Carbamazepine-induced bradycardia-tachycardia syndrome with pharmacological analysis and concurrent ECG monitoring

The authors present a patient with carbamazepine-induced bradycardia-tachycardia syndrome, a rare type of drug-induced sinus node dysfunction. In this case, they established a clear-cut relationship between plasma carbamazepine concentration and the frequency of sinus arrests, following episodes of supraventricular tachycardia. As the pharmacological analysis of drug-induced sinus node dysfunction by concurrent ECG monitoring is very limited, the findings give an insight into the mechanism of this disorder.

Effect of autografting on the diameter of collagen fibrils in human postburn wounds

The effect of skin grafts on the size of collagen fibrils in autografted human burn wounds was examined. In autografted burn wounds, the mean (+/- standard deviation) diameter of collagen fibrils was 61.16 +/- 15.18 nm, against 39.77 +/- 6.51 nm in ungrafted burn wounds. This result indicates that autografts (0.1 mm thick) promote the maturation of collagen in burn wounds.

Xanthogranulomatous pyelonephritis

Four patients with xanthogranulomatous pyelonephritis are presented; all patients were male and their symptoms were not urinary but nonspecific. Three of the patients are from a low socioeconomic class and did not have adequate medical services; therefore, we suggest that the disease is underreported.

[Intraspinal lipoma in an infant: a case report of MRI study]

A 6-month-old boy having intraspinal lipoma with lumbosacral subcutaneous lipoma and occult spinal dysraphism is described. CT scan and magnetic resonance imaging (MRI) are demonstrated. On admission, the patient showed no neurological deficits. Lumbosacral hemangioma and subcutaneous lipoma were noticed on physical examination. A plain spinal roentogenogram revealed occult spinal dysraphism extending from L 4 level down to the sacral region. A plain CT scan disclosed a round-shaped low density area surrounded by a relatively high density area corresponding to the neural tissue in the spinal canal. MRI (1.5-T superconducting system) with sagittal views clearly showed an oval-shaped high signal intensity (SI) area-an intraspinal lipoma-with the neural tissue running longitudinally within and on its surface. The lipoma appeared to be attached to the spinal cord at L 1/2 level. On operation, we found an extramedullary lipoma which had a certain connection to the sacral epidural adipose tissue with an opening of the dural sac, as far as the subcutaneous lipoma. Tethered cord and thickened filum terminale were not identified. Generally, lipoma is demonstrated as a low density area of approximately -90 H.U. on a CT scan. In MRI, we can obtain a high contrast between the lipoma, the spinal cord, and the cerebrospinal fluid, since they are shown as a high, an intermediate, and a low SI area respectively, on T1-weighted spin echo images. Furthermore, sagittal section of MRI is regarded as a potent diagnostic modality to get the precise anatomy of the spinal cord lesion. These short spin echo images can be taken in a relatively brief time. It is a great advantage for patients with spinal lipoma, who are usually infants. MRI is considered to be a quite useful modality to diagnose spinal lipoma, and is able to lead to an early diagnosis non-invasively and accurately, facilitating appropriate surgical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Effectiveness of continuous arteriovenous hemofiltration for patients with refractory heart failure

Continuous arteriovenous hemofiltration (CAVH) was carried out in 8 patients with refractory congestive heart failure. All these patients had heart failure and oliguria for over 24 hours and intensive treatment with digitalis, diuretics, catecholamines and vasodilators was prescribed. Hemodynamics were followed closely during CAVH. During CAVH, pulmonary arterial pressure and pulmonary capillary wedge pressure were significantly reduced in all patients, the right atrial pressure decreased in 6 with right cardiac failure, the heart rate decreased in 3 with tachycardia and the blood pressure and cardiac index were elevated in 3 with hypotension. These observations show that CAVH can be performed safely and effectively in patients with congestive heart failure, oliguria and hypotension.

