An acquired bullous dermatosis due to an autoimmune reaction against uncein

A 59-year-old male showed acquired, mechanically induced, scarring blisters on the fingers, toes, scalp and abdomen, as well as in the oral cavity. Ultrastructural and immunohistochemical examination of the bullae revealed junctional epidermal-dermal separation and IgG deposits in the lamina lucida of the basement membrane zone (BMZ), where the reactivity of the 19-DEJ-1 monoclonal antibody was decreased. Anti-BMZ autoantibodies detected in his serum were reactive to the lower lamina lucida region of normal human skin. SDS-PAGE of affinity purified antigens from human keratinocytes with IgG from the patient's serum revealed three polypeptide bands at 165, 135 and 100 kDa, in reduced condition. The indirect immunofluorescence test of his serum was negative on skin cryosections from patients with lethal junctional epidermolysis bullosa. Pretreatment of normal human skin sections with the patient's serum, blocked the binding of 19-DEJ-1 monoclonal antibody but not that of the GB3 monoclonal antibody. This case is considered to be an acquired autoimmune bullous dermatosis due to an autoantibody reaction against uncein (19-DEJ-1 antigen), a component of anchoring filaments.

Evaluation of sialyl Lewisx antigen in the skin and the sera of patients with psoriasis vulgaris

The roles of sialyl-Lewisx antigen were evaluated in the pathogenesis of psoriasis. Sialyl-Lewisx expression was investigated immunohistochemically in the epidermis of normal human skin and erythematous lesional skin of psoriasis vulgaris by avidin-biotin-peroxidase complex procedures. A few sialyl-Lewisx positive dendritic cells were detected in the epidermis of normal human skin. In 7 out of 9 cases of psoriasis vulgaris, the number of sialyl-Lewisx-positive epidermal dendritic cells increased in the erythematous lesion over the adjacent normal skin; there were no marked changes in the numbers of CD1a-positive cells in the epidermis between the two skin types. In the double immunofluorescence studies, more than half of the sialyl-Lewisx-positive epidermal cells in psoriatic erythema were stained with a monoclonal Lag antibody that specifically reacts with Birbeck granules and related structures of human Langerhans cells. Furthermore, we determined the changes in serum levels of sialyl-Lewisx antigens in patients with psoriasis. Although levels in the sera were not significantly elevated over those of controls, the increases correlated with the degree of disease activity. These findings suggest that sialyl-Lewisx antigen is possibly involved in the development of psoriasis.

Establishment of a human cell line secreting neuron-specific enolase from a primitive neuroectodermal tumor of the retroperitoneal cavity

Primitive neuroectodermal tumor (PNET) is one of the small round cell malignancies of presumed neural crest origin for which an effective treatment has not yet been established. In the present study, a human cell line, designated KU-9, was established from a 27-year-old male patient with PNET of the retroperitoneal cavity and has been successfully maintained in nude mice and in culture. On histological examination, the primary tumor was composed of poorly differentiated small round cells arranged in clusters showing a variety of mitotic changes, and contained Homer-Wright rosettes. The histopathological appearance of the KU-9 xenografts was similar to that of the primary tumor. Electron microscopy revealed neurosecretory granules and cytoplasmic processes in the xenograft. No significant amplification of N-myc gene was observed in the KU-9 cells. The KU-9 cells showed chromosome numbers ranging from 56 to 61 with consistent structural abnormalities being add(2)(q31), +add(11)(p11.2), +add(13)(p11.1), and +del(22)(q12). Cultured KU-9 cells grew exponentially with a doubling time of about 50 h and a time-dependent increase in medium levels of neuron-specific enolase (NSE) was noted. Serum levels of NSE in KU-9 tumor-bearing nude mice were significantly elevated and a linear relationship between the serum NSE levels and the tumor NSE content or tumor volume was observed, suggesting that serum levels of NSE may reflect the PNET tumor burden and tumor extent. These results indicate that the KU-9 cell line provides a reproducible model system which could be useful in gaining some insight into the histogenesis and oncogenesis of PNET and in establishing an effective treatment for PNET.

