Effect of body position on the blood gases and ventilation volume of infants with chronic lung disease before and after feeding

The effect of body position before and after tube feeding was evaluated in six extremely immature infants who were being mechanically ventilated because of chronic lung disease. Their mean birthweight and gestational age were 722.7 g (range, 540 to 994) and 24.9 weeks (range, 23.9 to 26.0), respectively. This study was performed at a mean postnatal age of 47.5 days (range, 21 to 85 days). The prone position resulted in a significant increase in arterial oxygen saturation before and after feeding, whereas the tidal volume demonstrated an increase only before feeding. Also the prone position showed a significant decrease in heart rate before and after feeding and a tendency to decrease transcutaneous carbon dioxide tension values before feeding. There were no significant differences in minute ventilation despite increased tidal volume in the prone position, most likely due to a decrement of the spontaneous respiratory rate in the prone positioning. We conclude that the prone position may offer an advantage over the supine position in the management of extremely immature infants with chronic lung disease before and after feeding.

Two cases of monozygotic twins, in each of which one fetus was prenatally diagnosed as having a heart anomaly

In each of the 2 cases of monozygotic twins reported here, 1 of the fetuses was suspected, as a result of a prenatal ultrasonographic examination, of having congenital heart disease (CHD). One of twins (Case 1) had a hypoplastic left heart (HPLH), coarctation of the aorta (CoA), mitral stenosis (MS), and an atrial septal defect (ASD). Of the other twins (Case 2), 1 fetus had pure pulmonary atresia (PPA) and tricuspid regurgitation (TR). In Case 1, the fetus with CHD had a single umbilical artery, the other had otherwise. In Case 2, the fetus with CHD had a velamentous insertion and an accessory placenta, and the other fetus had a marginal insertion. These findings suggest that environmental factors such as blood flow, blood pressure and so on have a role in the etiology of CHD.

Clinical usefulness of the dye-injection method for diagnosing premature rupture of the membranes in equivocal cases

OBJECTIVE

In 1981, we preliminarily reported on the clinical value and safety of the intra-amniotic dye (Phenol-sulfonphthalein, PSP)-injection method for diagnosing PROM. In the current study, through examination of 64 equivocal cases in the midtrimester of pregnancy, we investigated the clinical efficacy of the PSP test.

METHODS

In the present study we examined patients with equivocal PROM in their 14th week to 33rd week of gestation, whose findings were positive according to a combination of conventional diagnostic methods. The results of the PSP test and conventional diagnostic methods were compared with the final diagnosis of PROM.

RESULTS

The conventional diagnostic methods showed an accuracy rate of 63.9%-70.5%, in contrast to the PSP test, which had a 100%-accuracy rate (p < 0.001).

CONCLUSION

Using the PSP test in combination with amnioscopy, we have established a method of differentially diagnosing PROM. We have reconfirmed the clinical efficacy of the PSP test in 64 equivocal PROM cases.

Fetal fibronectin concentration in amniotic fluid decreases with advancing gestational age

OBJECTIVE

The purpose of this study was to investigate the changes in the level of fetal fibronectin in amniotic fluid during the course of pregnancy.

METHOD

Amniotic fluid samples were obtained from 74 women whose pregnancies ranged in gestation from 14 to 38 weeks. Fetal fibronectin in amniotic fluid was examined with a sensitive immunoassay using a monoclonal antibody FDC-6 which recognizes a unique epitope (III-CS) of the molecule.

RESULTS

Fetal fibronectin levels in amniotic fluid decreased significantly during pregnancy (r = -0.79, P < 0.0001). The mean levels at less than 20 weeks of gestation were significantly higher than those at 20-29 weeks (P < 0.0001) and at 30 weeks to term (P < 0.0001).

CONCLUSION

These results must be considered when fetal fibronectin in vaginal fluid is used as an indicator of the rupture of membranes.

