The left ventricular remodeling assessment by cardiac magnetic resonance in chronic aortic regurgitation; implications for outcome

Background

Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload resulting in progressive LV remodeling, which negatively affect clinical outcome. Clinical Guidelines recommend assessment of LV remodeling by echocardiography, but little is known about comparative remodeling quantification by cardiac magnetic resonance (CMR) and association with outcomes.

Purpose

To assess LV remodeling in AR by CMR, compared with echocardiographic measures and determine its impact on clinical outcome.

Methods

Patients with native, ≥moderate, chronic AR by echocardiography who underwent CMR exam within 90 days of diagnosis from January 2012 to February 2020 were enrolled. The endpoint was a composite of death, heart failure hospitalization, and heart failure symptom exacerbation during follow-up.

Results

The 178 patients included had median age (IQR) of 58 years (44–69), and most (88%, n=158) presented with no or minimal symptoms (NYHA class I/II). At diagnosis symptomatic vs. no/minimal symptoms patients presented with much more advanced LV remodeling by CMR (EDVI 133 [83–151] vs. 96 [80–123] p=0.024, ESVI 66 [46–85] vs. 42 [30–58], P=0.001) while echocardiography showed limited differences (EDVI 76 [57–93] vs. 65 [54–87] p=0.507, ESVI 38 [30–58] vs. 27 [20–42], p=0.072). During follow-up (3.3 years [1.6–5.8]), aortic valve replacement (AVR) was performed in 49 patients. In patients with no/minimal symptoms, the composite endpoint occurred in 54 (34%) patients including eight deaths and 30 heart failure hospitalizations. Patients with LV end-systolic volume index (LVESVi) >45 ml/m2 by CMR had higher likelihood for composite endpoint (Panel A) confirmed in multivariate models, adjusting for age, sex, AVR (time-dependent), EuroSCORE2, and LV End-systolic-dimension-index (LVESDi) >25 mm/2, with adjusted hazard ratio 1.84 [1.02–3.33], p<0.044 (Panel B). LVESVi by CMR was at least as powerful in determining clinical outcomes as guideline-recommended Doppler-Echocardiographic variables.

Conclusion

Assessment of LV remodeling by CMR in patients with clinically significant AR is feasible in routine clinical practice, detects with high sensitivity LV remodeling associated with development of HF symptoms and is independently predictive of clinical outcome. Hence, CMR provides a powerful tool for evaluation and risk stratification of patients with AR.

Funding Acknowledgement

Type of funding sources: None. Panel APanel B

Computed tomography derived left ventricular global longitudinal strain associate with clinical outcomes in patients undergoing transcatheter aortic valve replacement

Funding Acknowledgements

Type of funding sources: None.

Background

Computed tomography angiography (CTA) is key imaging modality for procedure planning for transcatheter aortic valve replacement (TAVR). Functional assessment by CTA with LV global longitudinal strain (LVGLS) has recently shown to be feasible. However, there is limited data on its prognostic value in patients with severe aortic stenosis (AS) who treated with TAVR.

Purpose

To evaluate the association of baseline CTA-LVGLS with post-TAVR outcome.

Methods

 Patients who underwent contrast multiphasic gated CTA for TAVR planning were studied. LVGLS was measured using dedicated feature-tracking software (Medis®). Cox regression analysis evaluated the association of baseline LVGLS with a composite outcome of all-cause death and heart failure hospitalization after TAVR.

Results

A total of 431 patients were included (median [IQR] age, 83 [77,87]years; 44% female); the society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score, 3.3 [2.3,5.1]%; CTA-LVGLS, -18.0 [-21.6,-14.2]%; LV ejection fraction was preserved at 60 [55,65]%. After a median follow-up of 19 [13,27] months, 99 composite outcomes occurred after TAVR. On multivariable Cox regression analysis, LVGLS was associated with the risk of composite outcome even after adjustment for baseline characteristics (Figure A). Patients with reduced LVGLS (above the median >-18.0%) had higher risk of the composite outcome than those with preserved GLS (p = 0.003; Figure B).

Conclusion

Baseline CTA-LVGLS was associated with the risk of death or heart failure hospitalization over the clinical and echocardiographic characteristics in severe AS patients undergoing TAVR.

Abstract Figure.

Computed tomography characteristics of patients with functional MR receiving MitraClip

Funding Acknowledgements

Type of funding sources: None.