[Efficacy of the artificial ventilation for the treatment of IgE-mediated anaphylactic shock in dog]

To evaluate efficacy of artificial ventilation with 100 % oxygen for treatment of IgE-mediated anaphylaxis, we compared survival of control ventilated dogs with one of dogs with spontaneous ventilation. Fourteen dogs sensitized to Toxica canis were randomly assigned to two groups: spontaneous respiration group (Group S, n = 8) and artificial ventilation group (Group A, n = 6). All dogs were anesthetized with pentobarbital. In Group S, all dogs breathed spontaneously with constant flow of 4 l.min-1 of oxygen. Spontaneous respiration maintained an end-tidal CO2 level between 40 and 50 mmHg. In Group A, the dogs, paralyzed with pancuronium, were ventilated mechanically with 100 % oxygen, and the tidal volume was adjusted to maintain an end-tidal CO2 level between 35 and 40 mmHg. After measurements of pulmonary resistance (RL), dynamic compliance (Cdyn), and circulatory parameters at baseline, Ascaris suum antigen was administered intravenously into the systemic circulation to induce IgE-mediated anaphylaxis. RL, Cdyn and circulatory parameters were recorded continuously for 120 min after antigen challenge. Analysis of arterial blood gases was done throughout the study. Survival rates were 100 % and 50 % in Group A and Group S, respectively. In 7 of 8 dogs in Group S, apnea was observed during the period of 1 min to 5 min after antigen challenge, and the apnea continued during the period of 30s to 22 min. Four dogs died during the period of 20 min to 30 min after antigen challenge. In both groups, RL increased significantly and Cdyn decreased significantly after antigen challenge.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anesthesia in a patient with history of multiple drug allergies]

A 38-year-old woman was admitted for intranasal ethmoidectomy. She had a history of serious anaphylactic reactions, including respiratory distress, hypotension and unconsciousness, to nonsteroidal anti-inflammatory drugs (Loxonin, Niflan) and antibiotics (Kefral, Minomycin). Preoperative intradermal skin tests against anesthesia-related drugs showed positive reactions to succinylcholine and vecuronium. After bilateral maxillary nerve block with 0.5 % bupivacaine (negative intradermal test) 3 ml, anesthesia was induced with diazepam, nitrous oxide, oxygen and sevoflurane. Trachea was intubated smoothly without muscle relaxants. Anesthesia was maintained with nitrous oxide, oxygen and sevoflurane 0.5-1 %. The anesthesia and postoperative course of this patient were uneventful. To confirm the initiation of allergic reaction to anesthetics used in the patient, serum histamine, tryptase, and complement 1, 3 and 4 factors were measured at 3 points: preoperatively, immediately after the induction, and after extubation. They showed normal levels. These results showed that no allergic reaction occurred perioperatively. In conclusion, the valuable information was provided for the choice of anesthetics by thorough evaluation of the past history and intradermal testing.

Common mutations in the low-density-lipoprotein-receptor gene causing familial hypercholesterolemia in the Japanese population

Familial hypercholesterolemia (FH) is a common genetic disorder caused by mutations of the LDL-receptor gene. In the present study, we investigated four Japanese FH homozygotes and identified five point mutations: a splice site mutation in intron 12 (the 1845 + 2 T-->C mutation), a missense mutation in exon 7 (the C317S mutation), a nonsense mutation in exon 17 (the K790X mutation), a missense mutation in exon 14 (the P664L mutation), and a missense mutation in exon 4 (the E119K mutation). We developed simple methods for detecting these mutations. When we examined the presence of these mutations in 24 unrelated FH homozygotes, the 1845 + 2 T-->C mutation was found in 7 of them, and the other four mutations were unique for each proband. We also screened 120 unrelated FH heterozygotes for these mutations and found that the frequencies of the 1845 + 2 T-->C, C317S, K790X, P664L, and E119K mutations were 13.3% (16/120), 6.7% (8/120), 6.7% (8/120), 3.3% (4/120), and 1.7% (2/120), respectively. These mutations were found in more than 30% of unrelated Japanese FH patients. By using the detection methods developed in this study, the diagnosis of more than 30% of the genetic bases of Japanese FH heterozygotes is expected.

