[Application of measuring 99mTc-MAG3 plasma clearance based on one-compartment model (MPC method) to renal transplantation]

Measurement of 99mTc-MAG3 plasma clearance (CLmag) based on one-compartment model (MPC method) was applied to renal transplantation and evaluated for the factors which might affect the calculated results, especially concerning renal depth. Correlation coefficient of CLmag between MPC method using real renal depth and Russell or Bubeck single sampling method was good (r = 0.852 or 0.876, respectively). Regression equation between MPC method and Russell method was y = 1.044x - 3.0 and was more closer to y = x than that between MPC method and Bubeck method. CLmag of MPC method calculated by estimated renal depth from the abdominal thickness was also similar to that by real renal depth. Even if the fixed renal depth, 4 cm, was applied, the coefficient and regression equation between MPC method and Russell method were r = 0.884 and y = 1.004x - 10.2. In conclusion, MPC method is applicable to the evaluation of renal transplants. Though measuring renal depth is best, calculation with fixed renal depth of 4 cm might be practically acceptable.

Stretching of the ductus: an important factor in determining the outcome of coil occlusion

The present study measured the minimal diameter of the ductus (minimal D), the stretched minimal diameter (stretched D), and the stretch index (SI) before coil occlusion in 25 patients with a patent arterial duct. The following factors were compared in the success group (22 cases, coil successfully placed after initial deployment) versus the failure group (3 cases): minimal D, stretched D, SI, the sum of the loop diameter of coils (the loop diameter), the sum of the product of the loop diameter and the number of loops (the loop diameter and number), the loop diameter/minimal D, the loop diameter/stretched D, the loop diameter and number/minimal D, and the loop diameter and number/stretched D. In the failure group, minimal D, stretched D, SI, the loop diameter, and the loop diameter and number were larger than in the success group. The loop diameter/stretched D, and the loop diameter and number/stretched D were smaller in the failure group. Although the loop diameter and number/minimal D was slightly smaller in the failure group, the loop diameter/minimal D was comparable. It is concluded that the stretched D is more reliable than minimal D to determine the appropriate size of coil for successful initial deployment.

[Comparison between continuous intravenous and oral administration of 5-FU with LV]

In case of 5-fluorouracil (5-FU)/leucovorin (LV) treatment, which is one of the most effective forms of chemotherapy for colorectal carcinoma, 5-FU is usually continuously infused from the venous route. However, since this continuous infusion limits the patients' active daily life, oral administration is preferable. In the present study, we evaluated the efficacy and side effects of orally administered 5-FU/LV.

MATERIAL AND METHODS

In the continuous intravenous infusion group (civ group), colon 26 bearing mice were cannulated into central vein from external jugular vein. From this route, either 5, 10, or 20 mg/kg of 5-FU was continuously infused for 7 days (n = 6). In another group, either 10, 20, 40 mg/kg of 5-FU was infused orally (po group, n = 6). The other 6 animals were used for the non-treatment group. In the next series, 100 mg/kg of LV was added for each group above. Tumor volume, thymidylate synthase inhibition rate (TSIR) and body weight were measured at the end of infusion. During the experimental period, mice had free access to chow and water.

RESULTS

The tumor/control (T/C) volumes ratio showed that approximately twice the orally administered 5-FU dose had an anti-tumor effect equal to that of 5-FU administered intravenously. Synergic antitumor effects by LV were only revealed in the civ group. Significant body weight loss was recognized only in the po group at a 5-FU dose of more than 20 mg/kg. In summary, since the modulation effect of LV was recognized only with continuously intravenous infusion of 5-FU, further improvement of oral administration is required in the LV/5-FU combination therapy.