Background

Percutaneous leaflet repair with the MitraClip device (Abbott Vascular, Menlo Park, CA) is safe and effective in patients with severe functional mitral regurgitation (FMR). Residual or recurrent MR may occur in up to 40% of patients and is associated with persistent symptoms and impaired survival. The anatomical characteristics associated with residual or recurrent MR after MitraClip are not well defined by computed tomography angiography (CTA) in FMR population.

Methods

A retrospective analysis of patients with significant FMR, who underwent retrospective-gated CTA at Minneapolis Heart Institute between July 2015 to January 2020, identified those who underwent percutaneous leaflet repair with MitraClip. Anatomical and functional parameters were assessed by pre-procedure CTA and compared between those with and without residual (≥2) MR.

Results

  A total of 25 patients were included (median[Q1, Q3]; age, 80[75, 85]; 44% men) and classified into ventricular FMR (V-FMR, n = 12) and atrial FMR (A-FMR, n = 13) according to anatomical and functional characteristics by CTA. 50% of V-FMR and 38% of A-FMR had residual/worsening MR. Among V-FMR patients with residual/worsening MR, shorter coaptation length was observed (2.2[2, 2.3] mm vs. 3.5[3, 4], p = 0.006) (Figure). No differences in anatomical or functional characteristics were seen in A-FMR patients.

Conclusion

Longer coaptation length in V-FMR is predictive of successful MitraClip procedure, whereas mitral annulus size and cardiac volumes are not.

<Ventricular FMR> Total (N = 12) No residual/no worsening MR (N = 6) Residual/worsening MR (N = 6) P value Septal-lateral diameter, mm 31.9 (30.5, 37.9) 32.2 (30.1, 39.8) 31.9 (29.5, 35) 0.749 Annulus area, cm² 11.2 (10.4, 13.6) 11.3 (10.1, 14.6) 11.1 (9.6, 12.6) 0.631 Tenting area, cm² 1.6 (1.3, 2.1) 1.6 (1.2, 2.2) 1.7 (1.2, 2.3) 0.873 Tenting height, mm 8.5 (6.5, 9.7) 8.5 (6.6, 9.3) 8.3 (6.3, 10.1) 0.749 Coaptation length, mm 2.6 (2.1, 3.5) 3.5 (3.0, 4.0) 2.2 (2.0, 2.3) 0.006 <Atrial FMR> Total (N = 13) No residual/no worsening MR (N = 8) Residual/worsening MR (N = 5) P value Septal-lateral diameter, mm 32.3 (29.5, 39.0) 32.0 (29.2, 39.9) 34.3 (30.8, 39.02) 0.464 Annulus area, cm² 10.3 (9.2, 14.7) 10.2 (9.0, 14.6) 12.4 (9.4, 14.7) 0.661 Tenting area, cm² 1.2 (0.8, 1.8) 1.1 (0.7, 2.2) 1.3 (0.7, 1.8) 0.884 Tenting height, mm 5.5 (4.1, 6.9) 6.3 (4.1, 8.7) 4.6 (3.7, 5.8) 0.213 Coaptation length, mm 2.3 (1.5, 2.8) 2.5 (1.4, 3.5) 1.9 (1.5, 2.6) 0.464 Comparison of baseline CT parameters between no residual/ no worsening MR and residual/ worsening MR Abstract Figure.

Functional DSCT assessment of tricuspid regurgitation: AROA reproducibility and comparison with 3D TEE

Funding Acknowledgements

Type of funding sources: None.

onbehalf

Minneapolis Heart Institute Foundation

Background

Tricuspid regurgitation (TR) assessment by echocardiography is often challenging. Functional dual-source CT (DSCT) with third-generation scanners allows accurate evaluation of leaflet anatomy and mobility.

Purpose

Investigate the reproducibility of tricuspid anatomical regurgitant orifice area (AROA) by DSCT, and its correlation with TR quantification by 3D TEE.

Methods

We evaluated patients with symptomatic TR referred for transcatheter tricuspid repair. DSCT (SOMATOM Force [Siemens, Erlangen, Germany]) and 3D TEE was performed on the same day as part of our institutional registry. DSCT scans were retrospective and ECG-gated, with a contrast protocol to enhance the right heart. The reproducibility of tricuspid AROA was assessed in 20 patients. The tricuspid AROA was compared with the TR severity (5-grade classification) and the 3D VCA by TEE (Panel 1).

Results

We included 60 patients (Table). The AROA had excellent intra and interobserver reliability (ICC 0.99 [0.97, 0.99] and 0.99 [0.96, 0.99]). We found a stepwise increase in tricuspid AROA from moderate to torrential TR (Panel 2A). Of 60 patients, 3D VCA was feasible in 39; in those, we found an excellent linear correlation of AROA and 3D VCA (Panel 2B).