Bordetella bronchiseptica dermonecrotizing toxin stimulates assembly of actin stress fibers and focal adhesions by modifying the small GTP-binding protein rho

We studied the biochemical mechanism of morphological changes in cells treated with Bordetella dermonecrotizing toxin (DNT). DNT caused the morphological changes of serum-starved MC3T3-E1 cells from flat shapes to reflactile ones. These changes were accompanied by the assembly of actin stress fibers and focal adhesions, which is known to be regulated by the small GTP-binding protein rho. Clostridium botulinum C3 exoenzyme, which ADP-ribosylates and inactivates rho protein, ‘rounded’ the cells within 2 hours after addition to the extracellular fluid and their rounded shapes were maintained for at least 10 hours. However, when the cells were co-treated with C3 exoenzyme and DNT, they were rounded at 2 hours but recovered an apparently intact morphology after 3–8 hours of incubation. rho proteins in lysates from DNT-treated cells and untreated cells were radiolabeled by [32P]ADP-ribosylation with C3 exoenzyme and analyzed by SDS-polyacrylamide gel electrophoresis. Whereas the lysate from untreated cells showed a single band of [32P]ADP-ribosylated rho protein, the lysate from DNT-treated cells showed an additional two bands as well as the band identical to that of the lysate from untreated cells. Recombinant rhoA protein treated with DNT in vitro also showed a mobility shift in SDS-polyacrylamide gel electrophoresis. These results indicate that DNT causes the assembly of actin stress fibers and focal adhesions by directly modifying rho protein.

A case of autoimmune bullous dermatosis with features of pemphigus vulgaris and bullous pemphigoid

Pleomorphic blisters, including tense bullae and annularly arranged vesicles around the erythema as well as erosive eruptions in the oral cavity, appeared on a 61-year-old woman 5 years after surgery for cholangiocellular carcinoma. A biopsy specimen from the oral cavity showed intraepidermal blisters, and those from skin lesions showed subepidermal blisters with infiltrates of eosinophils and neutrophils. The early-stage vesicles showed infiltrates along the epidermal-dermal junction, where electron microscopy disclosed disruption of the lamina densa, basal cells remaining on the dermis, and acantholytic keratinocytes among the infiltrates, but there was no cleavage of the epidermal-dermal junction at the lamina lucida. Direct immunofluorescence studies showed immune deposition at the intercellular space (ICS) and along the basement membrane zone (BMZ). Indirect immunofluorescence studies confirmed coexistence of IgG class anti-ICS and anti-BMZ antibodies. Although this case showed immunohistochemical features of bullous pemphigoid, the presence of suprabasal cleavage in the oral mucosa, acantholytic cells in the blister cavity, the deposition of IgG at the ICS of the perilesional epidermis, and circulating anti-ICS antibodies strongly suggested that this case was primarily pemphigus. The strong inflammation along the epidermal-dermal junction due to unknown factors may have modified the clinical appearance and the histopathology.

Effects of Bordetella bronchiseptica dermonecrotizing toxin on bone formation in calvaria of neonatal rats

The effects of Bordetella bronchiseptica dermonecrotizing toxin on bone formation were investigated using a purified toxin preparation. Single injection of 4.3 ng of the toxin into the subcutaneous tissue overlying the calvariae of neonatal rats necrotized periosteum of parietal bone and degenerated osteoblasts within two days. Nine days after the injection, the lesion of the bone tissue became severe; the bone matrix became thin and fragmented. These observations indicate that dermonecrotizing toxin without other factors produced by the organisms impairs bone formation.

[Usefulness of measurement of mast cell tryptase for differential diagnosis of anaphylaxis and anaphylactoid reaction]

We described a case of anaphylaxis diagnosed by the evaluation of plasma mast cell tryptase and a case of anaphylactoid reaction. In a patient undergoing pulmonary lobectomy, anaphylaxis, showing the elevation of plasma tryptase, was provoked by physiological glue for hemostasis during the operation. During the operation, cardiovascular collapse occurred suddenly, at which time the cause was not diagnosed. After completion of the operation and removal of drapes, diffuse urticaria with wide erythema on the torso and the upper extremity was noticed. Suspecting allergic adverse reaction, plasma tryptase was measured 2h and 5h after the start of the episode, showing 34.6 ng.ml-1 at 2h and 15.3 at 5h. Because these elevations of plasma tryptase indicated degranulation of mast cells, evaluation of the causative drugs was performed 7 weeks after the episode. Physiological glue was confirmed to be causative drug. In another patient for total hysterectomy and bilateral oophorectomy, adverse reaction occurred after completion of the operation and extubation. Increase in plasma histamine concentration to 4.94 ng.ml-1 that could induce systemic reaction was noticed; however, concentrations of plasma tryptase 25 min, 3h and 7h after the episode were not elevated. This finding indicated that the adverse reaction was not based on degranulation of mast cell, and was anaphylactoid reaction provoked by nonspecific histamine-release. In conclusion, measurement of plasma tryptase is a useful method for differential diagnosis of anaphylaxis and anaphylactoid reaction.