Disopyramide improves hypoxia in patients with tetralogy of Fallot through a negative inotropic action

The hemodynamic and right ventricular volumetric effects of disopyramide were investigated in patients with tetralogy of Fallot (TF). Intracardiac pressure and oxygen saturation were measured, before and after intravenous administration of disopyramide (2 mg/kg) in 7 patients who had not had previous surgery. Right ventricular volume and the diameter of its outflow tract were analyzed in these 7 and in a further 4 patients with a previous shunt. Aortic oxygen saturation increased from 90.4+/-7.5 (mean+/-SD) to 94.1+/-5.5% (p<0.05) with an increase in pulmonary blood flow and pressure. The systolic pressure gradient between the main pulmonary artery and the right ventricle decreased from 59+/-8 to 42+/-9 mmHg (p<0.01). Aortic pressure fell from 77+/-5 to 67+/-4 mmHg (p<0.05). Systemic vascular resistance increased from 15.3+/-2.2 to 19.4+/-3.3 u x m2 (p<0.05). Pulmonary vascular resistance remained unchanged. The diastolic and systolic diameter indices of the right ventricular outflow tract increased from 17.8+/-3.8 to 20.5+/-3.4 and from 6.5+/-3.0 to 10.4+/-2.2 mm/m2, respectively (p<0.01), whereas the right ventricular ejection fraction decreased. Disopyramide improves systemic oxygen saturation in patients with TF through its negative inotropic action on the right ventricle.

Successful stenting of congenital bronchial stenosis in infancy

Recently, stent implantation has become the treatment of choice for patients with tracheobronchial stenosis due to malignant tumours, tuberculosis and recurrent stenosis following lung transplant. However, reports on this procedure in infants with congenital bronchial stenosis are extremely rare. We report successful stent implantation in an infant with congenital left bronchial stenosis followed by rapid improvement in his respiratory condition.

CONCLUSION

The use of a stent in infants is still controversial because size mismatch will take place with growth. However, we believe that implantation of a metallic stent can be the preferred treatment of congenital bronchial stenosis even in small infants.

Epinephrine-induced constriction of the persistent ductus arteriosus and its relation to distensibility

The aim of this study was to investigate whether distensibility of the persistent ductus arteriosus (PDA) might predict its potential for vasoconstriction. Epinephrine-induced constriction and stretching were investigated in 10 patients with PDA. Age, sex, ductus type, its minimal diameter, its stretched minimal diameter, and its stretch index were compared between epinephrine responders and non-responders. Age, sex, weight or the configuration or size of the PDA did not predict stretchability. The stretch index was significantly greater in responders (1.7-2.0, 1.8+/-0.1) than in non-responders (1.3-1.7, 1.4+/-0.2, p<0.01). Stretching of the PDA may depend on the elasticity of the vascular wall, which in turn is determined by preservation of vascular smooth muscle.

An infant with Costello syndrome complicated with fatal hypertrophic obstructive cardiomyopathy

We report a 3-month-old girl with Costello syndrome complicating fatal hypertrophic obstructive cardiomyopathy. She had typical findings of this syndrome, slight dyspnea and persistent wheezing. Doppler echocardiography revealed asymmetric septal hypertrophy and systolic anterior movement of the anterior mitral leaflet. There was grade 1 mitral regurgitation. Although once her heart failure had been controlled medically, she died suddenly following deterioration of her heart condition. Costello syndrome can complicate fatal hypertrophic obstructive cardiomyopathy.

Disopyramide: a promising new approach to the medical treatment of the hypercyanotic spell complicating tetralogy of Fallot

Under continuous ECG and oxygen saturation (SpO2) monitoring, the following measurements were taken by Doppler echocardiography in 6 consecutive patients with tetralogy of Fallot (TF) before and after intravenous administration of disopyramide (2mg/kg): left ventricular shortening fraction (LVSF); peak velocities in the right ventricular outflow tract (RVOT); diastolic and systolic internal diameters of the right ventricular outflow tract (dRVOT, sRVOT); and systolic blood pressure. SpO2 increased (p<0.01) from 78 to 98 (89 +/- 7, mean +/- standard deviation)% to 86-99 (94 +/- 5)%. LVSF decreased (p<0.05) from 0.34-0.56 (0.42 +/- 0.08) to 0.22-0.54 (0.33 +/- 0.13). The systolic blood pressure fell slightly (p<0.05) from 68-92 (79 +/- 8) to 64-92 (71 +/- 11)mmHg. The sRVOT increased (p<0.05) from 2.1-4.8 (2.7 +/- 1.5)mm to 3.0-8.1 (4.9 +/- 2.4)mm, while RVOT peak velocity decreased (p<0.05) from 2.20-4.88 (3.70 +/- 0.97)m/sec to 2.05-4.07 (2.92 +/- 0.72)m/sec. Disopyramide alleviates hypoxia in patients of TF through its negative inotropic action on right ventricular outflow obstruction.

