objective. FVIII deficiency is an excellent gene therapy model because it is a single gene defect with a broad therapeutic window. One 5% correction of FVIII levels can prevent spontaneous bleeding episodes, and a number of experimental animal models exist. Current gene therapy approaches are limited by immune reaction to the gene product and viral proteins, and the need for multiple administrations. In this study, we investigate whether in utero administration of AAV or lentiviral vectors containing the Factor VIII gene would overcome these obstacles and allow sustained expression. Methods. AAV and lentiviral vectors containing a canine Factor VIII construct with an upstream liver-specific promoter were generated. Fourteen-day gestation fetuses of Factor VIII deficient mice were injected intraperitoneally or intravenously with AAV2/8 serotype vector or VSV-g pseudotyped lentiviral vector. Canine Factor VIII levels in plasma have now been assessed at monthly intervals up to 8 months after in utero treatment. FVIII levels are expressed as the percentage of canine plasma Factor VIII activity in knockout mouse serum. Results. In utero injections with AAV and lentiviral constructs resulted in 33 and 68% survival rates to weaning, respectively, with the differences related to known technical issues. Approximately 45% (5/11) of mice injected with the AAV vector had greater than 1% FVIII at 4 weeks, with a mean of 3.8 ± 2.0%. These levels remained stable for up to 8 months after injection. In addition 53% (9/17) of mice given the lentiviral construct showed FVIII levels greater than 1% with a mean of 1.0 ± 0.1%, with levels remaining stable for 6 months. Conclusions. In utero gene delivery of Factor VIII of AAV or Lentiviral vectors results in durable, postnatal plasma levels of Factor VIII protein in a murine model of Hemophilia A. Further optimization of dosage, titer, route of administration (intravenous versus intraperitoneal), and viral constructs are being investigated to achieve higher levels of expression. However, the sustained expression demonstrated in this study supports the promise of prenatal gene transfer.     

Acute renal failure as a complication of acquired hemophilia due to autoantibody to factor VIII

A 53-year-old Japanese woman, without any specific medical or family history, was admitted to our hospital for acute renal failure with macrohematuria. Routine blood analysis, including blood coagulation test, revealed azotemia accompanied by prolonged activated partial thromboplastin time (aPTT). Computed tomography revealed bilateral kidney swelling with dilatation of the renal pelvis. An extensive coagulation analysis revealed that the concentration of factor VIII had decreased to 1.8% and the level of factor VIII inhibitor was markedly elevated to 19 BU/ml. The final diagnosis was acquired hemophilia induced by autoantibodies against factor VIII, which was complicated by postrenal acute renal failure due to the obstruction of urinary tracts by renal bleeding and clots. The patient was treated with a combination of prednisolone at a dose of 50 mg/day (1 mg/kg body weight) and cyclophosphamide. The levels of factor VIII inhibitor decreased gradually, and the activity of factor VIII was improved after treatment. The levels of aPTT and concentrations of factor VIII and factor VIII inhibitor were monitored during the subsequent follow-ups.     

Propofol emulsion for induction and maintenance of anaesthesia. A combined technique of general and regional anaesthesia

To provide general anaesthesia with endotracheal intubation during regional blockades, three dose regimens of propofol emulsion were studied: induction 2 mg kg-1, infusion rate 9 mg kg-1 h-1 (Group 1); induction 2.5 mg kg-1, infusion rate 12 mg kg-1 h-1 (Group 2); induction 2.5 mg kg-1, infusion rate 9 mg kg-1 (Group 3). Each group comprised 10 healthy (ASA class 1 or 2) unpremedicated patients. The induction times measured from the start of injection until counting ceased (+/- 50 s) and until eye-lash reflex disappeared (+/- 80 s) showed no statistical differences between groups. In five patients in Group 1 and one patient in each of Groups 2 and 3 the induction dose was too low for intubation. Pain on injection was seen in 13 cases (mild 6, moderate 6 and severe 1). Cough accompanied by hypersalivation was the most important side-effect. Recovery times varied widely and showed no statistical differences. Answering simple questions was possible after 14 min in Group 1, 23 min in Group 2 and 19 min in Group 3. Apart from a short period of euphoria, recovery was uneventful. There was no tendency to fall asleep again. None of the combinations of induction doses and infusion rates provided good anaesthesia conditions for an acceptable number of patients.     

The maximum safe dosage of the low molecular weight hydroxyethyl starch, HESPANDAR (HES), estimated from HES induced changes in coagulation parameters and clinical bleeding

The effects of hydroxyethyl starch on the coagulation system have received attention, and safe dosage of high molecular weight hydroxyethyl starch is generally found to be 20 ml.kg-1. Low molecular weight hydroxyethyl starch, HESPANDAR (HES), seems to induce weaker specific effects on blood coagulation than high molecular weight hydroxyethyl starch. The aims of this study are to estimate the maximum safe dosage of HES, and to investigate the etiology for coagulopathy induced by HES. Forty three patients (18 to 75 years old) who were free of bleeding disorders scheduled for abdominal operations received 20, 30, or 40 ml.kg-1 of HES. We measured coagulation parameters of them including platelet, hematocrit, total protein, activated partial thromboplastin time, prothrombin time and Factor 8, and observed the evidence of clinical microbleeding. As the HES was infused, the values of coagulation parameters except Factor 8 changed with blood dilution. Factor 8 decreased more than expected from the values calculated for hemodilution. The evidences of clinical microbleeding were observed when patients had received HES more than 30 ml.kg-1. The decrease of Factor 8 and the observed tendency of clinical microbleeding showed a significant positive relationship (P = 0.0002). We conclude from our results that the maximum safe dosage of HES is about 30 ml.kg-1, and HES may affect blood coagulation by lowering the plasma concentration of Factor 8.     

Acquired hemophilia, meningioma, and diphenylhydantoin therapy

A patient is reported in whom a meningioma of the lateral one-third of the sphenoid ridge was completely removed and long-term prophylaxis for seizures with diphenylhydantoin was prescribed. One and a half years later, a powerful inhibitor developed that specifically neutralized Factor VIII, the antihemophilic factor, and caused an acquired state of hemophilia. The 4-month hemorrhagic disorder was characterized initially by painless hematuria and later by intracerebral and extradural hematomas at the operative site of the previously excised meningioma. Despite the transfusion of massive quantities of concentrates of clotting factors, and the surgical evacuation of the recurrent hematomas on two occasions, the localized bleeding could not be staunched and the patient died. The types of inhibitors that cause acquired hemophilia and their modes of treatment are examined. Although it is possible that the Factor VIII inhibitor in this patient was induced by the meningioma, most previously reported tumors associated with acquired hemophilia have had an immunological basis. The most probable explanation for the acquired hemophilia in this patient was an inhibitor to Factor VIII from an autoantibody induced by the long-term use of diphenylhydantoin.     

Epinephrine decreases plasma potassium

The effects of epinephrine infusion on plasma potassium were examined in rats. Potassium infusion (1 mEq.kg-1.h-1 over 2 hours) elevated plasma potassium 4.23 mEq.l-1. Insulin (0.064 U.kg-1.h-1) combined with glucose (0.32 g.kg-1.h-1) or epinephrine (0.05, 0.1, 0.5, 1, or 5 micrograms.kg-1.min-1) added to potassium infusion significantly depressed the increments of plasma potassium levels. Epinephrine infusions (0.05 or 0.1 microgram.kg-1.min-1) were more effective than insulin infusion combined with glucose. These results suggest that epinephrine infusion may be useful for the control of hyperkalemia.