Effects of feeding high volumes of milk replacer on reproductive performance and on concentrations of metabolites and hormones in blood of Japanese black heifer calves

We evaluated the effects of feeding high volumes of milk replacer on growth and reproductive performances in Japanese black heifers. Fifty-one heifers were fed milk replacer at 9 L/day for 60 days (9 L × 60 days; n = 18) or 41 days (9 L × 41 days; n = 15), or at 7 L/day for 40 days (7 L × 40 days; n = 18). Artificial insemination (AI) was performed on heifers with ≥270 kg body weight and ≥116 cm body height at 300 days of age. The age at the first AI was 0.35 month later for 7 L × 40 days than the other groups (p < .01). However, age at calving did not differ among treatments (22.1 months). The interval from the first AI to pregnancy tended to be ~2 months longer for the 9 L × 60 days than the other groups (p = .07). Our results showed that feeding high volumes of milk replacer may reduce the age at calving via an improved rate of growth. In addition, we propose that feeding a maximum of 7 L milk replacer for 40 days may be the most appropriate rearing regime because the success of pregnancy per AI may be reduced in calves fed a maximum of 9 L for 41 and 60 days.

Decreased Perfusion in Myocardial Region of Normal Donor Artery Secondary to Collateral Development

Thirty-one patients suffering from single vessel exertional angina with collaterals (Group A) were evaluated by stress 201T1 myocardial emission CT (T1-SPECT) with 16 controls of severely stenotic single vessel exertional angina without collaterals (Group B). Group A included 21 patients (68%) who showed an extensive perfusion defect in double artery myocardial regions, including the normal donor artery myocardial region (DMR). However, there were no such cases in Group B, giving a significant difference between these 2 groups (p < 0.001). Four patients in Group A, having a perfusion defect both in DMR and in the collateral dependent myocardial region (CMR) underwent a successful percutaneous transluminal coronary angioplasty (PTCA) with disappearance of collaterals. T1-SPECT findings after PTCA showed no perfusion defect either in CMR or in DMR. This has been explained on the basis that the coronary collaterals stole blood and produced perfusion defect in DMR.

Imaging findings of radiation-induced sarcoma of the head and neck

We set out to retrospectively review the clinical and imaging features of patients with post-radiation sarcoma, especially in the head and neck region. We reviewed the records of 4194 patients with carcinoma of the head and neck region who had a history of radiation. They had undergone CT and/or MRI. Medical records were reviewed for the primary diagnosis, radiation history and latency period to the development of sarcoma. The patients included four men and two women with a mean age of 64.5 years. The mean latency period for the development of sarcoma was 11.5 years. Primary diagnoses were maxillary carcinoma, nasopharyngeal carcinoma, adenoid cystic carcinoma of the oral floor, tonsilar carcinoma, soft palate carcinoma and tongue carcinoma. Histopathological examinations revealed osteosarcoma, spindle cell sarcoma, chondrosarcoma, malignant peripheral nerve sheath tumour, spindle cell carcinoma and malignant fibrous histiocytoma, respectively. Common findings were a heterogeneous and well-enhanced soft tissue mass and bone destruction. There is at present little or no prospect for the effective prevention of radiation-induced sarcoma of the head and neck. This emphasizes the importance of the earliest possible diagnosis for such patients. The imaging findings are not diagnosis specific, but strict follow-up within the radiation field by CT and MRI and an appreciation of the expected latency period may help to provide the diagnosis. When radiotherapy is performed for head and neck neoplasms, periodic follow-up observations may be necessary for many years.

Contrasting effects of dopamine therapy in experimental brain injury

Management of cerebral perfusion pressure (CPP) is thought to be important for the treatment of traumatic brain injury (TBI). Vasopressors have been advocated as a method of increasing mean arterial blood pressure (mABP) and cerebral perfusion pressure (CPP) in the face of rising intracranial pressure (ICP). There are unresolved issues and theoretical risks about this therapy. This study therefore examined the effects of dopamine on physiological and MRI/MRS parameters in (1) a rodent model of rapidly rising intracranial pressure, caused by diffuse injury with secondary insult and (2) a model of cortical contusion. Dopamine was capable of restoring CPP in the model of rapidly rising ICP. This CPP restoration was associated with a partial restoration of CBF. Two profiles of change in the Apparent Diffusion Coefficient of water (ADCw) were seen; one in which ADCw recovered to baseline, and one in which ADCw remained persistently low. Dopamine did not alter these profiles. MRI assessed tissue water content was increased four hours after injury and dopamine increased cerebral water content in both subgroups of injury; significantly in the group with a persistently low ADCw (p < 0.01). In contusional injury, dopamine significantly worsened edema in both the ipsi- and contralateral hippocampus and temporal cortex. This occurred in the absence of ADCw changes, except in the contralateral hippocampus, where both water content and ADCw values rose with treatment, suggesting extracellular accumulation of water. In conclusion, although dopamine is capable of partially restoring CBF after injury, situations exist in which dopamine therapy worsens the swelling process. It is possible therefore that subgroups of patients exist who experience adverse effects of vasopressor treatment, and consequently the effects of vasopressor therapy in the clinical setting need to be more carefully evaluated.