Coarctation of persistent right fifth aortic arch and pulmonary sequestration

A 41-day-old boy was transferred to our department with severe congestive heart failure. Digital subtraction counter current aortography, and antegrade aortography, revealed coarctation of a persistent right fifth aortic arch, stenosis of the origin of an aberrant left subclavian artery, and sequestration of the lower lobe of the right lung. As his heart failure seemed to be caused not only by pressure overload to the left ventricle following coarctation, but also by the volume load associated with the shunting effect of the pulmonary sequestration, we performed transcatheter balloon dilation of the coarctation and the origin of the aberrant subclavian artery, together with embolization of the aberrant pulmonary artery. His heart failure responded dramatically to these procedures.

Stretched minimal diameter of the ductus and coil occlusion

BACKGROUND

Stretching of the ductus was supposed to determine the size mismatch of the coil with the ductus in coil occlusion that results in residual leak or migration.

METHODS

We measured the minimal diameter (D) and the stretched minimal diameter (S) of the ductus in 12 patients with patent ductus arteriosus (PDA). The stretch index (SI) was calculated as S divided by D. We calculated ratios of the loop diameter of the first implanted coil to D (C1/D) and S (C1/S) and those of the sum of all the loop diameters of all implanted coils for complete closure to D (total C/D) and to S (total C/S).

RESULTS

Stretched minimal diameter divided by D was 1.8 +/- 0.3. Ratios of the loop diameter of the first implanted coil to D (C1/D), and S (C1/S) were 3.7 +/- 1.8 and 2.1 +/- 0.9, respectively. Ratios of the sum of all the loop diameters of all coils to D (total C/D) and S (total C/S) were 5.2 +/- 1.6 and 2.9 +/- 0.9, respectively. Standard deviations of C1/S and total C/S are significantly smaller than those of C1/D and total C/D, respectively.

CONCLUSIONS

The narrowest segment of the ductus could be stretched to twice the size of the minimal diameter. The stretched minimal diameter may be a more reliable parameter to select the loop diameter of coils than the angiographic minimal diameter.

[Somatic mosaicism of p(CTG)n expansion in a case of myotonic dystrophy with parotid tumor]

Myotonic dystrophy (MD) is an autosomal dominant systemic disorder with an unstable expansion of the CTG triplet repeat in the 3'-untranslated region of the gene encoding myotonine protein kinase (DMPK) which maps to chromosome 19q13.3. Somatic mosaicism of CTG repeats in MD has been reported; and it has been observed that CTG repeats in tumor tissues associated with MD are more expanded than the other tissues. It is not rare that parotid tumors are found in patients with MD. We performed Southern blot analysis for tissues from the parotid tumor, the normal parotid gland, the skeletal muscles, and the leukocyte from a 60-year-old patient with MD. CTG repeat was most expanded in the parotid tumor, and the normal parotid gland had longer expansion of CTG repeat than the skeletal muscles. The leukocyte had the shortest expansion of CTG repeat. The expansion of CTG repeat in the parotid tumor may be related to active cell division and may underlie the occurrence of tumors in MD.

Is early surgery always necessary in patients with aortic valve prolapse complicating an Eisenmenger-type ventricular septal defect?

BACKGROUND

The report presents three patients who showed a typically prolapsed aortic cusp with or without aortic regurgitation associated with a malalignment-type perimembranous defect, the so called Eisenmenger-type ventricular septal defect.

RESULTS

Each patient developed spontaneous complete or near closure of the ventricular septal defect without worsening of the aortic regurgitation.

CONCLUSIONS

These cases suggest that prolapsed aortic cusp complicating a malalignment perimembranous ventricular septal defect is not always an absolute indication for early surgery to prevent progressive aortic regurgitation.