Coronary vasoconstriction is the most probable cause of death of rats intoxicated with botulinolysin, a hemolysin produced by Clostridium botulinum

The pathophysiology of lethal intoxication by botulinolysin (Blyn) was studied using anesthetized rats and isolated rat organs. Intravenous injection of 10,000 and 1000 hemolytic units (HU) of Blyn killed rats rapidly while 100 HU of the toxin did not. Congestion and edema of lungs were observed at autopsies of the rats killed by intoxication. Hemoglobinemia was obvious in rats injected with 1000 HU of Blyn but not in rats with 10,000 HU. Electrocardiograms of the intoxicated rats showed depression of T waves but not changes characteristic of hyperpotassemia. All the rats injected with the above doses of Blyn showed a rapid fall in arterial blood pressure (BP) immediately after the toxin injection, and BP soon recovered in rats injected with 100 HU, partially and transiently in rats with 1000 HU, and not in rats with 10,000 HU of Blyn. Perfusion of Blyn (1 HU/ml) to isolated rat hearts caused a rapid and marked increase in perfusion pressure and cessation of spontaneous heart beat. Acetylsalicylic acid (10(-3) M) and quinacrine dihydrochloride (10(-5) M) did not essentially influence the effects of Blyn on the isolated hearts, but verapamil (10(-6) M) inhibited at least the initial increase in perfusion pressure elicited by Blyn. Spontaneous contractions of the isolated atria were little influenced by Blyn (60 HU/ml). Perfusion pressures of isolated kidneys, lungs and livers were also increased by Blyn (1 HU/ml). The results indicate that Blyn caused vasoconstriction but had little direct effect on myocardium. Based on the above findings, we conclude that coronary vasoconstriction elicited by direct action of Blyn causes acute cardiac dysfunction leading to systemic hypotension and death of the intoxicated animals.

Nitric oxide synthase inhibition is detrimental to cardiac function and promotes bronchospasm in anaphylaxis in rabbits

We studied the effects of a nitric oxide synthase (NOS) inhibitor, N omega-nitro-L-arginine-methyl ester (L-NAME), on cardiac depression and bronchospasm provoked by systemic anaphylaxis in vivo in rabbits. Animals pretreated with L-NAME showed lower survival rates than control animals pretreated with normal saline. The survival rate in L-NAME-pretreated animals was increased by the administration of L-arginine after initiation of anaphylaxis. Cardiac output fell significantly in animals pretreated with L-NAME compared with controls, although venous return was increased. In animals pretreated with L-NAME, pulmonary resistance was significantly increased, and administration of arginine attenuated the bronchospasm. In conclusion, these results, along with the low survival rates in the L-NAME-treated animals, suggest that NO production may be beneficial to cardiac depression and bronchospasm in anaphylaxis in vivo.

Evaluation of left ventricular diastolic function in IgE-mediated anaphylaxis in dogs

Depressed left ventricular (LV) systolic function remains controversial in patients with anaphylaxis and anaphylactic animal models. However, LV diastolic function has not yet been investigated in either patients or animal models. Therefore, we assessed LV diastolic and systolic function in IgE-mediated anaphylaxis in dogs. Seven dogs sensitized to Ascaris suum antigen were studied. An aqueous extract of Ascaris suum antigen was administered over 30 s into the systemic circulation to induce anaphylaxis. To assess LV function, the time constant of the fall of isovolumic LV pressure (T), as an index of LV diastolic function, and the maximum rate of rise of LV pressure (dP/dtmax), as an index of LV systolic function, were measured for a period of 120 min after antigen challenge. T was prolonged during the period of 5 to 15 min; however, changes in T were not significantly different from prechallenge values. LV d}/dtmax significantly decreased to 0.49 +/- 0.12 times the prechallenge value 5 min after antigen challenge, and significantly increased during the period from 30 to 120 min. However, these changes in dP/dtmax almost paralleled the changes in LV end-diastolic pressure, indicating that left ventricular systolic function was relatively well preserved. In conclusion, LV diastolic function, i.e., isovolumic relaxation, is little impaired in anaphylaxis, and LV systolic function is relatively well preserved during the early stage following the onset of anaphylaxis.