The permissive nature of blood brain barrier (BBB) opening in edema formation following traumatic brain injury

The contribution of blood brain barrier opening to traumatic brain edema is not known. This study compares the course of traumatic BBB disruption and edema formation, with the hypothesis that they are not obligately related. Sprague-Dawley rats were divided into three groups: Group A (n = 47)--Impact Acceleration (IAM); Group B (n = 104)--lateral cortical impact (CCI); Group C (n = 26)--IAM + hypoxia & hypotension (THH). BBB integrity was assessed using i.v. markers (Evan's Blue, or gadolinium-DTPA). Edema formation was evaluated with gravimetry, and T1-weighted MRI. In IAM, BBB opened immediately but closed rapidly, and remained closed for at least the next 36 hours whilst 24-hour hemispheric water content (HWC) rose by 0.9% (p < 0.01). In CCI, BBB opened in both hemispheres for up to 4 hours; four hour HWC in the uninjured hemisphere was indistinguishable from Sham, where HWC in the injured hemisphere rose by approximately 1.5% (p < 0.005). We distinguished two THH animals based on Apparent Diffusion Coefficient (ADC) recovery: in ADC-recovery animals 4 hour cortical water content (CWC) was 80.4 +/- 0.6%, cf 81.4 +/- 1.3% in ADC-non-recovery (p < 0.05). In all animals the BBB was open, however two populations of permeability were seen which likely related to flow-limited extravasation of gadolinium. In IAM edema forms despite only brief BBB opening. Although there is diffuse BBB opening with lateral contusion, edema only forms in the injured hemisphere. In THH, edema formation in the face of a widely permeable barrier is driven by ADC changes or cell swelling. Edema formation clearly does not correspond with BBB opening and an open BBB is clearly not required for edema formation. However we hypothesize that a permeable BBB permissively worsens the process, by acting as a low resistance pathway for ion and water movement. These findings are consistent with our general hypothesis that edema formation after TBI is mainly cytotoxic.

The effects of dopamine on edema formation in two models of traumatic brain injury

The risk of vasopressors worsening cerebral edema has been raised. Previously we have reported that dopamine was able to restore cerebral blood flow in a model of monotonically rising intracranial pressure. In this study the effects of dopamine on cortical contusion and diffuse injury with secondary insult are examined. Adult male rats were divided into two groups: group 1 (n = 32)--Impact Acceleration Injury (IAM) with 30 minutes hypoxia and hypotension; group 2 (n = 12)--controlled cortical impact (6.0 m/sec, 3 mm depth). Dopamine was administered 2 hours post-injury (10-60 micrograms/kg/min i.v.). Cerebral water content and apparent diffusion coefficients (ADC) values were measured at baseline and four hours post-injury using MRI. Preinjury water content was the same in each group. Group 1 was subdivided into Groups 1A & 1B based on the ADC profile. Post-injury water content in Group 1A did not differ between saline or dopamine treated animals. Water content was higher in Group 1B-dopamine (83.4 +/- 1.1%) than Group 1B-saline animals (81.4 +/- 1.3%, p = 0.006). Contusion caused significant edema formation, however there was no significant difference between the dopamine treated or untreated group when considering either ipsilateral or contralateral cortex. Dopamine however significantly worsened edema in ipsilateral and contralateral hippocampus and both temporal cortices. ADC remained unchanged except in the contralateral hippocampus where both water content and ADC rose with dopamine suggesting precipitation of a vasogenic edema. In this study dopamine clearly worsened edema formation in two models of traumatic brain injury, and we conclude that there may be analogous clinical situations; therefore pressors should not be considered a 'blanket' therapy for all patients with a low cerebral perfusion pressure.

Atrial ectopy originating from the posteroinferior atrium during radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia

Atrial ectopy sometimes appears during RF ablation of the slow pathway in patients with atrioventricular nodal reentrant tachycardia (AVNRT). However, its origin, characteristics, and significance are still unclear. To examine these issues, we analyzed 67 consecutive patients with AVNRT (60 with slow-fast AVNRT and 7 with fast-slow AVNRT), which was successfully eliminated by RF ablation to the sites with a slow potential in 63 patients and with the earliest activations of retrograde slow pathway conduction in 4 patients. During successful RF ablation, junctional ectopy with the activation sequence showing H-A-V at the His-bundle region appeared in 52 patients (group A) and atrial ectopy with negative P waves in the inferior leads preceding the QRS and the activation sequence showing A-H-V at the His-bundle region appeared in 15 patients (group B). Atrial ectopy was associated with (10 patients) or without junctional ectopy (5 patients). Before RF ablation, retrograde slow pathway conduction induced during ventricular burst and/or extrastimulus pacing was more frequently demonstrated in group B than in group A (9/15 [60%] vs 1/52 [2%], P < 0.001). Successful ablation site in group A was distributed between the His-bundle region and coronary sinus ostium, while that in group B was confined mostly to the site anterior to the coronary sinus ostium. In group B, atrial ectopy also appeared in 21% of the unsuccessful RF ablations. In conclusion, atrial ectopy is relatively common during slow pathway ablation and observed in 8% of RF applications overall and 22% of RF applications that successfully eliminated inducible AVNRT. Atrial ectopy appears to be closely related to successful slow pathway ablation among patients with manifest retrograde slow pathway function.

Acute myocardial infarction and increased soluble intercellular adhesion molecule-1: a marker of vascular inflammation and a risk of early restenosis?

BACKGROUND

Plasma levels of soluble intercellular adhesion molecule-1 (sICAM-1) have been shown to predict activities of inflammatory disorders and malignancies. However, it is unknown whether the plasma level of sICAM-1 is increased in patients with acute myocardial infarction (AMI) with coronary intervention and whether the levels have any diagnostic or predictive values for vascular disease activity in patients with AMI.

METHODS

We prospectively observed the time course of the plasma sICAM-1 levels in 20 patients with AMI whose infarct-related coronary artery was successfully recanalized by emergency balloon angioplasty. sICAM-1 was measured by enzyme-linked immunoassay.

RESULTS

At admission, 48 hours, 1 week, and 2 weeks after angioplasty, sICAM-1 levels were significantly elevated in patients who had early (3 weeks) restenosis develop compared with those who did not (p < 0.05). At the other time points examined, there was a tendency of higher sICAM-1 levels in patients with than without restenosis (0.06 < p < 0.09). The relation of sICAM-1 levels and total white blood cell counts, neutrophil counts, or numbers of diseased major coronary artery branches was not statistically significant.