Plasma thromboxane B2 concentration in patients with ventricular septal defect and pulmonary hypertension

Plasma thromboxane B2 (TXB2)-a stable metabolite of thromboxane A2 (TXA2)-conventional hemodynamic parameters, mean pulmonary input energy (input energy), and mean pulmonary output energy (output energy) were measured to assess platelet activation in 21 patients with pulmonary hypertension and a ventricular septal defect (VSD). The patients were divided into 2 groups: group A (normal range) and group B (high level). TXB2 levels were measured by radioimmunoassay. There was no relationship between plasma TXB2 concentrations and conventional hemodynamic parameters except the pulmonary-to-systemic pressure ratio. Output-to-input energy ratio was correlated logarithmically with the plasma TXB2 concentration. We concluded that patients with output/input energy ratio >0.15 had a high TXB2 concentration and activated platelets in pulmonary capillaries.

Hemolysis complicating coil occlusion of patent ductus arteriosus

We report on 5 patients who developed hemolysis (the Hemolysis group) following coil occlusion for PDA, and compare their data to 66 cases which were not complicated by hemolysis despite residual leak (the No Hemolysis group). A significant leak with a heart murmur was more frequent in the Hemolysis group than in the No Hemolysis group. The ratio of the sum of the loop diameter of coils to the minimal diameter of the ductus (C/D) in those who developed persistent hemolysis that needed a second intervention (2.2+/-0.4) was significantly smaller than in the No Hemolysis group (3.1+/-1.1). Persistent hemolysis can occur if a significant residual shunt remains after implantation of coils with small C/D. As this complication may be avoided by complete closure or, if not complete, a minimal leak, we should be careful to make residual leaks as small as possible by the use of multiple coils.

Coil occlusion for patent ductus arteriosus in Japan

We surveyed Japanese experience of coil occlusion of patent ductus arteriosus up to 30 September 1996 by sending questionnaires to 175 hospitals. Thirty-four hospitals reported outcome data for 231 procedures in 218 patients. Successful implantation was achieved in 94% and acute complete closure of the ductus occurred in 71% of those in whom implantation of the coil was successful. Of the latter, 83% reported late complete closure. When those patients who underwent reocclusion for residual shunt are included, 89% attained complete closure. No life-threatening complications have occurred so far. Late reopening was reported in 3 cases. Although the angiographic type of ductus was significantly related to successful implantation (p < 0.01), there was no significant correlation with complete occlusion. Ductuses with a minimum diameter greater than 3 mm had a decreased chance of successful implantation, whereas those less than 2 mm had a greater incidence of complete closure.

Antegrade or retrograde catheterization across a ventricular septal defect

The success rate and the most suitable catheter tip for crossing over various types of ventricular septal defects (VSDs) were examined as a preliminary study for transcatheter closure of VSD. The 18 consecutive patients with various types of VSD were aged from 1 to 95 (mean [+/- SD] 13 +/- 22) months. Body weight was 3.7 to 25.0 (8.0 +/- 5.1) kg. Two-dimensional echocardiography showed that the maximal diameter of the defects ranged from 1.0 to 12.0 (7.5 +/- 3.1) mm. There were 10 patients with perimembranous defects, 4 with outlet defects, 2 with muscular defects, and 2 with tetralogy of Fallot with perimembranous defects. An angiographic balloon catheter, or an original or modified Judkins right coronary catheter could be passed through the VSD antegradely or retrogradely in 16 of 18 patients. In only two patients, with a small VSD of 2.0 and 1.0 mm, the catheter could not cross over the defect. The catheter entered the ascending aorta antegradely in 12 cases. The Judkins right coronary catheter is most suitable for crossing a VSD either antegradely or retrogradely.

Combined use of detachable coil against persistent mechanical hemolysis after transcatheter occlusion using Rashkind umbrella device in adult patient with patent ductus arteriosus

Mechanical hemolysis after transcatheter occlusion of the patent ductus arteriosus using the Rashkind umbrella device has been postulated as a rare, but serious complication, even necessitating surgical repair. A rare, case of an adult patient with massive hemolytic anemia, successfully controlled by the combined use of several detachable coil devices is reported. The use of coil devices might be considered as a therapeutic option in such cases.