Conclusions

Tricuspid AROA by DSCT was reproducible, showed a stepwise increase from moderate to massive TR and correlated with 3D VCA by TEE.

Baseline Patient Characteristics All (n = 60) Age, years 82 ± 7 BSA, m2 1.8 ± 0.2 NYHA III-IV, n(%) 42 (70) Atrial Fibrilation 55 (91) Hypertension 44 (73) Pulmonary Hypertension 34 (56) Chronic Kidney Disease 25 (44) Coronary Artery Disease 17 (28) Chronic Lung Disease 14 (23) Permanent Pacemaker 13 (21) Diabetes Mellitus 10 (17) Mitral Valve Repair (MitraClip) 9 (15) Mitral Valve Replacement 7 (12) Mitral Valve Repair 3 (5) Aortic Valve Replacement 5 (8) Values are mean ± SD and n (%). BSA = body surface area. Abstract Figure. Panels

P1528 Prognostic impact of pulmonary arterial wave reflection in heart failure

Background

Pulmonary hypertension (PH) is prevalent and is associated with adverse outcomes in heart failure. The pathophysiology of PH is heterogeneous, including pre-capillary PH and combined pre- and post-capillary PH. The latter PH has been reported in experimental studies to cause wave reflection in pulmonary circulation, putting additional burden on right ventricle. This study tested the hypothesis that separating wave reflection would enhance risk stratification in heart failure.

Methods

This study included 152 patients with clinical stable heart failure associated with PH who were referred to echocardiography for hemodynamic assessment (age = 72 ± 13 years old, ejection fraction = 49 ± 21%). Pulmonary arterial wave reflection was characterised by separating PA pressure waveform into forward (Pf) and backward pressure (Pb) waves, based on the concept of wave intensity. PA pressure waveform was estimated from continuous Doppler tracing of tricuspid regurgitation. Flow velocity was measured by pulse Doppler at right ventricular outflow tract. Outcome data was obtained by reviewing medical charts. The endpoint was hospitalization for worsening heart failure (WHF).

Results

Figure A compares PA pressure waveforms (total and separated waves) obtained from 2 patients with and without WHF event. The patient with event had higher total pressure associated with late peak than the patient without event. Pb appeared later than Pf; it was markedly higher in the patient with event than the patient without event, although Pf was similar between both patients. Kaplan-Meier analysis demonstrated a significant separation of survival curves stratified by Pb (chi-square = 25.1, p < 0.001, figure B). During follow-up period of 1.5 ± 1.8 years, 65 patients (43%) experienced the endpoint. Sequential Cox analysis revealed that PASP remained significant after adjusted for left ventricular ejection fraction and E/e’ (hazard ratio = 1.017, p = 0.019). Pb also remained significant after the same adjustment (hazard ratio = 1.066, p = 0.003); the addition of Pb to a baseline model resulted in greater increase in predictive power than the addition of PASP (model chi-square: from 27.4 (baseline), to 37.6 (p = 0.004) for Pb, to 31.6 (p = 0.027) for PASP, figure C)

Conclusions

Pressure wave reflection in pulmonary artery is associated with early decompensation in heart failure.

Abstract P1528 Figure.

P1480 A case of triple left ventricular aneurysms diagnosed by CT and echocardiography

【Background】

Left ventricular aneurysms is complication of myocardial infarction (MI) that can lead to death or serious morbidity. False aneurysm is rare complications of myocardial infarction or iatrogenic perforation and represent a contained myocardial rupture. False aneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus. Definitive diagnosis is achieved by echocardiography, computed tomography (CT), angiography, or magnetic resonance imaging. Coexistence of true and false aneurysms is rare.

【Case】 A 58 years old man with a history of hypertension and MI was referred to our hospital for aneurysmectomy. During the course of prior MI, he got fever and pericardial effusion.

CT revealed that three left ventricular aneurysms were present. Also, three aneurysms were connected by narrow ducts each other. Transthoracic echocardiography (TTE) revealed that three ventricular aneurysms were connected via acceleration blood flow which swirling in the spherical aneurysm. We determined that this triple ventricular aneurysms were at high risk for rupture, so we performed surgery.

The postoperative course was good and he was discharged without any complications.

【Discussion】

False aneurysms occur after hemorrhagic dissection into an area of transmural infarction and most commonly result in free intrapericardial rupture of the heart, cardiac tamponade, and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture.