Coronary artery aneurysms and congestive heart failure--possible long-term course of Kawasaki disease in an adult--a case report

Multiple coronary artery aneurysms, rarely seen in patients with atherosclerotic heart disease, can be frequently observed in children with Kawasaki disease. However, their long-term clinical courses still remain obscure. A thirty-nine-year-old male came to our clinic because of congestive heart failure. A left ventriculogram revealed highly reduced wall motion. A coronary angiogram showed left main trunk aneurysm with complete occlusion of the left anterior descending artery and ramification of the right coronary artery close to the ostium. Six months after discharge, he died suddenly. On autopsy, aneurysms were observed in the left main trunk and right coronary artery, together with an old anteroseptal myocardial infarction. Although he did not have a clear history of febrile disease in childhood, he was highly suspected to be a long-term survivor of Kawasaki disease because of the unique form and distribution of the coronary artery aneurysms.

Biological activities of lipopolysaccharide-like substance (LLS) extracted from Leptospira interrogans serovar canicola strain Moulton

The biological activities of lipopolysaccharide-like substance (LLS) extracted from Leptospira interrogans serovar canicola strain Moulton by the hot phenol-water method were studied in mice. The addition of 12.5 micrograms/ml or more of LLS fraction increased the incorporation of [3H]thymidine into in vitro cultured spleen cells of C57BL/6 mice, while the activity of the LLS fraction was about 20 times weaker than that of Salmonella typhimurium lipopolysaccharide (LPS). Pretreatment of murine spleen cells with rabbit anti-mouse thymocyte antiserum did not diminish the mitogenic activity of leptospiral LLS, and the LLS could not increase the incorporation of [3H]thymidine into thymocytes, suggesting that LLS acts on a B-lymphocyte population of lymphocytes. When sheep erythrocytes and LLS fraction were injected intraperitoneally into BALB/c mice, LLS exhibited an enhancing effect on antibody response in vivo. However, lethal toxicity of the LLS fraction was about 500 times lower than that of LPS in C57BL/6 mice loaded with galactosamine. No antitumor activity of leptospiral LLS (250-1,000 micrograms/mouse) against the ascites form of Ehrlich carcinoma in ddY mice was observed. The biological activities of the LLS fraction from the organism were weaker than those of gram-negative bacterial LPS, suggesting that Leptospira possesses no typical LPS.

Chemical properties of lipopolysaccharide-like substance (LLS) extracted from Leptospira interrogans serovar canicola strain Moulton

The aqueous layer was isolated from Leptospira interrogans serovar canicola strain Moulton by the hot phenol-water method. After ultracentrifugation, the precipitate was designated as lipopolysaccharide-like substance (LLS) fraction and the chemical composition was compared with that of bacterial LPS. The LLS fraction consists of 35.2% carbohydrate, 3.8% amino sugar, 36.4% lipid, 15.2% protein, and 0.3% phosphorus. Neutral sugars were detected as rhamnose, arabinose, xylose, 4-O-methylmannose, mannose, galactose, and a small amount of erythrose, fucose and glucose by gas-liquid chromatography (GLC), but 2-keto-3-deoxyoctonic acid was not detected in the LLS by thiobarbituric acid test and high voltage paper electrophoresis. Fatty acids detected by GLC were decanoic acid (C10: 0), dodecanoic acid (C12: 0), dodecenoic acid (C12: 1), tridecenoic acid (C13: 1), tetradecanoic acid (C14: 0), hexadecanoic acid (C16: 0), hexadecenoic acid (C16: 1), and octadecenoic acid (C18: 1). With SDS-polyacrylamide gel electrophoresis, bacterial LPS showed many orderly bands, while the banding pattern of the leptospiral LLS was very simple. These findings demonstrate that the physicochemical properties and chemical composition of LLS fraction from Leptospira are different from those of LPS extracted from gram-negative bacteria such as Enterobacteriaceae, and suggesting that Leptospira has no typical LPS.

Pulmonary agenesis with esophageal atresia and tracheoesophageal fistula

A twin neonate with esophageal atresia, tracheoesophageal fistula, and agenesis of the right lung from consanguinous parents is reported. The twin brother was normal. The baby eventually made a good recovery after delayed primary esophageal anastomosis. Thirteen similar cases have been reported in the literature but all died.

