Atrial natriuretic factor after heart operations in children. Relation to hemodynamic and renal parameters.

The purpose of this study was to measure changes in serum atrial natriuretic factor concentrations immediately after heart operations in children under baseline conditions and in response to continuous infusion of dopamine (2.5 and 5.0 micrograms/kg/min). During control periods, levels of atrial natriuretic factor were elevated at 190 +/- 24 and 199 +/- 36 pg/ml. The cardiac index was 2.6 L/min/m2 and the renal plasma flow was decreased to 269 +/- 41 ml/min/1.73 m2, indicating a state of renal vasoconstriction (mean renal fraction of cardiac index of 10.0% +/- 1.0%). The mean sodium fractional reabsorption was 99.0% +/- 0.2%. During dopamine infusion, atrial natriuretic factor concentrations increased to 259 +/- 57 pg/ml and to 280 +/- 56 pg/ml, with dopamine 2.5 and 5.0 micrograms/kg/min, respectively (p = not significant), whereas left atrial pressure decreased from 11.7 +/- 0.9 mm Hg during the control period to 10.1 +/- 0.9 and to 9.9 +/- 1.0 mm Hg (p less than 0.05). No correlation was found between changes in left atrial pressure and atrial natriuretic factor levels. Dopamine at 5 micrograms/kg/min increased the cardiac index to 3.0 +/- 0.2 L/min/m2 (p less than 0.001) and the renal plasma flow to 406 +/- 61 ml/min 1.73 m2 (p less than 0.001), alleviating the renal vasoconstriction. The mean urinary sodium excretion increased to 0.33 +/- 0.08 mmol/kg/hr (p less than 0.01). The atrial natriuretic factor plasma concentrations were not related to the urinary sodium excretion, renal plasma flow, or glomerular filtration rate during the control period or during dopamine treatment. These data indicate that after heart operations in children, low urinary sodium excretion occurs despite high circulating atrial natriuretic factor levels. Atrial natriuretic factor concentrations were related neither to left atrial pressures nor to the renal changes induced by dopamine.

Assessment of lung volume and alveolar pressure during combined high-frequency jet ventilation in a child with adult respiratory distress syndrome.

Lung volume and alveolar pressure were assessed using inductance plethysmography, airway occlusion and pneumotachography in a child with severe adult respiratory distress syndrome during both conventional mechanical and combined high-frequency ventilation (HFJV). The results suggest that improved oxygenation during combined HFJV is associated with higher end-expiratory lung volume and lower peak and mean lung volume and alveolar pressure.

Combined high-frequency ventilation in children with severe adult respiratory distress syndrome.

Six children conventionally ventilated for acute pulmonary parenchymal failure developed severe hypoxemia (mean PaO2 48 +/- 7 mmHg at an FiO2 of 0.95 +/- 0.08) persisting for more than 6 h despite a progressive increase in positive end expiratory pressure (PEEP) to 14.7 +/- 1.5 cmH2O. Combined high-frequency jet ventilation (HFJV, mean rate 225 b/min superimposed on small tidal volume conventional ventilation) resulted in a sustained increase in PaO2 to 93 +/- 21 mmHg, p less than 0.05 while peak inspiratory pressure decreased from 47 +/- 8 to 35 +/- 6 cmH2O and positive end expiratory pressure could be reduced to 5.8 +/- 4.5 cmH2O, p less than 0.05 and FiO2 to 0.88 +/- 0.10. This improvement occurred without new barotrauma nor deleterious effects on hemodynamic function or diuresis. After a mean of 62 h of combined function or diuresis. After a mean of 62 h of combined HFJV, persistent improvement in gas exchange allowed us to resume conventional mechanical ventilation at lower airway pressures in 4 children who continued to improve and survived. The 2 other children maintained satisfactory gas exchange on combined HFJV, but ultimately died from multiple organ failure. We conclude that combined HFJV might prove helpful to relieve profound hypoxemia and possibly decrease the risk of barotrauma in children with catastrophic pulmonary failure.

Furosemide reduces lung fluid filtration in lambs with lung microvascular injury from air emboli.