[Anatomical analysis of small bronchial arteries in front of the trachea by 3D-CT and digital subtraction angiography: implications for esophageal cancer surgery]

To preserve blood supply to the trachea and bronchus in the surgical procedure for esophageal cancer, anatomical characteristics of small bronchial arteries which course in front of the trachea were analysed by three-dimensional computed tomography (3D-CT) and digital subtraction angiography (DSA). In the 3D-CT study using five mediastina, three dimensional images of the bronchial arteries were reconstructed after the injection of contrast medium into the intercostobronchial arteries. Thus the detailed vascular network of the course of the small bronchial arteries in front of the trachea could be delineated. In the DSA study using seven mediastina, through this network of bronchial arteries, the branches originating from the aorta and the arteries supplying the cranial portion of the trachea could be viewed. These results indicate that the bronchial arteries are connected by a vascular network in front of the trachea. Based on these detailed findings, it is considered critical to avoid damage to the intercostobronchial artery and also the network of bronchial arteries in order to preserve blood supply to the trachea and bronchus.

Symptomatic intraventricular arachnoid cyst in an elderly man

A case of intraventricular arachnoid cyst in an elderly man is reported. A 63-year-old man developed a progressive gait disturbance over a five-year period. CT scan showed a large cyst in the left lateral ventricle which was negative to contrast enhancement. CT cisternography revealed gradual accumulation and more than 48 hours retention of contrast medium in the cyst. The patient underwent left frontal craniotomy, and the cyst wall was partially resected for histopathological examination. Although limit microscopic examination could not establish a diagnosis, arachnoid cyst was diagnosed by electron microscopic findings. Biochemical analysis did not detect any difference between cyst fluid and CSF obtained during surgery. It is suggested that a ball-valve mechanism caused progressive enlargement of the cyst and gradual development of symptoms in this elderly patient.

Intraoperative stress for surgeons and assistants

1. Less experienced surgeons and assistants exhibit more stress during microsurgery. 2. This stress cannot be reduced easily, but can be overcome with experience. 3. Experienced surgeons should be aware of this stress when they train inexperienced surgeons and assistants.

Cloning of canine osteosarcoma cells

Six clonal cells were established from a canine osteosarcoma cell line (POS) by a limiting dilution method using feeder cells. Whereas histology of mass developed in nude mice by transplantation of POS cells revealed various cell types, clonal cells were morphologically consistent in size and shape. Doubling time of clonal cells ranged from 30 +/- 1.4 to 54 +/- 1.3 hr and alkaline phosphatase activity ranged from 0.040 +/- 0.001 to 2.61 +/- 0.435 mumol/min/mg protein depending on the cell types. When transplanted into nude mice, each clonal cell type formed following four histological types; osteoblastic, chondroblastic, fibroblastic, and undifferentiated types. Since each histological feature was found simultaneously in the primary tumor, osteosarcoma tissue might be a complex of various types of cells having different characteristics. Therefore, POS clonal cells may be useful as a potential tool for the studies of differentiation, phenotypic expression, and a new therapeutic modality of osteosarcoma.

Pregnancy complicated by Ebstein's anomaly: oxygen administration to mother for chronic fetal hypoxemia. A therapeutic case report

For chronic fetal hypoxia due to maternal Ebstein's anomaly, oxygen was administered daily to the mother by mask for 105 days. At 20 weeks of gestation, umbilical venous blood gases in room air showed pH 7.42, PO2 25.7 mm Hg, PCO2 33.7 mm Hg and O2 saturation 48.7%, and changed to 7.45, 39.1 mm Hg, 25.9 mm Hg and 77.4% on 3 liters/min of oxygen inhalation by mask, respectively. The PO2 of the maternal arterial blood gases increased to 30 mm Hg on oxygen administration at 15 weeks of gestation, but at 25 weeks of gestation the PO2 increased by only about 10 mm Hg. At 30 weeks, intrauterine growth retardation was suspected. Just after the second puncture of the umbilical cord at 31 weeks and 3 days of gestation, 80 bpm fetal bradycardia occurred for several minutes without recovery and emergency cesarean section was done under the general anesthesia.