We were able to evaluate the mechanism of development with triple left ventricular aneurysms using CT and TTE. We could know about spatial comprehension of triple aneurysms using CT. False aneurysms were restricted enlargement due to stiff pericardium because of complicating Dressler syndrome. We hypothesis that aneurysms were enlarging in the direction of the base of heart in the adhered pericardium space.

We were able to evaluate the thickness of aneurysms and blood flow condition using TTE. TTE revealed that the wall of aneurysm was fragile. Multimodality imaging like TTE or cardiac CT are useful diagnostic methods in this case.

Abstract P1480 Figure. Triple aneurysms

1638 A case of capturing changes in interatrial blood flow and anatomical structure during percutaneous PFO closure with platypnea orthodeoxia syndrome using intra-cardiac echocardiography

Background

Platypnea–orthodeoxia syndrome (POS) is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO). The most commonly associated conditions included pneumonectomy, ascending aortic dilation, and arch surgery, as previously reported. Percutaneous closure of PFO is useful treatment for POS.

Case

A 76 year old man used home oxygen therapy because of unexplained hypoxemia. A decrease in blood oxygen saturation was observed in sitting and standing positions. The patient was diagnosed as "POS" because a shunt blood flow with PFO and atrial septal aneurysm (ASA) and eustachian valve was observed at transesophageal echocardiography. He was admitted for the purpose of percutaneous PFO closure.

He was treated with intra-cardiac echocardiography (ICE) guidance under local anesthesia because of poor lung function.

PFO closure was performed successfully with 30mm AMPLATZER Cribriform. The ICE findings prior to PFO closure showed a right-to-left shunt blood flow through the PFO in the sitting position but almost disappeared after closure. Furthermore, it was observed that the aortic artery compression was stronger in the sitting position than in the supine position with right-to-left shunt blood flow. After PFO closure, hypoxia associated with postural change improved and patient’s symptom as shortness of breath also significantly improved.

Discussion

POS is a position-dependent condition of dyspnea and hypoxemia due to right-to-left shunting. It often remains unrecognized in clinical practice, possibly because of its complex underlying pathophysiology. It is considered that the cause of POS in this patient was multiple factors such as ASA, aortic displacement, and venous valve remnant. In addition, being able to observe the change of the atrium due to compression from the aortic artery using ICE during the operation was very significant to explain the mechanism of POS.

Abstract 1638 Figure. Intra-cardiac echocardiography

P1713 A case of quadricuspid aortic valve complicated with infective endocarditis diagnosed by 3D transesophageal echocardiography

Background

Quadricuspid aortic valve (QAV) is a rare congenital heart disease with an estimated incidence of 0.008% to 1.46%. The functional status of QAV is predominantly a pure aortic regurgitation. The extensive use of echocardiography has allowed an early and accurate diagnosis of this malformation. In many cases, the transthoracic echocardiography (TTE) is suitable for the diagnosis but, transesophageal echocardiography (TEE), especially 3-dimensional (3D) TEE, is a tool for the accurate definition of the valve anatomy.

Clinical case

A 60-year-old female underwent a head CT for intermittent headaches for one month ago. She was admitted to neurosurgery in our hospital diagnosed of subarachnoid hemorrhage. Four mm aneurysm was found on the periphery of the right middle cerebral artery on CT examination, and a cerebral aneurysm coil embolization was performed with a catheter in emergency. The possibility of infectious cerebral aneurysm was pointed out, and we examined in cardiovascular internal medicine. TTE revealed moderate aortic regurgitation. The ventricular septum exhibits sigmoid septum. A mobile mass was found near the left ventricular outflow tract in the sigmoid septum. TEE revealed a hypoplasia cusp (accessory cusp) is found between non coronary cusp and right coronary cusp. Aortic valve leaflets have become thickened and regurgitation from the central part of the cusps. 3DTEE was able to more accurately visualize that only the accessory cusp was hypoplastic, and the size of the other three leaflets appears almost the same. Similarly, vegetation on the left ventricular outflow tract were clearly revealed by 3DTEE.

Based on the above, it was diagnosed that quadricuspid aortic valve complicated with infective endocarditis (IE) with aortic valve regurgitation. After treatment with antibiotics according to IE, surgical treatment was scheduled.

Discussion

QAV is a rare congenital heart disease, and TTE is an important imaging tool for accurate diagnosis. Furthermore, TEE, especially 3DTEE, was a more appropriate diagnostic method in QAV and IE.