Plasma concentration and acute clinical effects of docarpamine, orally active dopamine prodrug, in infants

Currently, there are no data available on the optimal doses and efficacy of docarpamine in infants. In the present study, three doses of docarpamine, 15.0-20.4 (19.0 +/- 1.9; mean +/- SD) mg/kg per dose every 8 h to 10 infants suffering heart failure. Age and bodyweight were from 1 to 4 (1.4 +/- 1) months and 2960-5160 (3350 +/- 872) g, respectively. In all infants, plasma concentrations of free dopamine were measured 1, 2 and 3 h after the first administration. Heart rate and systolic blood pressure were examined before and at the same time as the first administration. In seven infants, the 24 h urinary output and urinary excretion of electrolytes and creatinine before and during docarpamine were measured. Peak plasma concentration of free dopamine (ng/mL) was achieved after 1 or 2 h of administration, 0-163.1 (37.9 +/- 47.2) and 0-105.0 (37.8 +/- 39.3), respectively. The concentration had decreased rapidly by 3 h to 0-34.2 (12.4 +/- 11.0). Both heart rate (b.p.m.) and blood pressure (mmHg) tended to increase from 120-154 (140 +/- 15) and 56-90 (76 +/- 11) to a peak of 124-162 (148 +/- 14) and 70-92 (79 +/- 8), respectively (P = 0.197, P = 0.289). There were no significant changes in urinary output or excreta. Oral docarpamine of 15-20 mg/kg per dose can achieve plasma free concentrations of dopamine that increase heart rate and systolic blood pressure.

High dose of intravenous antithrombin III without heparin in the treatment of disseminated intravascular coagulation and organ failure in four children

In several animal experiments, high doses of antithrombin III concentrates have shown beneficial effects on mortality and reversal of coagulation abnormalities which had resulted from disseminated intravascular coagulation. Other experiments have suggested that antithrombin III infusion without heparin is effective in the treatment of organ failure. We clinically treated children suffering disseminated intravascular coagulation only with antithrombin concentrate. Four patients suffering disseminated intravascular coagulation with organ failure were selected. We started antithrombin III concentrate infusion as soon as the diagnosis was established. The dosage of antithrombin III was 120-250 units/kg/day for 2 or 3 days. Heparin was not used. All 4 patients recovered completely and quickly without any complications within 14 days. We suggest that the high-dose antithrombin III infusion without heparin is an effective and safe therapy for disseminated intravascular coagulation with organ failure.

Diagnosis of renovascular hypertension by echo-Doppler velocimetry

A 13 year old boy suffering hypertension was examined for peripheral plasma renin, angiotensin-I, angiotensin-II and aldosterone. All data were within the normal range. The Captopril test and renal scintigraphy (both with and without Captopril) also showed normal patterns. Echo-Doppler velocimetry of the renal artery revealed that left renal arterial peak flow velocity was fast (3.4 m/s). The patient was therefore diagnosed with left renal arterial stenosis. Angiography demonstrated the duplex of the left renal artery and stenosis of the left lower renal artery. Percutaneous transluminal angioplasty was successfully performed.

Catecholamine-induced ductus arteriosus constriction in children

Our data suggest that the vascular smooth muscle of the PDA remains capable of constriction beyond a patient's infancy, at least at the pulmonary end. In some cases of PDA, catecholamines may induce late closure.

[Pure word deafness after cerebral hemorrhage in the left temporal lobe: a case report]

We report a patient with pure word deafness after subcortical hemorrhage in the left temporal lobe. Repetition and auditory comprehension were severely impaired, while reading and visual comprehension of the same material were almost normal. He did not show hearing loss, but speech discrimination and melody recognition was poor. On the speech discrimination test, his score was low especially in the right ear. The threshold on the directional hearing test was mildly elevated. There was no temporal summation by click sounds. CT and MRI disclosed a subcortical hematoma in the left superior temporal gyrus. PET demonstrated hypoperfusion in the surrounding area, which was not activated by hearing a story. It was considered that pure word deafness in this case was due to the interruption of auditory inputs to Wernicke's area from both hemisphere by the hematoma. After 5 months, auditory comprehension recovered so that he did not have difficulty in conversation. Speech discrimination improved in both ears, probably due to the recovery of two auditory pathways; the ipsilateral pathway through the left auditory radiation and the contralateral pathway through the right auditory radiation and the corpus callosum. This case suggests that in pure word deafness due to a unilateral lesion, the improvement in speech discrimination during follow-up period may provide a clue as to the site of the responsible lesion and its recovery.