[Transfer of cefotetan into exudates from excoriated skin wounds]

Transfer of cefotetan (CTT) into exudates from excoriated skin wounds was studied in 9 adult patients. Each subject was given an intravenous bolus injection of 50 mg/kg of body weight. Concentrations of CTT in serum and in exudate fluid were determined by bioassay using Escherichia coli NIHJ as the test organism. The mean (+/- S.D.) CTT concentration in serum reached 274.3 +/- 78.3 micrograms/ml at 30 minutes after the injection and decreased to 30.0 +/- 12.0 micrograms/ml at 8 hours after the injection. The peak value of CTT in exudate fluid was 143.1 +/- 22.3 micrograms/ml at 1 hour. Eight hours after the injection, the mean concentration in the exudate was 25.7 +/- 21.1 micrograms/ml. The data obtained were analysed pharmacokinetically: CTT concentrations in serum were analysed by two-compartment model, and those in exudate fluid from excoriated skin wounds were analysed by the model in which skin was considered as a small part of the peripheral compartment. Thus T1/2(beta) of CTT levels in serum was calculated as 2.38 hours, AUC0----infinity was 1,000.2 micrograms X hr/ml and Vd was 164.5 ml/kg. Tmax and Cmax of CTT levels in exudates were calculated as 1.05 hours and 131.2 micrograms/ml, respectively.

Effects of digitalis intoxication on pacemaker rhythm and synchronization in rabbit sinus node

Toxic doses of digitalis can induce severe arrhythmias in the sinus node. Since digitalis is known to induce electrical uncoupling in heart tissues, it is possible that the arrhythmias may be mediated by cell-to-cell uncoupling leading to desynchronization of pacemaker cells. We investigated this possibility using intracellular recordings and two different preparations of isolated rabbit sinus node. First, the whole sinus node region with the crista terminalis and a portion of right atrium were exposed to 2 microM ouabain in the presence of atropine (0.09 microM) and propranolol (0.77 microM). With ouabain superfusion, there was a gradual increase in spontaneous discharge, conduction delay, pacemaker shifts, and arrhythmias associated with multiple pacemaker sites. Interaction between pacemakers rapidly decreased, and finally atrial arrest was observed. Second, thin strips of sinus node were placed in a three-compartment bath. Superfusion of the central segment (1.0-1.5 mm) with 1-5 microM ouabain led to tachycardia and apparent conduction delay, followed by asynchronous firing and phasic interactions between pacemakers across the central segment. These interactions diminished in the course of intoxication, indicating a gradual increase of electrical uncoupling induced by the drug. All effects were reversible on washout. We conclude that digitalis-induced arrhythmias in the sinus node result from cell-to-cell uncoupling and loss of synchrony between pacemaker cells. The pattern of arrhythmias can be predicted by the phasic interactions between the pacemakers.

The electromotive force of the ventricular free wall and papillary muscle preparations

The electromotive force of the ventricular tissues with different anatomy and activation patterns was studied. The left ventricular wall was perfused with Tyrode's solution from the circumflex branch of the left coronary artery and was stimulated first at an epicardial and then endocardial site to induce ectopic beats. The early QRS voltage was compared with the activated area at the same instant. In other experiments, the whole heart was perfused from the aorta, and the anterior papillary muscle of the right ventricle was introduced into a small separate chamber. Different locations were stimulated to induce longitudinal and transverse activation, and the remote potential was measured with leads in both directions. By means of a calibration system with artificial dipoles, the strength of the double layer was expressed in terms of mA X cm per unit area of the activation wave front. The results indicated that epicardial stimulation of the left ventricular wall produced voltage proportional to the activated area; the average moment was found to be 0.11 mA X cm per unit area. The potential curve produced by endocardial stimulation of the same preparation was characterized by an initial low-voltage phase, followed by a sharp upstroke. The right ventricular papillary muscle produced a larger double layer moment during activation in the longitudinal direction, but voltage due to transverse activation was several times smaller.