An inhibitor of nitric oxide synthase, N omega-nitro-L-arginine-methyl ester, attenuates hypotension but does not improve cardiac depression in anaphylaxis in dogs

We investigated whether a nitric oxide synthase (NOS) inhibitor improves cardiovascular depression associated with anaphylaxis. After induction of anaphylactic circulatory depression, one group received an NOS inhibitor (Group I, n = 6) and the other received saline solution (Group II, n = 5). Mean arterial pressure and right atrial pressure were significantly higher in Group I than in Group II. Hematocrit was significantly lower in Group I than in Group II. Cardiac output, stroke volume, mean pulmonary arterial pressure, the maximum rate of increase in left ventricular pressure, and the time constant of the fall in isovolumic left ventricular pressure did not differ between the groups. In conclusion, L-NAME attenuates hypotension, but does not improve cardiac depression in anaphylaxis in dogs. Our finding that NOS inhibitor did not improve cardiac function implies that the production of NO in anaphylaxis may have a protective effect with regard to cardiac performance.

[Effect of horizontal lithotomy position on spread of hyperbaric dibucaine spinal anesthesia]

We have studied the effect of horizontal lithotomy position on the spread of hyperbaric dibucaine spinal anesthesia. In three groups of 20 patients, 7.2 mg of hyperbaric dibucaine was injected intrathecally in the lateral decubitus position. In group supine, the patients were kept in supine horizontal position in which patient's legs and thighs were extended throughout the operation. In group lithotomy A, immediately after the spinal injection, the patients were placed into the lithotomy position. In group lithotomy B, after the spinal injection, the patients were placed immediately in the supine horizontal position for 15 min and then placed into the lithotomy position. There were no significant differences in height of sensory blockade among the three groups. The lithotomy position did not significantly affect the level of sensory blockade with hyperbaric dibucaine.

Comparison of plasma total plasmin activities in male and female hypertensive rats

Plasma total plasmin activity in spontaneously hypertensive rats (SHR) was lower than in normal Wistar rats, and in male SHR, plasmin activity was higher than that in females. However, this sex-related difference in SHR was less than that observed in our previous study in normal Wistar rats. Furthermore, we and others have reported higher levels of coagulant functions in male than in female rats. These studies were taken to indicate that there is a greater necessity for higher fibrinolytic activity in males than in females. The results of the present study suggest that hypertension is a risk factor of thrombosis in view of the increased fibrinolytic activity, and in SHR there is also a sex-related difference in plasma total plasmin activity.

[Successful treatment of subacute sclerosing panencephalitis with long-term intrathecal large dose of alpha-interferon--a case report]

Recent effective treatments for subacute sclerosing panencephalitis (SSPE) are oral inosiplex and intrathecal interferon therapy. The former seems to be effective for life expectancy but not for neurological disability, and the latter is a debating antiviral treatment although favorable reports are increasing. A 12 year-10 month-old boy with SSPE was presented as a successful case of prolonged effectiveness in both neurological symptoms and life expectancy. There are no significant side effects by the 200 weeks treatment of intrathecal alpha-interferon of large dose (6 million unit/dose/week) and ordinary dose of inosiplex (100 mg/kg/day). Neurological disability index (Dyken) improved from 70% to 10%; speech and higher cerebral functions improved from aphasia and almost vegetative states to verbal communicable level; motor dysfunction from bedridden to wheel chair level; and myoclonic and other seizures were controlled. Laboratory data also improved; periodic synchronized discharge (PSD) and other paroxysmal discharges disappeared and alpha activity that had once disappeared in the background activity of active stages reappeared in the EEGs. Measles antibodies in serum and CSF improved, and oligoclonal bands disappeared. However diffuse brain atrophy remained on neuroimaging. Long-term intrathecal large dose treatment with alpha-interferon is effective and safe. It should be started as soon as the diagnosis is made, and a trial of large-dose and long-term therapy may be worthy even for more advanced cases irrespective of progress of neuroimages.

