Does indocyanine green accurately measure plasma volume early after cardiac surgery?

Potential overestimation of plasma volume (PV) determination by the conventional indocyanine green (ICG) dilution method (PV-ICG) can occur when generalized capillary protein leakage is present, because ICG binds to proteins. We recently reported that this overestimation can be recognized by simultaneous measurement of the initial distribution volume of glucose (IDVG). We examined whether overestimation of PV-ICG and further ICG-pulse dye densitometry-derived plasma volume (PV-PDD) can occur early after cardiac surgery by using the PV-ICG/IDVG ratio as an indicator. Possible overestimation was defined as a ratio higher than 0.45. Twenty-four consecutive postcardiac surgical patients were enrolled. PV-ICG, PV-PDD, and IDVG were calculated simultaneously after admission to the intensive care unit and on the first postoperative day. The mean +/- SD PV-ICG/IDVG ratio for 47 recordings was 0.38 +/- 0.05. Four had a PV-ICG/IDVG ratio higher than 0.45, and the highest was 0.48. The mean PV-PDD/IDVG ratio for a total of 47 recordings was 0.39 +/- 0.10. There were extremely high or low ratios observed in PV-PDD determinations, but they were not observed in PV-ICG determinations. Results suggest that most of the PV-ICG measurements are accurate, but inaccuracy of PV-PDD can occur early after cardiac surgery. IMPLICATIONS: Overestimation of indocyanine green-derived plasma volume can occur in the presence of generalized capillary protein leakage. This overestimation was examined early after cardiac surgery by using the simultaneous measurement of the initial distribution volume of glucose. We suggest that overestimation of the traditional dye dilution method is negligible, but apparent over- or underestimation of pulse dye densitometry-derived plasma volume cannot be negligible.     

Acute effects of methyl bromide gas in rats and mice--studies on survival time

Wistar male rats and ddY male mice were exposed to 500-10,000 ppm of methyl bromide gas up to 8 hours, and the survival time and weights of brain, lung, liver, kidneys, spleen and tests were measured. The survival time decreased with the gas concentration almost exponentially. In general, rats had a longer survival time than mice under the same exposure concentration. Difference of survival time between rats and mice was remarkable at low concentrations but small at high concentrations. Spleen weight decreased significantly and kidney weights tended to increase at 2000 ppm or greater exposure concentrations. Difference between wet and dry lung weight in the exposure group was significantly greater than that in the control group, especially for high concentrations, which suggested pulmonary edema or bronchopneumonia.     

Association between activating mutations of calcium-sensing receptor and Bartter's syndrome

Bartter's syndrome is a heterogeneous disorder characterised by deficient renal reabsorption of sodium and chloride, and hypokalaemic metabolic alkalosis with hyper-reninaemia and hyperaldosteronaemia. Mutations in several ion transporters and channels have been associated with the pathogenesis of Bartter's syndrome. We describe two hypocalcaemic patients with deficient parathyroid hormone secretion who also showed characteristics of Bartter's syndrome. We found activating mutations of the gene for the calcium-sensing receptor (CASR) in both patients. Activation of this calcium-sensing receptor inhibits the activity of a renal outer-medullary potassium channel that is mutated in type 2 Bartter's syndrome. We therefore suggest that some activating mutations of CASR could provide new mechanisms for the development of Bartter's syndrome.     

Early detection of hypoxia with BIS monitoring during percutaneous cardiopulmonary support

We report a patient in whom hypoxia developed during percutaneous cardiopulmonary bypass (PCPS) and was detected with the lowering of the bispectral index (BIS) values. A 7-yr-old boy was managed with PCPS for the treatment of cardiogenic shock after cardiac surgery. His circulation was dependent on PCPS and pulse pressure was nearly zero. Signals by pulse oxymetry were undetectable and periodical blood gas analysis was performed to confirm proper oxygenation. BIS was monitored, and a gradual decrease in the value was observed. Careful observation also revealed darkening of the blood in the PCPS circuit and blood gas analysis showed severe hypoxia. Oxygen concentration of the gas to a PCPS oxygenator was increased immediately and new PCPS circuit was prepared. It took almost two minutes to exchange the circuit. Near circulatory arrest might have occurred during the procedure and BIS and suppression ratio (SR) became below 10 and above 90, respectively. Both returned to the previous values 30 min after the replacement of the circuit. Severe hypoxia, otherwise overlooked, was detected with BIS monitoring and BIS reflected the circulatory status of the patient, especially of the brain. This monitoring is useful to confirm proper oxygenation during PCPS.     

The effects of family interventions for the patients with mental illness in health centers focusing on the relatives' own life

Recently, the burden on relatives of patients with mental illness has been recognized and the need for support to reduce such burden has increased. In Japan, family interventions have been conducted at Health Centers, most of them focusing on the family functioning as a caregiver. However, it is also important to focus on the relative's functioning to live their own life in family interventions. In this study, we executed a program focusing on relatives' life and health, and investigated the effects of this program on both family functioning. Family intervention programs were conducted at 10 Health Centers including both urban and rural areas in Japan. A total of 102 relatives responded to the self-administered questionnaire at the first and the last session of the family interventions. We measured functioning as a caregiver using the Support for the Disabled Score and Rejective Feeling Score, and functioning to live their own life by GHQ Distress in Daily life Score, Perceived Health Condition Score and Life Satisfaction Score. During interventions, GHQ score and Distress in Daily Life score which indicate the disfunction in living their own life decreased, and Support score increased in all sample. In the short-term illness group (n = 35), only the GHQ score decreased, while in long-term illness group (n = 44) Distress score decreased and Support Score increased. The intervention program focusing on relatives' life and health may improve both family functionings to give adequate care for patients, and to live their own daily life. Results suggested that the short-term illness group requires more intensive and personal advices, and the long-term illness group need continuous support focusing on the relative's own life. Expected roles of Health Centers are cooperation with family interventions provided at hospitals and coordination of the services in the community, as well as providing family interventions in terms of relatives' life.     