CONCLUSIONS

A persistent increase in plasma sICAM-1 levels may indirectly implicate vascular inflammation, which could predict the risk of early coronary restenosis after emergency angioplasty in patients with AMI. Hence, measurements of sICAM-1 in patients with AMI would serve as a potentially useful predictor of the risk of early postangioplasty restenosis.

Biphasic pathophysiological response of vasogenic and cellular edema in traumatic brain swelling

The objective of this study was to quantify the temporal water content changes and document the type of edema (cellular versus vasogenic) that is occurring during both the acute and the late stages of edema development following closed head injury. Adult Sprague rats (n = 50) were separated into two groups: Group I: Sham (n = 8), Group II: Trauma (n = 42). The measurement of brain water content (BWC) was based on T1, whereas the differentiation of edema on the measurement of the random, translational motion of water protons (apparent diffusion coefficients-ADC) by MRI. In trauma animals, we found a significant increase in ADC (105%) as well as in BWC (0.7 +/- 0.3%) during the first 60 minutes post injury indicating vasogenic edema formation. This transient increase; however, was followed by a continuing decrease in ADC beginning at 45 minutes post injury and reaching a minimum at days 7-14 (-103%). Since the BWC continued to increase during the next day (10.3%), it is suggested cellular edema formation started to develop soon after injury and became dominant between 1-2 weeks post injury. In conclusion we may consider, that there is a predominantly vasogenic edema formation immediately after injury and later a more widespread and slower edema formation due to a predominantly cellular swelling.

Detection of brain atrophy following traumatic brain injury using gravimetric techniques

We hypothesized, that with atrophy, the correlation between water content and specific gravity of brain solids would break down signifying the onset of the atrophic process. The correlation between tissue water content, specific gravity of solids and ventricular size was studied in an impact acceleration model of closed head injury of the rat. Adult Sprague Dawley rats weighing 350 to 375 grams (n = 63) were separated into two groups: Group 1: Sham (n = 21), Group II: Trauma (n = 42). Water content was assessed using both gravimetric method and drying-weighing method at 1 hour, on days 1, 3, 7, 14, 28, and 42 in the trauma group as well as in the control group. Ventricular size was measured in cm2 on the MRI computer console in the coronal section at the coronal suture at the same time points. In the trauma group we found a significant increase (p < 0.01) in water content during the first week except on day 3 and there was a good correlation between the results of water content using both methods (p < 0.001). However, this relationship was poorly correlated after day 14 (p = 0.25). Although the ventricular size was the smallest at 1 hour post trauma, it significantly increased over the next 3 days (p < 0.001). On day 7 and 14 ventricular size decreased to normal size, yet gradually increased and then reached a significantly larger size on 42 days post trauma again (p < 0.01). We may consider, that brain edema following CHI begins immediately following trauma and resolves within 2 weeks. After 14 days degenerative change occurs in the cortex, as detected by specific gravity measurements which signifies the onset of the atrophic process and subsequent post traumatic ventricular dilatation.

Contribution of vasogenic and cellular edema to traumatic brain swelling measured by diffusion-weighted imaging

The contribution of brain edema to brain swelling in cases of traumatic brain injury remains a critical problem. The authors believe that cellular edema, the result of complex neurotoxic events, is the major contributor to brain swelling and that vasogenic edema, secondary to blood-brain barrier compromise, may be overemphasized. The objective of this study, therefore, was to quantify temporal water content changes and document the type of edema that forms during the acute and late stages of edema development following closed head injury (CHI). The measurement of brain water content was based on magnetic resonance imaging-determined values of tissue longitudinal relaxation time (T1-weighted imaging) and their subsequent conversion to percentage of water, whereas the differentiation of edema formation (cellular vs. vasogenic) was based on the measurement of the apparent diffusion coefficient (ADC) by diffusion-weighted imaging. A new impact-acceleration model was used to induce CHI. Thirty-six adult Sprague-Dawley rats were separated into two groups: Group I, control (six animals); and Group II, trauma (30 animals). Fast ADC measurements (localized, single-voxel) were obtained sequentially (every minute) up to 1 hour postinjury. The T1-weighted images, used for water content determination, and the diffusion-weighted images (ADC measurement with conventional diffusion-weighted imaging) were obtained at the end of the 1st hour postinjury and on Days 1, 3, 7, 14, 28, and 42 in animals from the trauma and control groups. In the animals subjected to trauma, the authors found a significant increase in ADC (10 +/- 5%) and brain water content (1.3 +/- 0.9%) during the first 60 minutes postinjury. This is consistent with an increase in the volume of extracellular fluid and vasogenic edema formation as a result of blood-brain barrier compromise. This transient increase, however, was followed by a continuing decrease in ADC that began 40 to 60 minutes postinjury and reached a minimum value on Days 7 to 14 (10 +/- 3% reduction). Because the water content of the brain continued to increase during the first 24 hours postinjury (1.9 +/- 0.9%), it is suggested that the decreased ADC indicated cellular edema formation, which started to develop soon after injury and became dominant between 1 and 2 weeks postinjury. The study provides supportive evidence that cellular edema is the major contributor to posttraumatic swelling in diffuse CHI and defines the onset and duration of the increase in cellular volume.

Tissue factor expression on macrophages in coronary plaques in patients with unstable angina

Tissue factor is a membrane-bound glycoprotein that functions in the extrinsic pathway of blood coagulation by acting as a cofactor for factor VII, and the resulting complex leads to thrombin production in vivo. The purpose of the present study is to determine whether macrophages express tissue factor in human coronary atherosclerotic plaques. We examined directional coronary atherectomy specimens from 24 patients with unstable angina and 23 with stable exertional angina. In these specimens, macrophages were detected in 22 (92%) of 24 patients with unstable angina versus 12 (52%) of 23 with stable exertional angina (P = .003). The percentage of macrophage infiltration area was significantly larger in patients with unstable angina than in those with stable exertional angina (17 +/- 3% versus 6 +/- 2%, P = .008). The immunohistochemical double staining revealed the expression of tissue factor on macrophages in 18 (75%) of 24 patients with unstable angina versus 3 (13%) of 23 with stable exertional angina (P < .0001). Thrombus was identified in 20 (83%) of 24 patients with unstable angina versus 12 (52%) of 23 with stable exertional angina (P = .02). Fibrin deposition was mainly observed around macrophages expressing tissue factor in the patients with unstable angina. We have shown that tissue factor expression on macrophages was more frequent in coronary atherosclerotic plaques in patients with unstable angina. Tissue factor expressed on macrophages may play an important role in the thrombogenicity in coronary atherosclerotic plaques of these patients.