To study the effects of furosemide on the neonatal pulmonary circulation in the presence of lung injury, we measured pulmonary arterial and left atrial pressures, cardiac output, lung lymph flow, and concentrations of protein in lymph and plasma of nine lambs that received furosemide, 2 mg/kg iv, during a continuous 8-h intravenous infusion of air. Air embolism increased pulmonary vascular resistance by 71% and nearly tripled steady-state lung lymph flow, with no change in lymph-to-plasma protein ratio. These findings reflect an increase in lung vascular protein permeability. During sustained lung endothelial injury, diuresis from furosemide led to a rapid reduction in cardiac output (average 29%) and a 2-Torr decrease in left atrial pressure. Diuresis also led to hemoconcentration, with a 15% increase in both plasma and lymph protein concentrations. These changes were associated with a 27% reduction in lung lymph flow. In a second set of studies, we prevented the reduction in left atrial pressure after furosemide by inflating a balloon catheter in the left atrium. Nevertheless, lymph flow decreased by 25%, commensurate with the reduction in cardiac output that occurred after furosemide. In a third series of experiments, we minimized the furosemide-related decrease in cardiac output by opening an external fistula between the carotid artery and jugular vein immediately after injection of furosemide. In these studies, the reduction in lung lymph flow (average 17%) paralleled the smaller (17%) decrease in cardiac output. These results suggest that changes in lung vascular filtration pressure probably do not account for the reduction in lung lymph flow after furosemide in the presence of lung vascular injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimation of the onset of bone atrophy.

Disturbances of bone growth were investigated in the skeletal remains of two individuals. These two--unrelated--mature males possessed limbs with marked atrophy as a result of immobilization, while the non-affected limbs showed a massive hyper-robusticity of the bones. The atrophied bones were investigated metrically and histologically. We assessed the time of onset, the duration and the extent of the immobilization. Both males suffered from paralysis, whereby one was apparently paralyzed from the pelvis down, the other had both lower extremities and the right arm affected. It appears that the onset occurred during the juvenile period.

Enamel thickness of human maxillary molars reconsidered.

Forty-four modern human maxillary molars (M1 = 21, M2 = 12, and M3 = 11) were sectioned through the mesial cusps in a plane perpendicular to the cervical margin of the crown. Eight measurements of enamel thickness as well as bucco-lingual (BL) and mesio-distal (MD) diameters were recorded for each tooth in order to investigate differences in these dimensions between tooth categories. Uni- and multi-variate analyses revealed first maxillary molars to have generally thinner enamel than second or third upper molars, especially with regard to the occlusal basin. Furthermore, the decrease of MD diameters from anterior to posterior is greater than that of BL diameters. Principal Component Analysis using enamel thickness measurements resulted in complete separation of first molars, while second and third maxillary molars showed a certain amount of overlap. This finding casts doubt on using an overall measure of "molar enamel thickness" derived from mixed samples of molars for taxonomic purposes. There appears to be a relationship between bite force and enamel thickness such that posterior molars, where masticatory forces are stronger, have thicker enamel than anterior teeth. It is suggested that the gradient of enamel thickness between (and within) teeth in extant and extinct species may thus provide further information about relative wear resistance as well as the biomechanical constraints of the orofacial skeleton.

Enamel thickness and the helicoidal occlusal plane.

In the present study 38 unworn maxillary molars (M1 = 16, M2 = 12, M3 = 10) of modern humans from a Slavic necropolis were sectioned through the mesial cusps in a plane perpendicular to the cervical margin of the crown. Five slightly worn M1s and one slightly worn M3 were also used thus increasing the total sample to 44, but measurements made on the worn areas were coded as missing values. Seven measurements of enamel thickness as well as the heights of the protocone and the paracone dentine horns were recorded in order to analyze whether changes in these dimensions in anteroposterior direction can be related to the helicoidal occlusal plane. Uni- and multivariate analyses revealed that the distribution of enamel thickness within and between maxillary molars corresponds to a helicoidal occlusal wear pattern. Enamel thickness along the occlusal basin increases from anterior to posterior, which may lead to rapid development of a reverse curve of Monson in first molars when compared to posterior teeth. However, although these overall differences together with the serial, especially delayed eruption pattern of human molars, contribute to the marked expression of the helicoidal occlusal plane in Homo, differences in enamel patterning between molars indicate that a helicoidal plane is a structural feature of the orofacial skeleton. In contrast to first upper molars, second and third molars show absolutely and relatively thicker enamel under the Phase I wear facet of the paracone, i.e., the lingual slope of the paracone, than under the Phase II facet of the protocone, i.e., the buccal slope of that cusp. These proportional differences are most pronounced in M3, as evidenced by uni- and multivariate statistics. It thus appears that the pattern of enamel thickness distribution from M1 to M3 follows a trend towards providing additional tooth material in areas that are under greater functional demands, that is, corresponding to a lingual slope of wear anteriorly and to a flat or even buccal one posteriorly. In addition, the heights of the dentine horns in anteroposterior direction change in a way that lends support to the hypothesis that the axial inclination of teeth could be one of the most important factors for the development of the helicoidal occlusal plane. Finally, the changes in morphology and enamel thickness distribution from first to third upper molars found in this study suggest that molars could be "specialized" in their function, i.e., from performing proportionally more shearing anteriorly to increased crushing and grinding activities posteriorly.