Purpura fulminans in neonates and childhood

Three cases of purpura fulminans are reported. A five-year-old boy was successfully treated for purpura fulminans but had autoamputation of both legs and autolysis of bladder and urethra. He did not show any sign of shock at the onset of the disease. However, before an irreversible change of the skin lesion and organ involvement occurred, prompt diagnosis was effected, and aggressive treatment was given. An eight-day-old girl suffered from purpura fulminans at her four extremities, skull, bladder, ovary and vagina. Interesting findings were obtained in case 2, who had a positive family history. Several black spots in the extremities had disappeared spontaneously before admission, whereas the other lesions got progressively worse, with subsequent severe attack. Her general condition was not parallel to the severity of the disease. A 20-day-old boy had purpura fulminans after severe aspiration pneumonia, and showed a typical clinical course of the disease. In all patients, sudden drop of Hb and leukocytosis occurred after the skin lesion appeared. The diagnosis was unequivocal in these cases. Clotting time and FDP were good indicators of the progress of the disease in conjunction with the clinical features. Prompt diagnosis and aggressive therapy are necessary, not according to the patient's condition, but according to the laboratory findings and the serious nature of the disease. Internal haemorrhage must be considered as well as the skin lesion, this being a fatal complication.

Studies on the mechanisms of secondary pause after high rate atrial pacing

Atrial pacing up to 400 beats per minute (bpm) was performed in 20 open chest dogs. Measurements were made on the first five return cycles. Instances with the first cycle shorter than the basic cycle length were excluded. Secondary pauses (SP) were frequently observed at pacing rates equal to or faster than 280 bpm. Intravenous application of propranolol and atropine did not diminish SP, nor did bilateral vagotomy. Additional subthreshold stimuli, as well as stimulation with electrodes with large interpolar distance influenced neither the length of sinus node recovery time (SNRT) nor the SP phenomenon. Simultaneous pacing of the right atrium and right ventricle had no significant effects on SNRT and SP. Pacemaker shifts occurring frequently after high rate pacing were not necessarily accompanied by SP. The velocity of activation spread over the sinoatrial region was significantly slower (46.9 +/- 7.3 cm/s) in cases with SP than in those with primary pauses (PP) (72.5 +/- 8.1 cm/s). It was concluded that high rate induced SP was a feature indicating suppression of sinoatrial conduction.

On the absolute magnitude of the human lead vector

Twelve cases with temporary artificial pacing were used to investigate on the efficacy of a bipolar current source within the heart to generate potential variations in Frank lead ECGs. A constant current, subthreshold square pulse was applied to the catheter electrodes and the artefact was recorded with the Frank system. Assuming that the Frank system was normalized and orthogonal, the lead vector magnitude was calculated as 0.58 ohm/cm on the average. The value of the lead vector was inversely related to the thorax size. The direction of the vector determined from the recorded potentials approximated the direction of the catheter tip on the X-ray film. In addition, similar measurements were made with a homogeneous torso model and the results were compared with those of clinical cases.

Ruptured abdominal aortic aneurysm in a 7-year-old girl

A case of ruptured abdominal aortic aneurysm (AAA) in a 7-yr-old girl is reported. She required a graft of the abdominal aorta in an emergency operation and recovered successfully. AAA in children is extremely rare, and rupture of AAA to our knowledge has not been previously reported. The literature is reviewed and the possible etiology discussed.

Clinical and experimental studies of the effects of atrial extrastimulation and rapid pacing on atrial flutter cycle. Evidence of macro-reentry with an excitable gap