Ethylene oxide sterilization of bone grafts. Residual gas concentration and fibroblast toxicity

We examined the concentration of ethylene oxide in bone allografts after gas sterilization. Chips of the human femoral head were investigated. Residual gas concentration was determined by gas chromatography after the bone chips had been subjected to defatting and freeze-drying, followed by ethylene oxide gas sterilization. Bones were prepared in various ways in an attempt to reduce the concentration of residual ethylene oxide. The concentration was higher when gas sterilization was performed before freeze-drying than when it was done afterwards. An experiment performed with fibroblasts showed the high toxicity of residual ethylene oxide in bone chips, even when the concentration was very low. The growth of fibroblast was reduced more in medium which had been shaken with bones sterilized with ethylene oxide before freeze-drying than in medium which had been shaken with bones sterilized after freeze-drying. The higher residual ethylene oxide concentrations resulted in a decrease in fibroblastic culture activity. Our experiment showed the importance of reducing the residual ethylene oxide gas concentration. Defatting and freeze-drying result in lower residual ethylene oxide concentrations.

Inflammatory chemical mediators during conventional ventilation and during high frequency oscillatory ventilation

Inflammatory chemical mediators, platelet-activating factor (PAF), thromboxane (TX) B2, and 6-keto-prostaglandin (PG)F1 alpha, were extracted from lung lavage fluid after conventional mechanical ventilation (CMV) and high frequency oscillatory ventilation (HFOV) to clarify the relation between mode of ventilation and lung injury in surfactant-depleted rabbit lungs. Anesthetized adult rabbits were tracheostomized, and surfactant depletion was induced by repeated saline lavage. Lung lavage for measurement of mediators was performed after 4 h of CMV at an FIO2 of 1.0 and a mean airway pressure of 15 cm H2O or HFOV (15 Hz) at an FIO2 of 1.0 or 0.21 and a mean airway pressure of 15 cm H2O. The number of total cells and polymorphonuclear leukocytes (PMN) and the levels of PAF, TXB2, and 6-keto-PGF1 alpha were measured by radioimmunoassay. Total respiratory compliance (Crs) was measured by the passive flow-volume curve method. The numbers of PMN, and the levels of PAF and TXB2 in lung lavage fluid were significantly greater during CMV than during HFOV. HFOV resulted in decreased production of PAF and TXB2 in a surfactant-depleted rabbit lung. Crs was significantly less during CMV than during HFOV. These results suggest that HFOV could prevent the release of such inflammatory chemical mediators and result in less lung injury than CMV.

Vertebral pedicle diameter as determined by computed tomography: inaccuracies observed by direct measurement of cadaveric lumbar spine

The isthmic diameter of the vertebral pedicle is an important dimension affecting the stability of transpedicular screwing. The isthmic diameter of the pedicle was measured in the lumbar spines of 18 Japanese cadavers (10 male, 8 female) by axial computed tomographic (CT) scan and directly with calipers. In L1 and L2, there was no significant difference between the average value of the isthmic diameter as determined by the two methods (Student's t-test). However, in L3-5, the average value of the isthmic diameter as determined by axial CT scan was significantly greater than that given by caliper measurement. In view of the fact that caudally the longitudinal axis of the pedicle diverges towards the mid-line of the vertebral body in the coronal plane, the plane of the CT scan cannot be parallel to the real isthmic diameter of the pedicle. Therefore, it is suggested that below L2 the diameter as determined by axial CT scanning is greater than the real isthmic diameter.

Nutrient balance, metabolic response, and bone growth in VLBW infants fed fortified human milk

The effects of fortification of preterm human milk were evaluated by comparing two groups of very low birth weight infants (birth weight < or = 1300 g, gestational age < or = 30 weeks): six fed preterm human milk fortified with a commercially available protein-mineral supplement (protein 0.7 g/dl, calcium 90 mg/dl, phosphorus 45 mg/dl) and seven fed unfortified preterm human milk. Nitrogen and energy balance studies were performed at an average age of 56 postnatal days. Nitrogen retention in the fortified group (348.2 +/- 70.5 mg/kg/day) was significantly greater than that in the unfortified group (196.0 +/- 50.0 mg/kg/day) and similar to that of fetuses of comparable gestational age. Energy stored by the two groups did not differ. At age 8 weeks, the infants in the fortified group had higher serum protein, higher serum albumin, and better mineral status (higher serum calcium and phosphorus and lower alkaline phosphatase and renal tubular reabsorption of phosphate). The bone density and width of the distal third radius, as measured by X-ray microdensitometry, were greater in the fortified group than in the unfortified group 12 weeks after birth. These results suggest that the supplement corrects any nutritional inadequacies of preterm human milk for very low birth weight infants.