Abstract P1713 Figure. 3DTEE

Inhibition of ADAMTS4 (aggrecanase-1) by tissue inhibitors of metalloproteinases (TIMP-1, 2, 3 and 4)

ADAMTS4 (aggrecanase-1) is considered to play a key role in the degradation of aggrecan in arthritides. The inhibitory activity of tissue inhibitors of metalloproteinases (TIMPs) to ADAMTS4 was examined in an assay using aggrecan substrate. Among the four TIMPs, TIMP-3 inhibited the activity most efficiently with an IC(50) value of 7.9 nM, which was at least 44-fold lower than that of TIMP-1 (350 nM) and TIMP-2 (420 nM) and >250-fold less than that of TIMP-4 (2 microM for 35% inhibition). These results suggest that TIMP-3 is a potent inhibitor against the aggrecanase activity of ADAMTS4 in vivo.

Acylated delphinidin 3-rutinoside-5-glucosides in the flowers of Petunia reitzii

Two acylated anthocyanins were isolated from selected individuals of Petunia reitzii, and identified to be delphinidin 3-O-[6-O-(4-O-(4-O-(6-O-(trans-caffeoyl)-beta-D-glucopyranosyl)-tr ans-p-coumaroyl)-alpha-L-rhamnopyranosyl)-beta-D-glucopyranoside]- 5-O-[beta-D-glucopyranoside] and delphinidin 3-O-[6-O-(4-O-(4-O-(beta-D-glucopyranosyl)-trans-p-coumaroyl)-alph a-L-rhamnopyranosyl)-beta-D-glucopyranoside]-5-O-[beta-D-glucopyranoside ]. Nine known anthocyanins were also identified.

Differences in the floral anthocyanin content of red petunias and Petunia exserta

In order to resolve a conflict between previous papers regarding the floral anthocyanins of red flowers of Petunia exserta, a naturally occurring species, the HPLC profile of this species was compared with that of commercial red garden petunias. Both HPLC profiles extremely superficially resemble each other in terms of relative amounts and retention times of the major anthocyanins. However, co-elution on HPLC of the mixed sample resulted in clear separation of the components. Three major anthocyanins in red petunias were determined to be cyanidin 3-sophoroside, cyanidin 3-glucoside and peonidin 3-glucoside, which exhibited similar behaviors on HPLC to delphinidin 3-glucoside. delphinidin-3-rutinoside and petunidin 3-rutinoside, respectively, the major floral anthocyanins of P. exserta.

Three groups of species in Petunia sensu Jussieu (Solanaceae) inferred from the intact seed

The intact seed surface morphology in 45 taxa of Petunia sensu Jussieu native to South America (Petunia sensu Wijsman plus Calibrachoa) was compared under scanning electron microscopy. The existence of three groups of species, differentiated in terms of seed morphology, was revealed as follows: (1) all species of Petunia sensu Wijsman, having coarse wavy middle lamellae and anticlinal walls; (2) Calibrachoa parviflora and C. pygmaea, having fine wavy middle lamellae embedded in straight anticlinal walls; and (3) the other species of Calibrachoa, having straight middle lamellae and anticlinal walls. Close relationships between seed morphology and the other characteristics observable in the groups of species are discussed.

FGF-10 is a chemotactic factor for distal epithelial buds during lung development

Fibroblast growth factor (FGF) signaling is required for normal epithelial branching in the respiratory system of several species. Recent studies have shown that FGF-10 may be a key regulator of lung branching morphogenesis, based on its pattern of expression in the early lung and its ability to induce epithelial budding in vitro. In this study we investigate whether FGF-10 is able to direct lung epithelial buds to proper positions during development . We maintained localized high levels of FGF-10 in cultured lungs using FGF-10-soaked heparin beads. FGF-10 exerts a powerful chemoattractant effect on the distal but not on proximal lung epithelium. Epithelial buds grow toward an FGF-10 source within 24 h, and subsequently form concentric layers of epithelium around the bead. BrdU incorporation analysis suggests that FGF-10, in contrast to FGF-7, is a modest proliferation factor for the lung epithelium. In the absence of mesenchyme FGF-10 requires an associated proliferative signal to induce bud migration. This can be provided by extract from lung mesenchyme, or by FGF-7, a growth factor also present in the early embryonic lung. FGF-10 does not seem to interfere with early epithelial cell differentiation. The chemoattractant effect of FGF-10 in the lung epithelium is reminiscent of the patterning effect of the Drosophila FGF ortholog branchless in the developing tracheal epithelium, suggesting that the function of these genes has been conserved during evolution.