To investigate the mechanism of atrial flutter in human beings, effects of atrial pacing and extrastimulation on flutter cycle length were studied. In four cases, properly timed extrastimuli shortened the F-F interval after the extrastimulus without affecting the stimulus-encompassing interval. The width of the excitable gap ranged from 14 to 25 percent of the basic flutter cycle length (mean +/- standard deviation 20.4 +/- 4.1). Entrainment to rapid atrial pacing was demonstrated in each case. The width of the entrainment zone nearly coincided with that of the excitable gap in each case. In 16 days, atrial flutter was induced by electrical stimulation after an obstacle was placed between the superior and the inferior venae cavae according to Rosenblueth and Garcia Ramos. In 11 dogs, extrastimuli shortened the F-F interval next to the stimulus-encompassing interval as in the clinical study. The excitable gap, measured in six dogs, ranged from 15 to 24 percent of the basic flutter cycle length (mean 20.6 +/- 3.0). Entrainment was observed in six dogs studied and, during entrainment, the atrial activation sequence was almost the same as that during the basic flutter cycle. It is concluded that shortening of the F-F interval next to the stimulus-encompassing interval that is not affected favors macro-reentry as the mechanism of atrial flutter in human beings.

Necrotising enterocolitis in older infants

Thirteen children, ranging in age from 45 days to 2 years, had severe gastrointestinal illness with the features characteristic of neonatal necrotising enterocolitis. All 13 children had preceding gastroenteritis leading to hypovolaemia. Necrotising enterocolitis can occur in children beyond the neonatal age group and it may occur as a sequel to gastroenteritis.

An experimental model of giant negative T wave associated with QT prolongation produced by combined effect of calcium and isoproterenol

Changes of the surface ECG and monophasic action potential induced by isoproterenol injection were investigated under normo- and hypercalcemic conditions in dogs. (1) Biphasic time course of T wave changes, initially inverted and subsequently uprightly tall, was observed after intravenous injection of isoproterenol in doses of more than 2 microgram. (2) Initial prolongation and subsequent shortening of the phase 2 of action potential were observed on the ventricular surface in accordance with the biphasic time course of the T wave changes on the surface ECG after isoproterenol injection. (3) Giant T wave inversion associated with QT prolongation was obtained by isoproterenol injection under hypercalcemia. (4) Marked prolongation of total duration as well as phase 2 of action potential was observed in accordance with the giant negative T wave on the surface ECG. Although the mechanism of this experimental model of giant negative T wave is not clear, this model could have important suggestions on the unknown mechanism of giant negative T wave observed in various clinical status.

The potential distribution on the epicardial surface and in the surrounding volume conductor

An experimental study was performed on the potential distribution surrounding the heart. The dog heart was isolated, perfused with Tyrode solution and was placed in a spherical container filled with the same solution. The potential measurement was made at 156 sites on the epicardial surface as well as at the same number of locations on the corresponding surface in the solution 0.5 to 2.0 cm apart from the epicardium. The results indicated that considerable simplification of isopotential lines occurred already at a distance of 2 cm from the heart. With the electrode array on the spherical surface enclosing the heart, similar maps were constructed and an index to express the complexity of the map was calculated. With artificial extrasystoles arising from an epicardial site, the potential on the epicardium showed a main negative area with very closely located positive areas. The basis and methods for the determination of epicardial potential from the surface measurements were critically discussed.

Postural changes of vectorcardiogram in defect of the left pericardium

Effects of postural changes upon the vectorcardiograms (VCGs) of four cases with a defect of the left pericardium (three complete and one partial) were compared to those of 115 control cases. Changes in the direction of a given instantaneous vector brought about by postural changes were significantly larger in cases with a pericardial defect than in controls. By turning to the left lateral position, the magnitude of the maximum leftward force decreased in all cases with complete defect, and increased in the case with partial defect and in 96% of controls. These findings were considered to reflect the increased mobility of the heart in cases with pericardial defect due to the lack of the restraining function of the pericardium.

Nocturnal angina pectoris. Comparison between angina with ST segment elevation and depression documented by continuous orthogonal ECG recording

In 30 patients with nocturnal angina, the night-time ECGs were continuously recorded, and the time and duration of attack, cyclic character of attacks, the relation of chest pain to ischemic ECG changes and arrhythmias during attack were compared between 18 cases with ST elevation and 12 cases with ST depression during attack. In cases with ST elevation, 1) attacks occurred between 2:00 and 8:00 a.m., being most frequent between 4:00 and 5:00 a.m. 2) the duration of attack measured from the duration of ischemic ECG changes was less than 5 min in 88% of the attacks, 3) the attack often recurred with intervals less than 30 min and ECG changes were often unaccompanied bt chest pain, 4) the attack was complicated with various kinds of arrhythmias. These features were in marked contrast to the cases with ST depression, in which attacks were evenly distributed over the night-time, of longer duration, sporadic in occurrence and far less complicated with arrhythmias. These data suggest that the difference of mechanisms causing attacks between both groups.