Increased plasma soluble intercellular adhesion molecule-1 levels in patients with acute myocardial infarction

Intercellular adhesion molecule-1 (ICAM-1) is a major ligand for 2 members of the CD18 family of leukocyte integrin adhesion molecules and mediates adhesion between leukocytes and stimulated endothelial cells. We examined plasma soluble ICAM-1 (sICAM-1) levels in 30 patients with acute myocardial infarction (AMI) within 6 h of symptom onset, 21 patients with unstable angina (UA), 35 patients with stable exertional angina (SEA) and 21 control subjects. Plasma sICAM-1 levels (ng/ml) were significantly higher in both the acute and chronic phases of AMI and in the UA group than in the SEA and the control groups (195 +/- 14, 198 +/- 16 in the acute and chronic phases of AMI, 188 +/- 11 in the UA group vs 142 +/- 7 in the SEA group, 141 +/- 10 in the control group, p < 0.01). Plasma sICAM-1 levels were significantly higher in AMI patients when preceded by unstable angina than when not preceded by unstable angina at any point over the time course except 1 week after admission (p < 0.01 vs admission, 12 h, 2 days, 3 days, 5 days, 2 weeks, 3 weeks. p < 0.05 vs 24 h). These results suggest that the increase in sICAM-1 is associated with repeated episodes of myocardial ischemia and reperfusion not leading to myocardial necrosis. The increase in sICAM-1 may play an important role as an inflammatory component in the pathogenesis of the ischemic myocardium.

Serum levels of vascular endothelial growth factor in patients with acute myocardial infarction undergoing reperfusion therapy

1. Vascular endothelial growth factor, a potent angiogenic mitogen, is known to be induced in response to ischaemia as well as being secreted from tumour cells. However, the precise mechanism of vascular endothelial growth factor release in acute myocardial infarction and the effects of coronary reperfusion on the circulating levels of vascular endothelial growth factor are still unknown. 2. Nineteen patients with acute myocardial infarction who underwent early reperfusion therapy were studied. Serum levels of vascular endothelial growth factor before reperfusion were markedly increased as compared with those in 19 healthy control subjects [252.4 +/- 158.1 pg/ml (mean +/- SD) compared with undetectable]. After reperfusion, the serum vascular endothelial growth factor levels rapidly returned almost completely to the normal control range. 4. These data strongly suggest that the serum level of vascular endothelial growth factor is one of the most sensitive indicators of myocardial ischaemia.

[Effect of thrombolysis on rupture of the left ventricular free wall following acute myocardial infarction]

Rupture of the left ventricular free wall is one of the most serious sequels of acute myocardial infarction (AMI) and results in hospital death. The effectiveness of thrombolytic therapy for AMI to prevent rupture of the left ventricular free wall was studied retrospectively in 31 patients (2.6%) among 1,210 consecutive patients admitted to our hospital within 48 hours after the onset of AMI. All patients were divided into three groups: 758 without reperfusion therapy (conventional group), 113 who underwent direct percutaneous transluminal coronary angioplasty (direct PTCA group), and 339 who received thrombolytic therapy with or without PTCA (thrombolysis group). No rupture was found in the direct PTCA group. No significant difference could be found in the incidence of the rupture between the conventional group (19 patients, 2.5%) and the thrombolysis group (12 patients, 3.5%). When early rupture and late rupture are defined as occurring less and more than 48 hours from the onset of AMI, 14 early ruptures (1.8%) and 5 late ruptures (0.7%) were found in the conventional group, and 9 early ones (2.7%) and 3 late ones (0.9%) in the thrombolysis group. There was no significant statistical difference between the two groups. The incidence of the rupture according to the result of the reperfusion therapy was much higher in the unsuccessful group (five patients, 7.8%; p < 0.02) than in the successful group (seven patients, 2.5%; p < 0.002). All ruptures in the successful group appeared early; but only two early rupture cases (3.1%) out of five were found in the unsuccessful group. The mean interval between the thrombolysis and the rupture was 3.9 +/- 1.2 hours in the successful group, which was much shorter than that of the unsuccessful group (67.1 +/- 28.5 hours; p < 0.05). We conclude that thrombolytic therapy, if successful, may be effective to decrease late rupture of the left ventricular free wall, but may be ineffective to prevent early rupture.

Effects of angiotensin-converting enzyme inhibitor alacepril in patients with stable effort angina during chronic isosorbide dinitrate treatment

Nitrate tolerance has been reported to be reversed by certain types of angiotensin-converting enzyme (ACE) inhibitors. We examined whether alacepril, a new long-acting oral ACE inhibitor, has beneficial effects against exercise-induced angina in patients with stable effort angina after substantial isosorbide dinitrate (ISDN) treatment. Thirteen men with stable effort angina were treated with oral ISDN (80 mg/d) for >3 weeks. After this period, efficacy of single oral administration of either alacepril (50 mg) or its placebo on exercise-induced angina and electrocardiographic changes was examined by treadmill exercise test in a double-blind crossover design. Alacepril significantly improved the exercise duration by 9.1% (p=0.03), the time to 1 mm ST-segment depression by 19% (p<0.01), and the maximal ST-segment depression by 33% (p=0.015) compared with placebo. Alacepril did not significantly alter the rate-pressure product, a marker of myocardial oxygen demand, during exercise test compared with placebo. Plasma renin activity was significantly increased (p<0.05) after administration of alacepril, indicating that alacepril significantly blocked ACE activity in our patients. In conclusion, a single oral administration of the ACE inhibitor alacepril (50mg) elicited beneficial effects against exercise-induced myocardial ischemia in patients with stable effort angina during chronic nitrate treatment. These effects may be mediated by increased coronary blood flow.