In vitro assay of the invasive potential of malignant bone and soft tissue tumours through basement membranes

We have used reconstituted basement membrane molecules which have formed into barriers in order to investigate the invasive potential of malignant bone and soft tissue tumour cells in vitro. A number of cell lines established from human malignant tumours demonstrated a high degree of invasiveness, although fibroblasts showed no ability to penetrate the basement membrane barrier. H-ras oncogene transfected cells into the fibroblasts were much more invasive than the parent lines. Primary cultures of malignant tumour cells demonstrated invasiveness, while those of nonmetastatic cells and fibroblasts did not. The binding of tumour cells to laminin in the basement membranes was found to induce secretion of collagenase and motility which are crucial factors for invasion. A synthetic peptide, Tyr-Ile-Gly-Ser-Arg, was able to suppress the invasiveness of HT1080 human fibrosarcoma cells, and also reduced lung colonisation in vitro. The results suggest that the in vitro assay was useful, firstly to determine the invasive potential, secondly to investigate the mechanism of invasion, and finally to development treatment against invasion and metastases.

Drug-induced endothelial injury potentiates lung colonization in a murine fibrosarcoma model

Lung colonization induced by the intravenous injection of fibrosarcoma cells into syngeneic mice was enhanced by the pretreatment of mice with cyclophosphamide (CPA), adriamycin (ADM), cis-diammine-dichloroplatinum II (DDP) and methotrexate (MTX). At equitoxic levels, CPA showed greater enhancement of the lung colonization than the other drugs treated. After a two-hour pretreatment of an endothelial monolayer culture, the adhesion of fibrosarcoma cells to endothelial cells was enhanced by all drugs, and the greatest enhancement was obtained with CPA. Data from these experiments supports the hypothesis that endothelial cell damag by anticancer drugs may facilitate metastasis of circulating tumor cells.

Postnatal reference growth curves for very low birth weight infants

To construct standard growth curves for Japanese infants of very low birth weight (VLBW) with birth weights of 500-1499 g, we reviewed longitudinal data provided by 54 neonatal intensive care units in Japan. A total of 382 surviving singleton infants, appropriate for gestational age infants, and who were free of neurological sequelae at more than 2.5 years of age, were enrolled. Growth curves, including body weight, head circumference and body length were generated for four ranges of birth weight: 500-749 g, 750-999 g, 1000-1249 g, and 1250-1499 g. When compared with previously published growth data from western countries, Japanese infants of VLBW showed greater weight loss, regained birth weight more slowly, and exhibited smaller average gains in weight, head circumference, and body length. The growth curves reported in western countries may not be useful as reference standards of early postnatal growth in Japan. The new growth curves are a more accurate reflection of current in-hospital growth trends in Japan.

Molecular and crystal structure of (2,3,4,6-tetra-O-acetyl-beta-D-glucopyranosyl)-(1-->3)- [2,3,4,6-tetra-O-acetyl-beta-D-glucopyranosyl-(1-->6)]- (2,4-di-O-acetyl-beta-D-glucopyranosyl)- (1-->3)-1,2,4,6-tetra-O-acetyl-beta-D-glucopyranose