Effect of pulmonary perfusion on lung fluid filtration in young lambs.

To study the effect of pulmonary perfusion on fluid filtration in the newborn lung, we measured pulmonary vascular pressures, cardiac output, lung lymph flow, and concentrations of protein in lymph and plasma of nine healthy, awake lambs, 2-3 wk old, before and during sustained alterations in pulmonary blood flow. A 12% reduction in cardiac output (from partial occlusion of the inferior vena cava) led to a corresponding decrease in lymph flow, consistent with a reduction in net lung fluid filtration. A 20% increase in pulmonary blood flow (from opening an external shunt between the carotid artery and jugular vein) increased lymph flow by approximately 40%, without a significant change in lymph protein concentration. These findings suggest that lung microvascular surface area expanded in response to increased perfusion, with little or no change in filtration pressure. In five lambs, lung microvascular pressure was increased by inflating a balloon catheter in the left atrium to establish full patency of the pulmonary microcirculation. In the presence of left atrial pressure elevation, increased perfusion through the arteriovenous shunt had no significant effect on pulmonary vascular pressures or lymph flow. Thus, in young lambs, modest changes in pulmonary blood flow may affect lung fluid filtration by altering perfused microvascular surface area; this response is inhibited in the presence of left atrial hypertension.

Lung vascular effects of lipid infusion in awake lambs.

Numerous reports have shown that intravascular lipid infusion may cause pulmonary dysfunction in a variety of species, including humans. To determine the effects of parenteral lipid on neonatal pulmonary hemodynamics, lung fluid filtration, and respiratory gas exchange, we measured pulmonary arterial and left atrial pressures, cardiac output, lung lymph flow, lymph and plasma protein concentrations, and partial pressures of oxygen and carbon dioxide in arterial blood of 11 awake chronically catheterized lambs that received a 2-3 h control infusion of glucose-saline solution followed by Intralipid at a dose of 67.5, 125, or 250 (mg/h)/kg body weight for 6 h. Intralipid caused an acute dose-dependent increase in pulmonary arterial pressure, with no significant change in cardiac output or left atrial pressure. The pulmonary hypertension, which lasted for at least 2 h, was accompanied by a greater than 50% increase in lung lymph flow and a significant decrease in lymph protein concentration relative to plasma protein concentration. Pulmonary artery pressure gradually decreased to control values during the final 2 h of lipid infusion, but lymph flow remained 35% above control and lymph protein concentration remained low. Lipid infusion also was associated with a modest decrease in PaO2. Both arterial and venous administration of lipid gave similar results. In separate studies, lipid infusion caused a significant increase in plasma concentrations of thromboxane B2, the stable metabolite of thromboxane A2, without affecting plasma concentrations of 6-keto prostaglandin F1 alpha, the stable metabolite of prostacyclin. Pretreatment with imidazole, which attenuated the lipid-induced increase in thromboxane B2 concentration, completely blocked the pulmonary hemodynamic response to lipid.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum tumour necrosis factor in newborns at risk for infections.

Tumour necrosis factor-alpha (TNF-alpha) is an important mediator in the pathogenesis of Gram-negative shock. In order to assess the role of TNF-alpha as a marker of the severity of infections in the neonates, serum TNF-alpha concentrations were determined at the time of septic work-up in 69 newborns (gestational age: 28-40 weeks). Nine patients had systemic infection (group A), four of them with signs of circulatory failure. Eleven patients had positive cultures of gastric aspiration or placental smears (group B) and 49 patients had completely negative septic work-up. Patients of group A had significantly more elevated serum TNF-alpha levels than patients of group B and C. Within group A, patients with circulatory failure had mean serum TNF-alpha concentration of 2165 +/- 817 pg/ml versus 27 +/- 8 pg/ml in newborns without shock. Serum TNF-alpha concentrations of more than 15 pg/ml detected systemic infections in eight out of nine patients. The specificity was 98% (1 elevated TNF-alpha concentration out of 60 non infected patients). These data indicate that premature neonates and term newborns are able to produce TNF-alpha when they are infected. Highly elevated TNF-alpha concentrations are found in severe systemic infections causing cardiovascular impairment.