Augmented sympathoadrenal activity during treadmill exercise in patients with Wolff-Parkinson-White syndrome and atrial fibrillation

It is believed that reciprocating tachycardia and accessory pathways play important roles in atrial fibrillation (AF) in patients with Wolff-Parkinson-White (WPW) syndrome. However, the mechanism by which AF occurs is not yet fully understood. This study was performed to evaluate the contribution of sympathoadrenal activity to the onset of AF in patients with WPW syndrome. Symptom-limited treadmill exercise testing was performed and plasma norepinephrine and epinephrine concentrations were measured simultaneously in 27 patients with WPW syndrome and 20 control subjects. In 13 patients with WPW syndrome and AF, plasma norepinephrine and epinephrine concentrations increased to 3.69 +/- 2.44 and 0.76 +/- 0.69 ng/ml at maximum exercise, respectively. These values were significantly higher (p < 0.001) than those in control subjects and in patients without AF. Pretreatment with 0.2 mg/kg of propranolol significantly reduced the incidence of exercise-induced atrial premature complexes (chi 2 = 7.33, p < 0.05). With oral beta-blockade for an average of 22.8 months, the incidence of AF decreased significantly from 1.77 +/- 0.53/patient per year to 0.33 +/- 0.57/patient per year (p < 0.001). Augmented sympathoadrenal activity in patients with WPW syndrome may contribute to AF.

Effects of antecedent anginal episodes and coronary artery stenosis on left ventricular function during coronary occlusion

We evaluated the effects of antecedent anginal episodes and coronary artery stenosis on left ventricular function during coronary occlusion and the role of collateral filling in 33 patients with angina pectoris who underwent angioplasty. Wall motion abnormalities were investigated by echocardiography and classified into hypokinesia and akinesia. Collateral filling during angioplasty was evaluated by using a second artery catheter. Akinesia was observed as follows: 24% of the patients had > 30 anginal episodes, 38% had 5 to 30, and 87% of the patients had < 5 (p < 0.01); 12% of patients had a lesion of 99%, 47% had a lesion of 90%, and 83% had a lesion of 75% (p < 0.05). Akinesia was observed in none of the patients with grade 3 collaterals, 57% with grade 2, and 67% with grade 1 or 0 (p < 0.01). These observations suggest that the patients with antecedent frequent anginal episodes and severe coronary stenosis have less left ventricular dysfunction during coronary occlusion. This finding may be the result of more extensive collateral development.

Right ventricular wall motion disturbance and determinants of the appearance of hemodynamic right ventricular infarction

In order to elucidate the mechanisms of the appearance of hemodynamic right ventricular infarction (RVI), we studied right and left ventriculograms and hemodynamic findings in 52 patients with acute inferior myocardial infarction. Right ventricular wall motion disturbance (RVWMD) was detected in 69% of patient but hemodynamic RVI was observed only in 16%. Among patients with RVWMD, there was no significant difference in right ventricular ejection fraction between those with (group III) and without (group II) hemodynamic RVI, suggesting that right ventricular (RV) systolic dysfunction does not independently produce hemodynamic RVI. Right ventricular end-diastolic volume index was similar in groups II and III in spite of higher mRA in group III. The result suggested that the RV compliance of group III was decreased. Heart rate (HR) was significantly lower in group III than in group II. Not only physiologic pacing but also VVI pacing significantly improved hemodynamics in patients with hemodynamic RVI. A positive correlation between HR and cardiac index was observed (r = 0.56, p < 0.001) in patients with RVWMD. Decreased RV compliance and bradycardia were considered to be determinants of the appearance of hemodynamic RVI. Volume loading did not improve hemodynamics significantly in patients with hemodynamic RVI.

[An early phase II clinical study of cis-diammine glycolato platinum, 254-S, for head and neck cancers]

An early phase II clinical study of 254-S, a new anticancer platinum complex, for head and neck cancer was conducted by the 254-S Head and Neck Cancer Study Group consisting of 10 institutions. Based on the results obtained in the phase I study, 254-S was administered at 100 mg/m2 by 60 min intravenous drip infusion after being dissolved in 300 ml of 5% xylitol. In principle, the 254-S administration was repeated at least 2 times at 4 week intervals. Hydration was performed, if needed. All 24 cases registered were regarded as complete cases evaluable for tumor response. Complete response (CR) was observed in 4 patients (16.7%), partial response (PR) in 5 (20.8%), no change (NC) in 11 and progressive disease (PD) in 4, for a 37.5% response rate. Three CR and 3 PR (40.0%) were obtained in 15 patients with prior chemotherapy, including 1 CR and 2 PR (33.3%) in 9 patients previously treated with cisplatin. Side effects were observed in 19 patients (79.2%). Major toxic effects were hematotoxicity, including thrombocytopenia (58.3%), leukopenia (58.3%) and anemia (33.3%), and gastrointestinal toxicity, including nausea and vomiting (45.8%) and anorexia (37.5%). Abnormal parameter changes on renal function were found in 2 patients (8.3%). Based on these results, it was concluded that 254-S is potentially a useful anticancer agent for the treatment of head and neck cancer, and should be further investigated in a late phase II clinical study.