Crystals of the tetrasaccharide, (2,3,4,6-tetra-O-acetyl-beta-D-glucopyranosyl)-(1-->3)- [2,3,4,6-tetra-O-acetyl-beta-D-glucopyranosyl-(1-->6)]- (2,4-di-O-acetyl-beta-D-glucopyranosyl)-(1-->3)- 1,2,4,6-tetra-O-acetyl-beta-D-glucopyranose, belong to the monoclinic system, space group P2(1), with a = 12.709(4), b = 27.767(9), c = 9.567(4) A, beta = 105.07(2) degrees, and Z = 2. The crystal structure was solved by the direct method and refined by the full-matrix least-squares procedure to an R-value of 0.071 for 302- observed reflections in the X-ray data. All the four D-glucopyranose residues have the usual 4C1 chair conformations. The torsional angles at two (1-->3)-beta-linkages were phi(O-5-1-O-1-C-3) = -74 degrees and psi (C-1-O-1-C-3-C-2) = -122 degrees between the nonreducing and the middle residues, and phi = -67 degrees, psi = -111 degrees between the middle and the reducing residues. The orientation about the (1-->6)-beta-linkage was found to be phi(O5-C1-O-1-C-6) = -77 degrees, theta(C1-O-1-C-6-C-5) = 160 degrees, and chi(O-1-C-6-C-5-O-5) = 63 degrees (gt conformation). The primary acetate groups at C-6 of the reducing and the (1-->6)-branched residues were in the gt conformations (O-5-C-5-C-6-O-6 = 81 degrees and 84 degrees, respectively). On the other hand, the gg conformation was observed for the primary acetate group in the nonreducing residue (O-5-C-5-C-6-O-6 = 78 degrees).

Efficacy of synchronized IMV on weaning neonates from the ventilator

This study evaluated the efficacy of a new patient-triggered ventilator that triggered the patient's inspiratory effort by detecting the change in airflow by means of a 'hot wire' anemometer. This ventilator was used in both the conventional and the synchronized intermittent mandatory ventilation (SIMV) modes in seven neonates. Values for blood gas, spontaneous breathing rate, tidal volume of spontaneous breaths and minute volume were compared in all seven neonates. The resistive work of spontaneous breathing in five neonates, obtained with synchronized intermittent mandatory ventilation was compared with the values obtained using conventional mechanical ventilation on the previous day of weaning from the ventilator. At each the inflation time studied (0.4, 0.3, 0.24 s), all mechanical breath occurred synchronously with infants' inspiratory efforts. The median trigger delay was 80 ms. Oxygenation was improved on the new system compared with the conventional system. Tidal volume of spontaneous breathing and minute volume were increased with SIMV compared with conventional mechanical ventilation, although the resistive work of spontaneous breathing was decreased with SIMV. The tidal volume of spontaneous breaths was more constant with SIMV versus conventional mechanical ventilation. Thus, the airway flow-triggered SIMV may lessen inspiratory muscle fatigue during weaning process. We conclude that the SIMV is useful in weaning neonates from the ventilator.

[Studies on cell-mediated immunity (CMI) in the glomeruli: immunization with GBM antigen from Masugi nephritis in Wistar-Kyoto rats]

The role of cell-mediated immunity in glomerular injury has been extensively studied, but the precise mechanism remains obscure. This study was undertaken to determine whether the homologous glomerular basement membrane (GBM) combined heterogeneous anti-GBM antibody would induce cell-mediated immunity. Wistar-Kyoto rats were divided into three groups; group I rats were immunized with homologous GBM antigen that was derived from Masugi nephritis and emulsified in complete Freund's adjuvant (CFA); group II rats were immunized with homologous GBM antigen that was derived from normal rats and emulsified in CFA; group III rats were immunized with CFA only. Group I rats demonstrated proteinuria on days 7 and 10 after immunization. Histologically, mesangial cell proliferation and cell infiltration were observed in the glomeruli. No changes in tubulointerstitial tissue. CD4-positive cells, CD8-positive cells and macrophages were found in the glomeruli, and mononuclear cells were found in the glomerular capillary lumen. Group II and Group III rats demonstrated no proteinuria and no histological changes. These findings indicated that the altered GBM obtained antigenicity and induced cell-mediated immunity in the glomeruli.