Structure and expression of human fibroblast growth factor-10

We isolated the cDNA encoding a novel member of the human fibroblast growth factor (FGF) family from the lung. The cDNA encodes a protein of 208 amino acids with high sequence homology (95.6%) to rat FGF-10, indicating that the protein is human FGF-10. Human FGF-10 as well as rat FGF-10 has a hydrophobic amino terminus ( approximately 40 amino acids), which may serve as a signal sequence. The apparent evolutionary relationships of human FGFs indicate that FGF-10 is closest to FGF-7. Chromosomal localization of the human FGF-10 gene was examined by in situ hybridization. The gene was found to map to the 5p12-p13 region. Human FGF-10 (amino acids 40 to 208 with a methionine residue at the amino terminus) was produced in Escherichia coli and purified from the cell lysate. Recombinant human FGF-10 (approximately 19 kDa) showed mitogenic activity for fetal rat keratinizing epidermal cells, but essentially no activity for NIH/3T3 cells, fibroblasts. The specificity of mitogenic activity of FGF-10 is similar to that of FGF-7 but distinct from that of bFGF. In structure and biological activity, FGF-10 is similar to FGF-7.

Use of ultrasonography in the detection of ureteric reflux in children suspected of having urinary infection

The present study investigated whether ultrasonography was effective in detecting ureteric reflux in children suspected of having urinary infection. Seventeen children with febrile episodes and pyuria were enrolled. The ultrasound examination revealed ballooning of the renal pelvis during bladder contraction in 4 children, dilatation of the distal ureters in 6, and small kidney in 2. Cystography was performed on the 6 children with these ultrasound abnormalities and 1 child with two episodes of suspected urinary infection. Four children showed reflux. All of the 4 children had been found to have renal pelvic ballooning on ultrasound. None of the 10 children who did not undergo cystography had recurrence of urinary infection or significant bacteriuria during a median follow-up period of 12 months. Thus, scanning during bladder contraction was effective in detecting significant ureteric reflux.

Ultrasonography for the detection of ureteric reflux in infants with urinary infection

Several less harmful methods than voiding cysto-urethrography for detecting significant ureteric reflux have been proposed. The present prospective study investigated whether ultrasonography was effective in identifying ureteric reflux in infants with their first febrile urinary infection. The subjects were 27 infants (24 boys and 3 girls) aged from 0 to 8 months. The urinary tract was scanned when the bladder was full, and before and during induced voiding. Infants with abnormal ultrasound findings underwent voiding cysto-urethrography. The other infants were followed and those who had a recurrence of urinary infection underwent voiding cystography. Ten children underwent cysto-urethrography, with eight refluxing ureters identified in six boys. Ultrasound revealed transient dilatation of the renal pelvis on voiding in five kidneys, transient dilatation of distal ureters in 12 and hydro-ureteronephrosis in two. Each of the five kidneys with pelvic dilatation on voiding was associated with ureteric reflux grades III or IV. Of the 17 children who did not undergo cysto-urethrography, only one had recurrence of urinary infection and was diagnosed with ureteric reflux. This girl was one of the three babies who were not scanned during voiding. More than half of the infants with febrile urinary infection were excluded from invasive examination without having recurrence of urinary infection. Thus, ultrasound scanning during voiding was effective for screening infants with their first urinary infection to detect significant ureteric reflux.

Problems of trace elements and vitamins during long-term total parenteral nutrition: a case report of idiopathic intestinal pseudo-obstruction

An 8-year-old girl with chronic idiopathic intestinal pseudo-obstruction (CIIP), who is the first case of CIIP in Japan, has been receiving total parenteral nutrition (TPN) for more than 6 years. During this time, she experienced deficiencies of copper, zinc, vitamin A, vitamin B12, folic acid, and biotin, and an excess of vitamin A; she exhibited a series of signs and symptoms due to these deficiencies and vitamin A overdosage. Nevertheless, careful monitoring of serum levels of trace elements and vitamins and appropriate therapy have almost solved these problems. She has achieved normal physical and mental development and goes to school, while receiving home parenteral nutrition with an ambulatory infusion system.