[A late phase II clinical study of cis-diammine glycolato platinum, 254-S, for head and neck cancers]

A late phase II clinical study of 254-S, a new anticancer platinum complex, for head and neck cancer was conducted by the 254-S Head and Neck Cancer Study Group consisting of 31 institutions. As in the early phase II study for head and neck cancers, 254-S was administered at 100 mg/m2 by 60 min intravenous drip infusion, repeated at least twice at 4-week intervals. Of 80 cases registered, 66 were regarded as complete cases evaluable for tumor response. Complete response (CR) was observed in 7 patients (10.6%), partial response (PR) in 22 (33.3%), no change (NC) in 24 and progressive disease (PD) in 13, for a 43.9% response rate. Two CR and 11 PR (37.1% response rate) were obtained in 35 patients with prior chemotherapy, including 2 CR and 7 PR (33.3% response rate) in 27 patients previously treated with cisplatin. Of 70 patients evaluable for toxicity, side effects were observed in 60 patients (85.7%). Major toxic effects were hematotoxicity, including leukopenia (62.9%), thrombocytopenia (40.0%) and anemia (45.7%), gastrointestinal toxicity, including nausea and vomiting (64.3%), and anorexia (47.1%); grade 3 or 4 thrombocytopenia was found in 20.0% of the patients, and this toxicity was regarded as the dose limiting factor. Nephrotoxicity observed was mild and infrequent. Based on these results, it was concluded that 254-S is a very useful anticancer agent for the treatment of head and neck cancer.

[TNM classification system in cancer of the submandibular gland--a comprehensive retrospective study of 271 primary cases]

A total of 271 patients with submandibular gland cancer, treated in 149 hospitals in Japan in the period from 1958 to 1991, were retrospectively studied with regard to age, sex, TNM classification (UICC 1987, Geneva), histological diagnosis, therapeutic method and prognosis. The results were the following: 1. 157 males and 114 females 2. Stage I: 52 cases (19%); stage II: 64 cases (24%); stage III: 52 cases (19%) and stage IV: 103 cases (38%). 3. T1: 29 cases (11%); T2:116 cases (43%); T3: 93 cases (30%) and T4: 43 cases (16%). 4. Cervical lymph node involvement: 40%, ranging 25% in adenoid cystic carcinoma and acinic cell tumor, to 62% in undifferentiated carcinoma. 5. Distant metastasis: 11% 6.

HISTOLOGY

adenoid cystic carcinoma 37%, adenocarcinoma 20%, mucoepidermoid tumor 16%, carcinoma in pleomorphic adenoma 10%, epidermoid carcinoma 10%, undifferentiated carcinoma 3%, acinic cell tumor 3%. 7. Treatment method: Surgical procedure alone; 51%, Combination of surgery and postoperative radiation; 18%. 8. 5-year and 10-year survival rates were 36% and 11%, respectively. 9. 5-year and 10-year survival rates varied according to the stages, being 76% and 38%, respectively, for stage I, 68% and 20%, respectively, for stage II, 15% and 10%, respectively, for stage III, and 14% and 4%, respectively for stage IV.

Decreased perfusion in myocardial region of normal donor artery secondary to collateral development. Stress 201Tl myocardial emission CT performed in patients with single vessel exertional angina having collaterals

Thirty-one patients suffering from single vessel exertional angina with collaterals (Group A) were evaluated by stress 201T1 myocardial emission CT (Tl-SPECT) with 16 controls of severely stenotic single vessel exertional angina without collaterals (Group B). Group A included 21 patients (68%) who showed an extensive perfusion defect in double artery myocardial regions, including the normal donor artery myocardial region (DMR). However, there were no such cases in Group B, giving a significant difference between these 2 groups (p less than 0.001). Four patients in Group A, having a perfusion defect both in DMR and in the collateral dependent myocardial region (CMR) underwent a successful percutaneous transluminal coronary angioplasty (PTCA) with disappearance of collaterals. Tl-SPECT findings after PTCA showed no perfusion defect either in CMR or in DMR. This has been explained on the basis that the coronary collaterals stole blood and produced perfusion defect in DMR.

Usefulness of reinjection image for evaluating viable myocardium in the infarcted zone on exercise thallium-201 SPECT

Reinjection images were obtained in 23 patients with myocardial infarction by the additional injection of 37 MBq of thallium-201 after obtaining 4 hour delayed images on exercise thallium-201 SPECT (TSPECT). A redistribution index (RI) was derived of the changes in perfusion defects between immediate and 4 hour delayed images as well as immediate and reinjection images on polar bull's eye maps. The RI of reinjection images (46 +/- 27%) was significantly greater than that of 4 hour delayed images (26 +/- 26%) in patients with myocardial infarction (p less than 0.01). Significant redistribution after reinjection occurred in 4 of 9 patients (44%) without significant redistribution on 4 hour delayed images. Improvement in redistribution on reinjection images correlated significantly to the small extent of coronary artery disease and collateral development. The appearance of redistribution from 4 hour delayed imaging to reinjection imaging also might reflect the function of collateral development in the resting state in patients without significant redistribution on 4 hour delayed images. It has been demonstrated that underestimated viable myocardium on 4 hour delayed images in the infarcted zone can be better assessed on reinjection images. This reinjection technique is recommended in patients with no or partial redistribution on 4 hour delayed images.

Transcoronary chemical ablation of atrioventricular node for the treatment of paroxysmal supraventricular tachycardia--a case report

We applied transcoronary chemical ablation of the atrioventricular (AV) node to a patient with uncontrollable paroxysmal supraventricular tachycardia (PSVT). Through an angioplasty dilatation catheter. 99% ethanol at a dose of 1.0 ml was selectively infused into the AV nodal artery. Complete AV block with junctional escape rhythm occurred. Two weeks later, the treadmill exercise test was performed according to a modified Bruce protocol. The patient tolerated for 12 min, and the heart rate increased to 85 beats/min. His bundle electrocardiogram showed that the AV block resulted from atrio-Hisian block. Neither atrial nor ventricular extrastimulus could induce the tachycardia. It appeared that chemical ablation was a good method for controlling medically resistant PSVT. Elevation of serum creatine kinase was observed when ethanol overflowed during the ablation procedure. Occlusion of branches of the AV artery and mild hypokinesis in the inferobasal wall of the left ventricle were seen.

