Evaluation of conventional weaning criteria in patients with acute respiratory failure

We evaluated the reliability of conventional weaning criteria from a ventilator during 33 weaning trials on 25 patients with acute respiratory failure (ARF). Of 13 criteria, a ratio of maximal voluntary ventilation to minute ventilation (MV) 2, a vital capacity 12ml·kg^–1, a spontaneous respiratory rate 25 breaths·min^–1, and a MV 10l·min^–1 appeared to be useful for predicting successful weaning outcome. However, even using those criteria, there were many falsely-negative cases. The alveolar-arterial P_{O 2} gradient 350mmHg at an Fi _{O 2} 1.0 was not useful as a predictor of weaning outcome. The present study demonstrates that conventional criteria are frequently inaccurate for predicting weaning outcomes and suggests that the use of some of these criteria may unnecessarily prolong the length of ventilator support. Since ventilation of most patients with poor oxygenation can be successfully discontinued by placing them on a continuous positive airway pressure system, these results suggest that the improvement of oxygenation is not an indispensable prerequisite for weaning from mechanical ventilators.(Okamoto K, Iwamasa H, Dogomori H, et al.: Evaluation of conventional weaning criteria in patients with acute respiratory failure. J Anesth 4: 213–218, 1990)     

A case of dermatofibrosarcoma protuberans in the skin over the breast

Dermatofibrosarcoma protuberans (DFSP) is a slow-growing but locally aggressive, fibrous tumor that has a high rate of local recurrence after surgical resection. This tumor occurs most commonly in the trunk and proximal extremities. In this report we present a case of dermatofibrosarcoma protuberans in the skin over the breast which was re-excised after pathological diagnosis, considering cosmetic aspects. Only three other cases of dermatofibrosarcoma protuberans of the anterior chest wall have been encountered in our hospital, and all of these cases were male. The presence of this tumor in the skin over the breast appears to be rare in females. Careful complete resection is recommended for this type of tumor.     

Expression of p-glycoprotein in the normal colorectal epithelium and in colorectal-carcinoma

Expression of P-glycoprotein (pgp) was analyzed by immunohistochemical staining with monoclonal antibody JSB-1 in 145 frozen specimens (67 were samples of normal colorectal mucosa from sites adjacent to the tumor, 66 were colorectal carcinomas, 5 colorectal polyps, 5 metastatic lymph nodes, and 2 samples of metastatic liver tumors) of 67 patients with colorectal carcinoma and polyps. All 72 specimens of normal colorectal mucosa and adenomatous polyps expressed pgp to various degrees. By contrast, 18 of 39 (46.2%) samples from cases of well differentiated adenocarcinoma were positive for pgp but only 3 of 21 (14.3%) samples from cases of moderately differentiated adenocarcinoma and none of the 4 samples from cases of poorly differentiated adenocarcinoma were positive for pgp. There was no correlation between the clinicopathological stage of colorectal carcinoma and the expression of pgp. These findings indicate that the expression of P-glycoprotein is closely related to the differentiation of cells. In normal colorectal epithelium, pgp was expressed normally and in well differentiated adenocarcinomas, pgp was still expressed. However, expression of pgp was no longer detectable in carcinomas with moderate or poor differentiation.     

Handlebar hernia with intra-abdominal extraluminal air presenting as a novel form of traumatic abdominal wall hernia: Report of a case

An 18-year-old male was admitted to our Emergency Department with a traumatic abdominal wall hernia (TAWH) of the left lower quadrant (LLQ) after suffering hypogastric blunt injury and urogenital lacerations in a motorcycle accident. Upright chest X-ray showed a small amount of right infradiaphragmatic free air, and a computed tomographic (CT) scan demonstrated an abdominal wall hernia. At surgery, no impairment was found in the digestive tract, and an abdominal herniorrhaphy was performed. It is suggested that the free air had passed through a connection between the scrotal laceration and the contralateral abdominal defect via the subcutaneous space and was palpated as emphysema. This is a new type of TAWH, which suggests that blunt abdominal trauma may result in negative pressure in the subcutaneous and peritoneal cavity, and this could reflect the pathophysiology of TAWH.     