Sinoatrial responses to premature atrial stimulation: clinical observations and experimental study

Two clinically-observed patterns in the response curve relating coupling intervals of premature atrial stimulation to return cycles were experimentally reproduced and studied by microelectrode techniques in the sinoatrial preparations of rabbit hearts. The progressive prolongation pattern of the return cycles with shortening of coupling intervals was associated with progressive depressions both of atriosinus conduction and sinus node automaticity. The progressive shortening pattern of the return cycles was associated with progressive shortening in the duration of sinus node action potential in two-thirds of the preparations and with pacemaker shift in the remaining one-third of them. Possible "sinus node reentry" was demonstrated. The mechanisms and clinical implications of these phenomena were discussed.

Apparent suppression of ventricular parasystole by cardiac pacing

Complete disappearance of ventricular parasystolic beats by cardiac pacing with the rates of near multiples of the parasystolic rate was observed in 2 patients with ventricular parasystole. This finding represents a clinical counterpart of recently demonstrated experimental and mathematical models of electrotonic modulation of the parasystolic discharge.

Sinoatrial response to premature atrial stimulation during atrial pacing in aged patients with and without sinus node dysfunction

Sinus node function was analysed in 15 aged patients, including 8 with sick sinus syndrome and 7 without apparent sinus node dysfunction, by rapid artial pacing and premature atrial stimulation during sinus rhythm and 5 beats of atrial pacing. Three patterns of sinoatrial response were identified by premature atrial stimulation during atrial pacing. Type I response (3 cases) represented approximately constant return cycles and type II (2 cases) represented a markedly prolonged return cycles following premature stimulation. Type III response was characterized by a progressive shortening of return cycles as the prematurity of atrial extrastimuli was increased. Underlying mechanisms responsible for these responses were discussed in relation to the sinus node automaticity and sinoatrial conduction.

Three cases of sinoatrial block induced by anticonvulsants

Diphenylhydantoin (DPH) and Carbamazepine have been widely used as anticonvulsants and known to have antiarrhythmic properties. Previous reports have shown that arrhythmias such as sinus bradycardia and atrioventricular block can be induced by these agents. In this paper, sinoatrial block (SA block) induced by these agents which were used as anticonvulsants in 3 aged patients is reported. Thre patients, 2 women and 1 man, were over 60 years old. In 2 cases, administration of DPH for recurrent epileptic seizures was followed by SA block. After withdrawal of DPH, SA block disappeared, but resumption of DPH resulted in SA block again. In 1 of these 2 patients, overdrive suppression test revealed normal sinus node recovery time. In the third patient, in addition to DPH which was administered for epileptic seizures, Carbamazepine was given for shoulder pain, then SA block occurred. Withdrawal of these agents restored normal sinus rhythm and combined administration of these 2 agents again induced SA block. Autopsy revealed decreased conduction cells in the sinus node.

Enhancement of germination rate of aged seeds by ethylene

Naturally and artificially aged seeds of rape, Brassica napus L., produced less ethylene than freshly harvested seed during the early stage of germination. With freshly harvested seeds one peak of ethylene production was observed during germination, which coincided with the emergence and elongation of root and cotyledon, accompanied by splitting of the seed coat. Application of exogenous ethylene was effective in accelerating germination in aged seeds but did not significantly improve the percentage of germination. Ethylene as a hormone was considered to serve as a stimulator of germination and growth. One of the factors causing seed aging might be the degeneration of an ethylene-producing system in the seed. Exogenous ethylene may be effective only for the seeds in which the ethylene-producing system is weakened but the following responding systems are still functional.