[Inflammatory granulomas extending from the sphenoid sinus to the cavernous sinus: report of three cases]

We treated three cases of inflammatory granulomas extending from the sphenoid sinus to the cavernous sinus. Case 1 was that of a 36-year-old male with diplopia and right ptosis. Case 2 was that of a 40-year-old male with frontal headache. Case 3 was that of a 70-year-old female with left impaired vision and frontal headache. In the first case, MRI demonstrated a mass lesion extending from the right half of the sphenoid sinus to the cavernous sinus and retropharyngeal space. In the second case the granuloma extended from the right cavernous sinus to the right retroorbital space. In the last case, MRI demonstrated diffuse Gd-DTPA enhancement of the left cavernous sinus and the left half of the sphenoid sinus. In all cases an operation was performed using the sublabial rhinoseptal approach, and the tumor in the sphenoid sinus was removed. Histological examination revealed an inflammatory granuloma in all 3 cases. In the first case the clinical symptoms improved following administration of glucocorticoids. In the second case the mass in the cavernous sinus decreased in size postoperatively. In the last case, the clinical symptoms gradually improved with administration of antibiotics after surgery. Granuloma of the cavernous sinus is difficult to diagnose, but when a similar pathological lesion coexists in the sphenoid sinus, a definitive diagnosis can be easily made via the sublabial rhinoseptal approach.

Persistent primitive hypoglossal artery associated with arteriovenous malformation--case report

A case of persistent primitive hypoglossal artery (PPHA) associated with arteriovenous malformation (AVM) is reported. A 46-year-old male suddenly developed severe headache followed by transient unconsciousness and was admitted to our hospital 2 hours later. A computed tomographic scan showed subarachnoid hemorrhage. Angiograms revealed an AVM in the left cerebellar hemisphere and an ipsilateral PPHA. The AVM was completely removed and he was discharged 1 month after surgery without neurological deficit. Only three cases of PPHA associated with intracranial AVM have been reported in the literature. One patient died of rebleeding from the AVM before surgery, and another was conservatively treated because the AVM was too large for resection. The remaining one was surgically treated only by ligation of the feeding arteries. Ours is the first case treated by total removal of the AVM. Since these four cases, including ours, account for 3.0% of 134 cases of PPHA reported, PPHA associated with AVM is considered rare.

[Effects of intravenous aprindine on hemodynamics in patients with cardiac dysfunction and its pharmacodynamics in patients with premature ventricular contractions]

The effects of aprindine, 100 mg iv, on hemodynamics, and the relationship between its inhibitory effect on PVC and its levels in the blood were determined in patients with diminished cardiac function. PVC was inhibited in 7 of 13 patients (54%), compared with a 50% inhibition rate in controls. The levels of aprindine in the blood after intravenous administration, rapidly decreased from 1.78 +/- 1.09 micrograms/ml immediately after administration, to 0.80 +/- 0.25 micrograms/ml after 15 min, to 0.65 +/- 0.23 micrograms/ml after 30 min and to 0.56 +/- 0.19 micrograms/ml after 1 hour. The duration of blood levels of 0.55 +/- 0.35 micrograms/ml, which are the levels presumed to be effective, was one hour after administration. The mean elimination half-life of aprindine was 18.9 +/- 8.4 hours. Aprindine produced relatively little effect on hemodynamics in patients with moderate to severe heart failure, but when its effects in individual cases were studied, it was found that aprindine elicited such changes as reduction in cardiac index, stroke volume index and stroke work index, and elevation in pulmonary arterial diastolic pressure. These findings suggest that care should be exercised in aprindine therapy in patients with diminished cardiac function. At least there should be monitoring of blood pressure and heart rate at appropriate times after intravenous administration.

[Radiation therapy of carcinoma of the hypopharynx and recurrence in the epipharynx and mesopharynx]

The role that radiation therapy plays in the prophylaxis of an epi-and mesopharyngeal recurrence of a hypopharyngeal cancer remains undefined. Because of this 48 patients with a hypopharyngeal cancer, who had undergone radiation therapy from 1975 through 1987 at Chiba University Hospital, have been analyzed retrospectively. The 5-year-survival was 17% and an epi- or a mesopharyngeal recurrence was found in 8 patients. A radiation dose of more than 1350 ret seemed to prevent a recurrence in these regions, although it must be further studied as to whether an increase of the radiation field to include the epipharynx can be effectively improved the recurrence-free survival rate.

Primary squamous cell carcinoma of the parotid gland: a case report with electron microscopic findings

Primary squamous cell carcinoma of the parotid gland is a rare tumor. Histological and ultrastructural features of a primary squamous cell carcinoma arising in the right parotid gland is presented. Light microscopically the tumor consisted of poorly differentiated squamous cell nests. PAS reaction was negative. Ultrastructurally the tumor cells were oval or spindle shaped and the cytoplasmic processes were frequently found. The majority of the tumor cells contained numerous intermediate filaments in their cytoplasm. No secretory granule was found. The desmosomes were well developed. It is known that mucoepidermoid carcinoma may be often misdiagnosed as squamous cell carcinoma. These findings can enable us to distinguish primary squamous cell carcinoma from mucoepidermoid carcinoma of the parotid gland.

Radiation therapy of the nasopharyngeal cancer and its prognostic factors

39 patients with the regional nasopharyngeal cancer (NPC) underwent radiation therapy from 1975 through 1984 in the Department of Radiology, Chiba University Hospital. A retrospective study was carried out to find out prognostic factors of these NPC patients. Radiation therapy was performed under megavoltage condition. 31 patients were given more than 50 Gy. 41% of the whole had T4 extension and 69% had lymph node metastasis. The pathological slides were reviewed and classified by the proposal of Shanmugaratnam. Advanced N-stage and the absence of the lymphocytic infiltration tended to affect the survival unfavorably, whereas the prognostic significance of histology, especially of keratinizing squamous cell carcinoma remained unclear. T4 lesion often recurred even with high dose radiation therapy. To improve the local control rate in NPC, wide field irradiation from the base of skull to the lower neck seemed necessary as well as the dosage greater than 66 Gy.