Vasomotor control of the pulmonary circulation]

It was demonstrated that pulmonary vessels, in contrast to systemic vessels, 1) have a low basal vascular tone, 2) constrict in response to hypoxia and 3) do not display significantly prominent vasomotion during autonomic nerve stimulation. However, details about these characteristics have not been clarified sufficiently by conventional methods; namely, measuring pressure-flow relationships and vascular tension of isolated larger conduit pulmonary vessels. Recent technological advances in studying pulmonary circulation now permit us to reveal that vasomotor responses to respiratory gases and neurohumoral factors differ not only quantitatively but also qualitatively between the central conduit and peripheral resistance vessels (approximately 100- to 500-micron diam.). They also reveal that an increase in pulmonary sympathetic nerve activity can cause pulmonary vasodilation as well as vasoconstriction. The former has been partly explained by the most recent findings regarding the distribution differences of NO synthases and K+ channels between the resistance and conduit vessels. Concerning the latter, initial vascular tone appears to play an important role. The increased pulmonary sympathetic nerve activity has a beta-receptor-mediated pulmonary vasodilator effect under low pulmonary vascular tone conditions but an alpha-receptor-mediated constrictor effect under enhanced vascular tone conditions. This may serve to maintain homeostasis of the pulmonary circulation and a good balance between the right and left ventricle outputs. Here, I have reviewed new developments related to the mechanisms for controlling pulmonary vascular tone under different states: normal, acute and chronic hypoxia, and hemorrhagic hypotension. I have also described the effects of inhaled NO and PGI2 as selective pulmonary vasodilators used for pulmonary hypertension.     

Metabolism-dependent hepatotoxicity of methimazole in mice depleted of glutathione.

Methimazole (MMI) (>0.1 mmol kg(-1), p.o.) given in combination with DL-buthionine sulphoximine (BSO) (3 mmol kg(-1), i.p., 1 h before MMI administration), an inhibitor of glutathione (GSH) synthesis, caused liver injury in mice. The injury was characterized by centrilobular necrosis of hepatocytes and an increase in serum alanine transaminase (ALT) activity. Methionazole (2 mmol kg(-1)) alone resulted in only a marginal increase in serum ALT activity, but produced no histopathological changes in the liver. Pretreatment with hepatic cytochrome P-450 monooxygenase inhibitors--cobalt chloride, isosafrole, methoxsalen, metyrapone and piperonyl butoxide-prevented or tended to suppress the hepatotoxicity induced by MMI in combination with BSO. Treatment with N,N-dimethylaniline and ethyl methyl sulphide, competitive substrates of flavin-containing monooxygenases (FMO), also resulted in remarkable suppression of the hepatotoxicity caused by MMI in combination with BSO. These results suggest that MMI is activated by reactions mediated by both cytochrome P-450 monooxygenases and FMO, and that the inadequate rates of detoxification of the resulting metabolite are responsible for the hepatotoxicity in GSH-depleted mice.     

Lectin bindings in non-neoplastic esophageal epithelium and esophageal carcinomas

Lectin binding was examined histochemically in 22 cases of primary esophageal carcinomas (10 well differentiated, 8 moderately differentiated and 3 poorly differentiated squamous cell carcinomas, and 1 undifferentiated carcinoma) and was compared with the adjacent non-neoplastic epithelium by means of a panel of 10 different lectins (RCA-I, WGA, Con A, LCA, SEA, UEA-I, HPA, PNA, DBA and GS-I) on formalin-fixed paraffin-embedded sections. In the non-neoplastic epithelium, RCA-I and WGA showed basal/parabasal binding, Con A, LCA, SEA, UEA-I, HPA and PNA revealed prickle cell binding, while DBA and GS-I only stained the surface cells of the squamous cell layer. In squamous cell carcinomas, no clear difference was evident regarding the grade of differentiation. However, basal/parabasal specific lectins were expressed in all the cases, the prickle cell-specific lectins were expressed less frequently, whereas lectins expressed at the surface cells of the squamous cell layer were only infrequently expressed. Therefore, basal/parabasal cell specific lectins were widely preserved in squamous cell carcinomas. One case of undifferentiated cancer tested was devoid of all the lectins.     

Distribution of diaphragm blood flow during sevoflurane anaesthesia in dogs

Purpose

The purpose of this study was to determine the effect of increasing the concentrations of sévoflurane anaesthesia on the distribution of diaphragm blood flow (Qdi) in ten dogs during mechanical ventilation.

Methods

Animals were divided into two groups, sévoflurane (n = 6) and time control (n = 4) groups. Blood flow to the crural and the costal diaphragm (Qcru, Qcost) was determined by the hydrogen clearance technique at 0, 0.5, 1.0 and 1.5 minimum alveolar concentration (MAC) of sévoflurane after a 30 min period of steady-state conditions. Cardiac output (CO) and the mean arterial blood pressure (MBP) were also measured.

