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bilization but it is still unclear which situations are prone to favour PA. Risk factors for PA include peripheral circulatory failure, such as hypotension secondary to dehydration or massive blood loss. Endotracheal intubation and intraoperative Trendelenburg position have also been implicated.25 However, none of these risk factors were present in our patients. In summary, we describe three LDLT donors who developed occipital PA. Clinicians should be aware that LDLT surgery may be associated to PA. However, the reasons for this potential association remains obscure. Toshiya Tomioka MD Masakazu Hayashida MD Kazuo Hanaoka MD Tokyo, Japan References
1 Abel RR, Lewis GM. Postoperative (pressure) alopecia. Arch Dermatology 1960; 81: 7280. 2 Lawson NW, Mills NL, Ochsner JL. Occipital alopecia following cardiopulmonary bypass. J Thorac Cardiovasc Surg 1976; 71: 3427. 3 Patel KD, Henschel EO. Postoperative alopecia. Anesth Analg 1980; 59: 3113. 4 Wiles JC, Hansen RC. Postoperative (pressure) alopecia. J Am Acad Dermatol 1985; 12(1 Pt 2): 1958. 5 Calla S, Patel S, Shashtri N, Shah D. Occipital alopecia after cardiac surgery (Letter). Can J Anaesth 1996; 43: 11801.
FIGURE Degree of tension during the perioperative period. Values are mean SD. Statistical analysis was performed by the Friedman test followed by the Wilcoxon signed-rank test with Bonferroni correction (*P < 0.05 vs before entering the operating room), and Mann-Whitney U test at each evaluated time.

The relaxing effect of negative air ions on ambulatory surgery patients

To the Editor: Negative air ions are natural components of atmospheric air, which exist in a good quality environment and are considered to have beneficial biological actions.1 Of these, a relaxing effect, for example decreases of anxiety, depression, irritability and tenseness, has been demonstrated,24 whereas positive air ions have an opposite effect.5 There are two methods to generate negative ions: coronal discharge and water shearing. The latter method is, essentially, a natural source of negative ions.1 Whether negative ions exert a relaxing effect was examined in ambulatory surgery patients. After approval by our Institutional Committee, 95 patients receiving a minor skin surgery of short dura-

tion with local anesthesia alone were allocated, on alternative weeks, to a regular environment (n = 44) or a negative ion-rich environment (n = 51). A commercially available appliance for generating negative ions by means of water shearing (Aqua Air Rich, Matsushita Seiko, Osaka, Japan) was operated in the operating room (OR; 30 m3). An ion detector (Ion Tester KST-900, Kobe Denpa, Kobe, Japan) showed approximately 1000 parts/mL of negative ions and zero parts/mL of positive ions. In the regular OR environment, it showed a level of zero for both ions. The temperature and humidity of the room were measured by a digital thermohygrometer. Patients received no premedication and fluid infusion, and were asked by blinded nursing personnel to grade their degree of tension as: 1 = relaxed; 2 = normal tension; 3 = mild tension; 4 = moderate tension; and 5 = severe tension, before entering the OR. After leaving the OR, the same nurse asked the degree of tension during the first or latter half of the surgery. There was no statistical difference between groups with regard to age (37 18, 43 20 yr), male/female ratio (17/27, 23/28), height (159 16, 160 9 cm), weight (59 21, 57 8 kg), room temperature (25.6 1.4, 26.0 1.3C) and humidity (38.7 9.2, 40.6 12.0%), expressed as the mean SD or number. The



degree of tension decreased significantly and more rapidly in the negative ion-rich environment (Figure). The results suggest that negative ions produced by water shearing have a relaxing effect in the OR environment. Some air conditioners producing negative ions have been developed recently. They may be useful in the hospital to reduce the patients psychological tension or anxiety. Hiroshi Iwama MD Hiroshi Ohmizo DDS Shinju Obara MD Aizuwakamatsu, Japan References
1 Iwama H, Ohmizo H, Furuta S, et al. Inspired superoxide anions attenuate blood lactate concentrations in postoperative patients. Crit Care Med 2002; 30: 12469. 2 Buckalew LW, Rizzuto A. Subjective response to negative air ion exposure. Aviat Space Environ Med 1982; 53: 8223. 3 Livanova LM, Levshina IP, Nozdracheva LV, Elbakidze MG, Airapetyants MG. The protective effects of negative air ions in acute stress in rats with different typological behavioral characteristics. Neurosci Behav Physiol 1999; 29: 3935. 4 Nakane H, Asami O, Yamada Y, Ohira H. Effect of negative air ions on computer operation, anxiety and salivary chromogranin A-like immunoreactivity. Int J Phychophysiol 2002; 46: 859. 5 Giannini AJ, Castellani S, Dvoredsky AE. Anxiety states: relationship to atmospheric cations and serotonin. J Clin Psychiatry 1983; 44: 2624.

FIGURE Difference from normocapnic values of mean arterial pressure (MAP), heart rate (HR) and cardiac index (CI) during hypercapnia (PaCO2 = 55 mmHg). Values are mean SD. *P < 0.05 vs normocapnic value. P < 0.05 vs the other three subgroups.

Clonidine attenuates the hemodynamic responses to hypercapnia during propofol anesthesia

To the Editor: Clonidine, an alpha2-adrenergic agonist, is widely used as an anesthetic adjuvant,1,2 and is reported to decrease sympathetic nervous activity,2,3 plasma norepinephrine concentration,2 and sympathoadrenal responses.2,3 Propofol can cause hypotension and bradycardia via a profound decrease in sympathetic tone.4 The purpose of our study was to examine the hemodynamic changes to hypercapnia during propofol and isoflurane anesthesia, and to compare them in the presence and absence of clonidine premedication.

After obtaining approval from our institutional Human Investigation Committee and informed consent from each patient, 60 adult patients (ASA physical status I) were randomly assigned to one of two groups. Thirty patients received famotidine 20 mg (control group) orally 90 min before the induction of anesthesia, whereas the remaining 30 patients received clonidine 5 gkg1 and famotidine 20 mg (clonidine group). General anesthesia was induced with iv propofol 2 mgkg1, and tracheal intubation was facilitated with iv vecuronium 0.2 mgkg1. In 15 patients in each group, anesthesia was maintained with isoflurane 1% (end-tidal) in oxygen, and in the other 15 patients with iv propofol 100 gkg1min1 during ventilation with oxygen. The baseline measurements including mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), and plasma catecholamine concentration were made during normocapnia (an