Separation and identification of serum gamma-glutamyl transpeptidase isoenzymes by wheat germ agglutinin affinity electrophoresis: a basic analysis and its clinical application to various liver diseases

Serum gamma-glutamyl transpeptidase (gamma-GTP) was separated into four fractions by using wheat germ agglutinin (WGA) affinity electrophoresis. By two-dimensional analysis using gel filtration combining with affinity electrophoresis with WGA, anti-alpha 1-lipoprotein antiserum or anti-beta-lipoprotein antiserum, properties of each fraction were identified as a high molecular WGA affinity fraction (HM), a relatively high molecular beta-lipoprotein binding fraction (beta-LP), an intermediate molecular alpha-lipoprotein binding fraction (alpha-LP) and a low molecular fraction (LM). Quantitative alterations in each fraction of gamma-GTP in the serum of patients with various liver diseases and gall stones (GS) were also examined. In patients with hepatocellular carcinoma (HCC), the HM fraction was more increased compared with those in patients with non-alcoholic liver cirrhosis (LC) and chronic hepatitis (CH). The rate of HM fraction was correlated with total activity of serum gamma-GTP in HCC patients. In alcoholic liver disease (ALD), no remarkable differences of the rate of each gamma-GTP fraction were shown among alcoholic LC, alcoholic hepatitis, alcoholic CH and fatty liver patients. It was, however, shown that the rate of the LM fraction decreases and the HM fraction increases gradually in accordance with an increase in serum gamma-GTP activity in ALD. These data indicate that serum gamma-GTP isoenzymes can be separated clearly into four fractions by using WGA affinity electrophoresis, the HM fraction of serum gamma-GTP is relatively increased in HCC patients, and detection of the HM fraction may be useful to diagnose HCC, although it can be increased in ALD patients with high serum gamma-GTP activity.

[Anatomical study on the right bronchial artery for operation of esophageal cancer through right thoracotomy with special reference to the intercostobronchial arteries]

In view of the operative field of esophageal cancer, anatomical findings of the right bronchial arteries were studied in specimens of 71 cadavers. Intercostobronchial arteries were absent only in 3 cadavers (4.2%; group A). As 22.6% of the cadavers had only one intercostobronchial artery supplied as the right bronchial artery (group B), it was considered to be important to preserve this artery. Cadavers both with the intercostobronchial artery and with the other right bronchial-arteries were observed in 70.4% (group C). Right bronchial arteries deriving from the aorta to course similarly to intercostobronchial arteries were present in small number (group D). Further, right bronchial arteries were classified into three types according to the deriving arteries as follows: (I) intercostobronchial arteries, (II) bronchial arteries deriving from the aorta, (III) other right bronchial arteries deriving from right subclavian artery, right inferior thyroid artery or right interthoracic artery. Considering difficulty of the approach from the operative field with right thoracotomy and the anatomical relationship with neighboring organs, it was thought that preserving the type (I) arteries is easy, the type (III) has a possibility to be preserved, and (II) is hard to be preserved. We concluded that preserving intercostobronchial arteries is important in esophageal cancer surgery approached through right thoracotomy because of small number of cadavers without these arteries and ease of preservation.

Stability of transpedicle screwing for the osteoporotic spine. An in vitro study of the mechanical stability

The influence of bone mineral density on the stability of transpedicle screwing was studied in the human cadaveric lumbar vertebrae. The pull-out force correlated with bone mineral density. The tilting moment (load needed to tilt the screw 4 degrees cranially at the screw-plate junction) and the cut-up force (load needed to tip the end plate up by the screw) correlated with bone mineral density. A correlation was also found between the maximum insertion torque of the screw and bone mineral density. The maximum insertion torque correlated with the pull-out force, the tilting moment, and the cut-up force. In the cyclic tilting test (200 cycles), the mean value of the tilting moment at the 200th cycle was 67.4 +/- 6.1%, compared with the first cycle. The results suggest that preoperative measurement of BMD is necessary for transpedicle screwing in osteoporotic cases, and that the cyclic tilting motion decrease its mechanical stability. The authors have also concluded that the maximum insertion torque could predict the mechanical stability.