Results

Sevoflurane anaesthesia caused a reduction in CO (L · min^?1) from a control value of 1.51 ± 0.21 to 1.38 ±0.1 (0.5 MAC), 1.09 ± 0.15 (1.0 MAC) and 0.98 ± 0.12 (1.5 MAC) (Mean ± SD). Mean blood pressure, Qcru and Qcost also decreased with increasing depth of anaesthesia. In addition, the decrease of Qcru was greater than that of Qcost at all levels of MBP and CO. No change occurred in these variables in the lime control group.

Conclusion

Sevoflurane anaesthesia changes the distribution of Qdi with a greater reduction occurring in Qcru than in Qcost.     

Effects of DPI 201-106, a novel cardiotonic agent,on hemodynamics,cardiac electrophysiology and arrhythmias induced by programmed ventricular stimulation in dogs with subacute myocardial infarction: A comparative study with dobutamine

Summary DPI 201-106 (DPI), a novel and potent cardiotonic agent, exhibits its effects by prolonging the open state of Na⁺ channels, resulting in an increase in action potential duration, and thus, is supposed to share the class III antiarrhythmic activity. The effects of DPI on the hemodynamics, intraventricular conduction and refractoriness of heart, and the incidence of arrhythmias induced by programmed electrical ventricular stimulation (PES) were compared with (±)-dobutamine. Dogs which survived for 5 to 7 days after the induction of myocardial infarction were used as the model. The presence of sub-acute myocardial infarction caused by occluding the left anterior descending coronary artery elicited a mild left ventricular dysfunction represented by a significant decrease in peak LV dp/dt by about 20%.Both i.v. bolus injection of DPI (1, 3 and 5 mg/kg) and i. v. continuous infusion of dobutamine (3, 5 and 10 g/kg/min), which were administered in a cumulative manner, dose-dependently improved the hemodynamic parameters. At the higher doses of both DPI (3 and 5 mg/kg) and dobutamine (5 and 10 g/kg/min) the control values were reached or even exceeded. DPI dose-dependently increased the effective refractory period (ERP) of both non-infarcted and infarcted ventricular myocardia to a similar degree, but the conduction time showed a frequency-dependent increase in the infarcted myocardium to a greater degree than in the non-infarcted myocardium after DPI. In contrast, dobutamine decreased the ERP in both non-infarcted and infarcted myocardia, and slightly increased the difference of refractoriness between the non-infarcted and infarcted zones with no effect on the intraventricular conduction. In the PES study, DPI (3 and 5 mg/kg) produced a significant decrease in the incidence of ventricular tachycardia, whereas dobutamine (5 and 10 g/kg/min) tended to worsen the arrhythmias. These findings suggest that cardiotonic agents with a class III antiarrhythmic property such as DPI may be potentially useful for the management of heart failure accompanied by ischemic heart disease.Abbreviations DPI, DPI 201-106; PES programmed electrical ventricular stimulation - LV dp/dt the rate of rise of left ventricular pressure - ERP effective refractory period - RVOT right ventricular outflow tract - VT ventricular tachycardia - LAD left anterior discending coronary artery Send offprint requests to T. Uematsu at the above address     

Effects of pirarubicin,an antitumor antibiotic,on the cardiovascular system

Summary In the present study we examined the effects of pirarubicin [(2R)-4-0-tetrahydropyranyladriamycin, THP] on a cardiovascular system. An injection of THP (0.39–3.13 mg/kg, i. v.) reduced the mean blood pressure and caused an increase in the respiratory air rate in anesthetized rats. At 1.5×10^–6–1.5×10^–5 m, THP markedly relaxed a contraction induced by 10^–7 m norepinephrine in rat aorta with endothelium but not in that without endothelium. At a dose of 0.02–0.5 mg, THP produced an increase in the contractile force and the perfusion flow of isolated perfused guinea pig hearts. At a higher concentration (4.5×10^–5–1.5×10^–4 m), it produced a slight increase in the contractile force of the left atria in guinea pigs. This positive inotropic action of THP was inhibited by diphenhydramine (10^–6–5×10^–5 m), chlorpheniramine (3×10^–7–3×10^–5 m), and tripelennamine (3×10^–7–3×10^–5 m) but not by propranolol (10^–6 m), cimetidine (10^–5 m), diltiazem (10^–6 m), or ryanodine (10^–8 m). THP given i. v. at 2.5 mg/kg elevated the plasma histamine level in anesthetized dogs. From these data, we conclude that THP mainly relaxed the rat aorta in the presence of endothelium and that at higher concentrations, it increased the contractile force in the cardiac muscle, probably mediated through the release of histamine.