[Postoperative analgesia service by continuous epidural infusion with buprenorphine]

We examined the analgesic efficacy and side effects of continuous epidural infusion with buprenorphine in 340 surgical patients. The patients received epidural injection of 0.1 mg of buprenorphine in 8 ml of 0.25% bupivacaine immediately after surgery. The patients who underwent thoracotomy or intraabdominal surgery were subsequently infused with buprenorphine 15 micrograms in 1 ml of 0.25% buprenorphine at a rate of 1 ml.h-1 for 48 h. In the other kinds of surgery, patients were infused with buprenorphine 8 micrograms in 1 ml of 0.25% buprenorphine at a rate of 1 ml.h-1 for 48 h. The patients who did not need additional narcotics were 68% and 83% on the postoperative day 1 and 2, respectively. Visual analogue scale (VAS) was 22 +/- 2 mm at rest and 43 +/- 2 mm at movement on the postoperative day 1. Corresponding values on the postoperative day 2 were 16 +/- 2 mm and 37 +/- 2 mm, respectively. Nausea and vomiting were found in 12.4% of the patients.

The enterotoxin of Clostridium perfringens type A binds to the presynaptic nerve endings in neuromuscular junctions of mouse phrenic nerve-diaphragm

The enterotoxin of Clostridium perfringens type A, a channel-pore forming protein toxin, inhibited neuromuscular transmission in isolated mouse phrenic nerve-diaphragm preparation at low concentrations of calcium. We investigated immunohistochemically the localization of the binding sites of the enterotoxin in the preparation under the conditions in which the enterotoxin reduced maximally the amplitudes of the twitch tension elicited by electrical stimulations to the phrenic nerve. Under the conditions, double immunohistochemical staining of the preparation with (1) rabbit anti-enterotoxin IgG-rhodamine-labeled goat anti-rabbit IgG and (2) mouse anti-synaptophysin (one of the synaptic vesicle-specific membrane proteins)-fluorescein isothiocyanate (FITC)-labeled goat anti-mouse IgG showed that the enterotoxin binds specifically to most of the sites which were stained with anti-synaptophysin exactly in the same configurations having the shapes of the nerve endings in the endplates. The thin section electron micrographs of the enterotoxin-intoxicated preparation showed no alterations in the ultrastructure of the neuromuscular junction and the nerve endings filled with numerous synaptic vesicles. The present results, together with our previous electrophysiological findings, indicate that the enterotoxin binds specifically to the presynaptic nerve endings and inhibits neurotransmitter release at the neuromuscular junction.

[Patient's complaints preceding severe bradycardia and hypotension during spinal anesthesia]

We reported an episode of sudden bradycardia and hypotension during spinal anesthesia, in which the patient complained of nausea before the bradycardia and hypotension were recognized by the monitors, such as, intermittent measurement of arterial pressure, electrocardiography, pulse oxymetry and continuous arterial blood gas analysis. We emphasize the importance of strict vigilance during spinal anesthesia.

[Lumbar epidurography with iohexol: the effect of aging on the leakage of contrast media from the intervertebral foramina]

The lateral and longitudinal spread of contrast media was investigated by lumbar epidurography with 8 ml of iohexol in 47 patients aged 25 yr to 86 yr. Iohexol was injected through the epidural catheter epidurally advanced by 5 cm cephalad from the L 1-4 interspace. A significant correlation was found between the longitudinal spread of iohexol and aging. No correlation was found between the leakage of iohexol from the intervertebral foramina and aging. This finding may deny the hypothesis that in elderly patients, the more extensive longitudinal spread of local anesthetics in the epidural space may be caused by its smaller leakage from the intervertebral foramina.

Hemodynamic adaptations at birth and neonates delivered vaginally and by Cesarean section

In order to assess the possible influence of differences in delivery mode on cardiovascular adaptation at birth, we measured left ventricular output and its regional distribution in the major organs sequentially using an echographic technique during the first 96 h of life. We studied 27 normal newborns, of whom 15 were delivered vaginally and 12 by cesarean section. We also measured umbilical arterial and venous catecholamine concentrations. The umbilical arterial epinephrine and norepinephrine concentrations in the infants delivered vaginally were significantly greater than those in the infants delivered by cesarean section (epinephrine 1,195 +/- 208 vs. 565 +/- 81 pg/ml, p < 0.05; norepinephrine 11,832 +/- 3,819 vs. 5,153 +/- 1,400 pg/ml, p < 0.05). The left ventricular output and its regional distribution showed a similar pattern in the two groups, and there were no significant differences between them. These results indicate that the capacity of infants delivered by cesarean section to tolerate cardiovascular changes during the early neonatal period is comparable to that in infants delivered vaginally, even though there are significant differences in the catecholamine surge between these groups.