Treatment of superficial esophageal cancer by external radiation therapy alone: results of a multi-institutional experience

PURPOSE: To assess the effectiveness and toxicity of external radiation therapy for superficial esophageal cancer. METHODS AND MATERIALS: During the period from March 1979 to November 1996, 78 patients with superficial esophageal cancer received radiation therapy without intracavitary irradiation at nine radiotherapy institutions in Japan. All patients had histologically-proven squamous cell carcinoma. Endoscopic ultrasonography was performed in 34 patients to discriminate mucosal from submucosal cancer. Most of the patients had received radiation therapy using conventional fractionation at an average dose of 65.5 Gy. RESULTS: The survival rates at 1, 2, and 5 years were 88%, 73%, and 45%, respectively. The local control rates at 1, 2, and 5 years were 85%, 79%, and 66%, respectively. Although the difference was not significant, the survival rate of cancer patients with a tumor invading the submucosa was lower than that of the other patients. In 6 mucosal cancer patients, local recurrence was observed in 1 patient with extensive cancer. Regional lymph node recurrence and distant failure were not observed in mucosal cancer patients, while in 28 submucosal cancer patients, the 5-year survival rate and relapse free rate were only 49% and 43%, respectively. Univariate and multivariate analysis identified age as the only significant prognostic factor. Severe late injury, such as esophageal ulcer, perforation, and bleeding, was not observed. CONCLUSION: External radiation therapy is effective for mucosal cancer. However, further investigation is needed to establish a better standard treatment protocol for submucosal cancer.     

Prospective study of external radiotherapy with and without intraluminal brachytherapy for esophageal cancer in Japan. JASTRO Study Group

To improve the results of treatment of patients with esophageal cancer, it is important to achieve good local control. Since the esophagus is adjacent to highly radiation-sensitive organs such as the lungs, bone marrow, etc., it is difficult to irradiate tumors with high doses. Although irradiation techniques have improved as a result of advances in treatment-planning equipment and irradiation equipment, there are still some patients for whom radical radiation therapy within doses that the bone marrow and lungs can tolerate is difficult with external irradiation alone. On the other hand, intraluminal brachytherapy allows high-dose irradiation of esophageal cancer with little risk to adjacent organs. However, intraluminal brachytherapy, in which the dose sharply declines with the distance from the radiation source, is suggested to be a useful technique for tumors with relatively shallow invasion. With the aim of improving the results of esophageal cancer treatment, we designed this study to establish the optimal irradiation method in radical radiation therapy for esophageal cancer by clinically evaluating external irradiation alone and in combination with intraluminal brachytherapy.     

A Case-Control Study of the Effectiveness of Cervical Cancer Screening in Osaka, Japan

In the small town of Nose in Osaka, Japan, a population-based screening program for cervical cancer by Papanicolaou smear has been conducted since 1965. In order to evaluate the effectiveness of screening in terms of the reduction of the mortality and the incidence of invasive cervical cancer, two types of case-control studies were carried out. In the first study, the case series consisted of all women who died of cervical cancer under 80 years of age at the time of diagnosis in 1965-1987 (N = 15). For each case, 10 controls were chosen from living residents, matched by year of birth. It showed that the odds ratio (OR) of dying of cervical cancer for screened versus non-screened women was 0.22 (95%CI = 0.03-1.95). In the second study, the case series consisted of all women who were diagnosed as having invasive cancer under 80 years of age at the time of diagnosis in the same period (N = 28). For each case, 10 controls were chosen from living residents without invasive cancer, matched by year of birth and according to whether or not they were screened at the year of the diagnosis of the matched case. It showed that the OR of getting invasive cancer for screened versus non-screened women was 0,41 (95%CI = 0.13-1.29). From these results, it was estimated that 78% of cervical cancer mortality and 59% of invasive cervical cancer incidence among non-screened women could be prevented by cervical cancer screening.     

A case of primary adenosquamous carcinoma of the stomach preoperatively diagnosed by endoscopic biopsy

A 53-year-old complained of upper abdominal pain. A diagnosis of Borrmann III type gastric cancer in the posterior part of the corpus region was made by X-ray and endoscopy, and primary adenosquamous carcinoma was preoperatively diagnosed by endoscopic biopsy. Subtotal gastrectomy was performed. The part of the adenocarcinoma adjacent to squamous-cell carcinoma was poorly differentiated. Adenosquamous carcinoma of the stomach is rare. Furthermore, preoperative diagnosis by endoscopic biopsy is extremely unusual, having been reported in 7 cases in Japan including ours. And in 5 cases out of 6, region of the adenocarcinoma was the poorly differentiated type.