[Salivary gland cancer]

Till 1985, UICC had not developed the TNM-classification system of salivary gland cancer because of insufficiency of the number of cases. In this study, influences of various parameters such as age, sex, histological type, mobility of the tumors and facial nerve involvement were analyzed in a total of 354 cases of parotid gland cancer obtained by nationwide research. Furthermore, UICC classification system made in 1985 was assessed by application to these 354 cases.

Determination of left ventricular volumes with use of DSA density values

A computer program was developed to obtain left ventricular volumes from the density values of DSA. The highest density value along the horizontal pixel line over the left ventricle in 30 degrees RAO was considered to correspond to the greatest width on the same level of 60 degrees LAO. The left ventricular volume was obtained by converting the density values into the width and integrating these values. This method estimated experimental balloon volumes with considerable accuracy. Clinical evaluation revealed good correlation between DSA and conventional cine left ventriculography.

[On the time of cardiac aneurysm formation following acute myocardial infarction]

It has been said that ventricular aneurysm is formed in the relatively late stage after the onset of acute myocardial infarction. We examined the time of its formation using digital subtraction angiography (DSA) performed immediately after infarction and at various intervals thereafter. We also examined correlations between aneurysm formation and the degree of rest after infarction, blood pressures, sites of infarction and coronary angiographic findings. The subjects consisted of 35 hospitalized patients with acute myocardial infarction. They were examined by DSA immediately, and one week and one month after their admissions. DSA was performed in the 30 degree right anterior oblique projection, and cardiac aneurysms were diagnosed by the presence of regional protrusion or of dyskinesis of the left ventricular wall on left ventriculography. The results were as follows: Cardiac aneurysms were noted in eight men and four women. The mean age was 69.2 +/- 8.1 years. Infarctions were located in the anteroseptal region (nine patients), in the broad anterior wall (two patients) and in the inferior wall (one patient). The average onset-to-admission interval was 5.6 hours in the aneurysm group, and eight hours in the aneurysm-free group. Cardiac aneurysms were demonstrated by DSA immediately after hospital admission in all 12 patients in the aneurysm group and the size did not increase appreciably with time. The peak CPK was significantly higher in the aneurysm group (3,163) than in the aneurysm-free group (1,655), but there was no group-related difference in risk factors, hypertension, the duration of rest after infarction, or coronary angiographic manifestations. Cardiac aneurysm has been considered as a late complication of myocardial infarction. Many investigators have reported that its formation begins one to four weeks after the onset of infarction with gradual protrusion. In the present study, however, the formation of aneurysms was complete at very early stages after the onset of the myocardial infarction and often encountered in patients with relatively extensive infarction.

A proposal of TNM classification system for cancer of the salivary gland--comprehensive retrospective study

Until recently, there has not been a sufficient number of cases of salivary gland cancer to permit the development of a clinically useful TNM classification system. A comprehensive retrospective study of 354 patients with cancer of the parotid gland from 46 institutions in Japan was carried out at the request of the Japanese Committee on TNM Classification (JJC), and we propose JJC T-categories for parotid gland cancer. The characteristic of this proposal involves T-categories determined according to tumor size. Fixed tumors or tumors with facial nerve involvement were classified as T4 regardless of tumor size. In 1983, the AJC proposal for a TNM classification system of salivary gland cancers was tentatively approved at a AJC/UICC joint meeting. In comparison with the AJC classification, our proposal seems to be better in terms of simplicity and the balanced distribution in T-categories of parotid gland cancers.

Feasibility of ventricular function analysis by digital subtraction angiography

Continuous or cine mode of digital subtraction angiography (DSA) following intravenous injection of contrast media was evaluated in regard to feasibility of obtaining physiologic data in cardiac abnormalities. Computer programs for cardiac function analysis including stroke volume, ejection fraction and display of left ventricular wall motion in end-diastole and end-systole have been developed with use of automatic contour plotting and densitometry for depth information. Experiments with contrast-filled balloons demonstrated good correlation between the true volumes and the calculated volumes. Clinical study also demonstrated good correlation between the values obtained from conventional left ventriculography and DSA.

The clinical feature of pre-hospital phase of acute myocardial infarction--the advantages and limitations of the MCCU

For purposes of evaluating the clinical features in the prehospital phase of acute myocardial infarction, 22 patients presenting prehospital syncope and patients presenting in-hospital re-attack were chiefly studied. Cardiac or ventricular standstill, acute mechanical failure, ventricular fibrillation, serious block, bradycardia-hypotension syndrome, cardiogenic shock, cardiac failure and cardiac rupture may be cited as the complications likely to occur in the early phase of the onset of acute myocardial infarction. Among these complications, cardiac or ventricular standstill results from overactivity of the vagus nerve, and acute mechanical failure is a result of drastically decreased cardiac output due to extensive infarction. There is no report of either complication, and both may be considered to be the fatal complications occurring almost simultaneously with the onset of acute myocardial infarction. The time intervals from the onset of symptoms to hospital admission were perspectively analyzed on 72 patients transported by the MCCU and 139 by ordinary ambulance. The interval from the onset of symptoms to medical help and that from the examination by personal physician to the call for ambulance were the greatest of all time factors, while the interval for emergency transport of the patient was short. There was no significant difference in the interval to hospital admission between the patients transported by the MCCU and those by ordinary ambulance. However, the in-transit death rate was 1/72 patients transported by the MCCU and 8/139 by ordinary ambulance: in other words, this death rate tended to be high in the latter. Twenty-two normal volunteers were studied for changes in heart rate, blood pressure and double product with the speed of transport. The transport at a low speed caused less changes in these parameters than that at a high speed.