Antibody-dependent cell-mediated cytotoxicity against influenza virus-infected cells

The three major immunocompetent cells in human peripheral blood (lymphocytes, neutrophils, and monocytes) were shown to be effector cells for antibody-dependent cell-mediated cytotoxicity (ADCC) against influenza virus-infected baby hamster kidney cells in vitro. Lymphocyte cytotoxicity was mediated by FcIgG receptor-bearing null cells and T gamma cells. These effector populations were best defined by HNK-1, a monoclonal antibody to human natural killer and ADCC-mediator cells. Antibody responsible for ADCC against influenza virus-infected cells was detectable in sera of young children after natural infection and after vaccination with inactivated and live attenuated viruses. ADCC antibody appeared before hemagglutination-inhibiting antibody and persisted for at least one year after vaccination with live attenuated vaccine. ADCC antibody was subtype-specific but quite broadly reactive within a subtype. Both hemagglutinin and neuraminidase were antigenic determinants for ADCC antibody. An anamnestic response to the original strain was observed after challenge with influenza virus of a heterologous subtype.

Ability of human cord blood lymphocytes to mediate antibody-dependent cellular cytotoxicity against influenza virus-infected cells

Cord blood lymphocytes, monocytes, and neutrophils from newborns were shown to mediate antibody-dependent cellular cytotoxicity (ADCC) against influenza virus-infected cells. Antibody mediating ADCC was detectable in cord plasma, indicating that all components necessary for ADCC against influenza virus-infected cells are present in newborns. Among adult lymphocytes, two effector cell populations of influenza ADCC are recognized: non-T and T gamma cells. Each of these cell types expresses an antigen recognized by monoclonal HNK-1 antibody. The proportion of HNK-1 antigen-positive lymphocytes in cord blood was markedly lower than in adult blood; furthermore, ADCC was mediated by cord blood lymphocytes which were HNK-1 negative. By lymphocyte fractionation, the effector lymphocytes in cord blood were, as in adults, non-T and T gamma cells, suggesting that HNK-1 antigen is not expressed on these cell lineages in newborns.

Characterization of the human peripheral blood effector cells mediating antibody-dependent cell-mediated cytotoxicity against respiratory syncytial virus

Peripheral blood lymphocytes were separated into several subpopulations and evaluated for their ability to mediate antibody-dependent cell-mediated cytotoxicity (ADCC) against respiratory syncytial virus (RSV)-infected HeLa cells. Using erythrocyte rosetting methods, nylon wool filtration, and cytolysis with OKT-3 monoclonal antibody, two lymphocyte subpopulations were shown to mediate RSV-ADCC; non-T, non-B, and IgG-Fc receptor-bearing lymphocytes and E-rosetting cells with IgGFc receptors (T gamma cells). Removal of phagocytic cells did not alter ADCC activity. Monoclonal antibody to human NK and K cells, HNK-1, recognized these two lymphocyte effector subpopulations.

[Clinical evaluation of cefsulodin in Pseudomonas infections in children]

Cefsulodin (CFS) was evaluated for its safety and efficacy in 14 children with Pseudomonas aeruginosa infections. The diagnoses included pneumonia (4), sepsis (1), presumed sepsis (4), acute postoperative ascending cholangitis (1), acute postoperative peritonitis with wandering pneumonia (1), acute enterocolitis with acute UTI (1), recurrent UTI (1), and acute cystitis (1). CFS was administered intravenously with a daily dose of 93 to 299 mg/kg in the cases with normal renal functions. CFS was effective in all but one case both clinically and bacteriologically. A case of pneumonia whose isolate was resistant to CFS responded poorly. Mild transient eosinophilia was observed in 3 cases, but no severe adverse reactions were encountered. Peak MIC values of 18 clinical isolates of P. aeruginosa were 1.56 mcg/ml, 0.39 to 0.78 mcg/ml and 12.5 mcg/ml for CFS, gentamicin, and sulbenicillin, respectively. A half life of the serum CFS levels was 1.09 hours after intravenous bolus injection of 20 to 25 mg/kg of CFS (n = 2). A cerebrospinal-fluid level and biliary levels measured in cases with inflamed meninges or with cholangitis were well above the MIC value. From the present study, CFS appeared to be a safe and effective antibiotic when used in children with susceptible Pseudomonas infections. Combined use of another antibiotic should be considered in the case with polymicrobial infections because of the CFS's very narrow spectrum.

Conformational-energy studies of tetrapeptide opiates. Candidate active and inactive conformations

The conformational behavior of four tetrapeptide enkephalin analogues (Tyr-Gly-Gly-Phe-OH, Tyr-Gly-Gly-Phe-NH2, Tyr-D-Ala-Gly-Phe-NH2, and Tyr-D-Ala-Gly-(NMe)Phe-NH2) was examined to identify conformations that are active and inactive at the opiate analgesic receptor. By using an empirical energy program, conformational energies were obtained for the optimized geometries of each tetrapeptide. Two methods of selecting candidate active conformations from low-energy conformers were used. In the first method, inactive conformers were designated as low-energy conformations of the very weak tetrapeptide, Tyr-Gly-Gly-Phe-OH. These candidate inactive conformers had geometries resembling beta V, beta I, "random" peptide conformations. Candidate active conformers selected were low-energy conformations found for both Tyr-D-Ala-Gly-Phe-NH2 and Tyr-D-Ala-Gly-(NMe)Phe-NH2 but not low-energy conformers for Tyr-Gly-Gly-Phe-OH. In the second method of selection, conformers with relative energies in the active and inactive peptides that followed the potency order Tyr-Gly-Gly-Phe-OH much less than Tyr-D-Ala-Gly-Phe-NH2 less than or equal to Tyr-D-Ala-Gly-(NMe)Phe-NH2 were chosen as candidate active conformers. By using both methods of selection, a beta II' bend geometry was found as the active conformer. This beta II' conformer was not stabilized by a 1-4 hydrogen bond, but instead was stabilized by a hydrogen bond between the tyrosine amine hydrogen atom and the phenylalanine carbonyl oxygen atom. The effect of C-terminal amide derivitization on peptide conformation was also examined by comparing the conformational profiles of Tyr-Gly-Gly-Phe-OH and Tyr-D-Ala-Gly-Phe-OH with their amides Tyr-Gly-Gly-Phe-OH-NH2 and Tyr-D-Ala-Gly-Phe-NH2. No significant difference in conformational behavior was found for the Tyr-Gly-Gly-Phe pair; however, a difference in conformational behavior was found between the Tyr-D-Ala-Gly-Phe acid and amide. Thus, on the basis of conformational data, the Tyr-Gly-Gly-Phe-NH2 analogue is predicted to have very weak opiate activity.

[Clinical evaluation of cefoxitin in children (author's transl)]

Cefoxitin (CFX) was evaluated for its safety and efficacy in children. Fifteen patients were treated with 73-125 mg/kg per day of CFX by intravenous administrations. The diagnosis of the patients were acute pharyngitis (4), pneumonia (2), pertussis and pneumonia (1), urinary tract infection (3); and the remaining 5 patients were esteemed to have nonbacterial infections. All the 10 patients of bacterial infections were cured after the CFX therapy. The pathogens recovered were Streptococcus pyogenes (1), Streptococcus pneumoniae (3), Haemophilus influenzae (2), Escherichia coli (2), enteropathogenic Escherichia coli (1), and Klebsiella pneumoniae (1). All the strains isolated were susceptible to CFX, but the 2 isolates of Haemophilus influenzae had relatively high MIC values (12.5 mcg/ml). Diarrhea (3 cases) and transient neutropenia (1 case) were found to be associated with the CFX therapy. However, no severe adverse reactions were encountered. Half-life of the serum level was short (24.1 minutes) and excretion into the urine was rapid. CSF concentration obtained 30 minutes after an intravenous injection of 50 mg/kg of CFX in 1 case with inflamed meninges was considerably high (8.3 mcg/ml). CFX appears to be a safe and effective antibiotic when used in children with susceptible bacterial infections.

18p-Mosaicism: case report and review

The case of a 5-month-old male infant with 18p- mosaic, who has intractable seizures and severe ophthalmological abnormalities in addition to many clinical manifestations usually described in the 18p- syndrome, is reported. The proportions of abnormal cells are 7-8% in blood and 55% in skin. About 35% of the short arm of chromosome 18 is deleted. to our knowledge the present report is the fifth one of 18p-mosaic. The main interest of this case resides in the fact that it shows a serious clinical picture despite the low proportion of abnormal cells in blood and the small degree of deletion of the short arm of chromosome 18.

Studies on ferrous ion-induced lipid peroxidation of rat liver mitochondria. II. Relationship to incubation temperature

Ferrous ion-induced lipid peroxidation in rat liver mitochondria has a lag in the induction period. The characteristics of the lag were investigated under various conditions. This lag period lengthened proportionally to increased temperature (4 degrees approximately 37 degrees C). In the presence of inorganic phosphate the lag period lengthened, reaching a maximum at about 20 degrees C, and then shortened with increased temperatute. Elongated lag periods were shown in heat-treated or protein digested mitochondria. Shortened lag periods were shown in snake venom-treated mitochondria. On the other hand, almost no lag was observed in the peroxidation of the lipid extracted from mitochondria. The lag period also varied with incubation temperature. The results suggested that certain factors, which determined lag of the induction period in membrane lipid peroxidation associate with reaction-temperature and the lipo-protein structure in mitochondrial membranes.