Fetal echocardiographic assessment of cardiovascular impact of prolonged support on EXTrauterine Environment for Neonatal Development (EXTEND) system.

OBJECTIVE: EXTrauterine Environment for Neonatal Development (EXTEND) is a system to support ongoing fetal growth and organ development in an extrauterine environment, utilizing a pumpless low-resistance oxygenator circuit. The aim of this study was to evaluate hemodynamics and cardiac function in fetal sheep sustained on the EXTEND system. METHODS: This was a prospective study of fetal sheep supported for a minimum of 3 weeks on EXTEND. Hemodynamic parameters were assessed weekly and included heart rate, mean arterial pressure (MAP), Doppler-echocardiography-derived cardiac output (CO), pulsatility indices (PIs) of the fetal middle cerebral artery (MCA), umbilical artery (UA) and ductus venosus and cardiac function, as assessed by speckle-tracking-derived global longitudinal strain and strain rate in the right (RV) and left (LV) ventricles. Parameters were compared at 0 days and 1, 2 and 3 weeks following placement on EXTEND. RESULTS: Of 10 fetal sheep enrolled, seven survived for 3 weeks and were included in the analysis. Median gestational age at cannulation was 107 (range, 95-109) days. Heart rate decreased and MAP increased significantly, but within acceptable ranges, during the study period. The quantities and relative ratios of right and left CO remained stable within the anticipated physiological range throughout the study period. Vascular tracings and PIs appeared to be similar to those seen normally in the natural in-utero state, with MCA-PI being higher than UA-PI. UA tracings demonstrated maintained abundant diastolic flow despite the absence of placental circulation. In both the RV and LV, strain decreased significantly at 1 and 2 weeks relative to baseline but returned to baseline values by week 3. CONCLUSIONS: The EXTEND mechanical support system replicates natural physiology and creates a stable and sustainable cardiovascular construct that supports growth over a 3-week period. However, there is a period of depressed contractility within the first week with subsequent improvement by week 3. This may reflect a period of physiological accommodation that warrants further investigation. This study lays the foundation for further exploration as the EXTEND system moves towards human application. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

[Low-dose prednisolone therapy for idiopathic thrombocytopenic purpura].

Prednisolone (PSL) is widely used for the treatment of idiopathic thrombocytopenic purpura (ITP). We compared the effects of a relatively low dose (0.5 mg/kg/day, LD group) of PSL and the conventional dose (1.0 mg/kg/day, CD group) on 59 ITP patients. Twenty-six patients were treated with low-dose PSL, and 23 patients with the conventional dose. No statistically significant difference was observed in the complete remission rates for the LD group (35%) and the CD group (39%). However, the mean duration of hospitalization was significantly (p < 0.001) shorter for LD group patients than for patients in the CD group (20 days versus 50 days, respectively). In conclusion, low-dose PSL may be as effective as the conventional dose and capable of reducing the cost of hospitalization, thus, improving the quality of life for patients with ITP.

[The possibilities and problems of a home setting hospice service for a patient living alone].

We provided home care service for a patient in the terminal stage of lung cancer. This patient had some difficulties, such as living by himself, having little financial means, and unable to use welfare programs because of the age restrictions of certain institutions. We, however, arranged the home care the patient wanted by carefully making contact with the health and welfare institutions involved. Through this case, we reported the possibilities and problems of a home setting hospice service for a patient living alone.

Recovery of graft circulation following percutaneous transluminal angioplasty for stenotic venous complications in pediatric liver transplantation: assessment with Doppler ultrasound.

Percutaneous transluminal angioplasty was performed for venous stenosis after living related liver transplantation in three children. Two of them had hepatic vein stenosis and one had stenosis of both the hepatic and portal veins. Progressive development of ascites and deterioration of liver function were found in all cases. Serial Doppler ultrasound studies showed that the flow velocity in the hepatic vein gradually decreased with a flattened velocity waveform, followed by a decrease in portal blood flow. After a successful hepatic vein angioplasty, the velocity in the hepatic and portal veins increased and the Doppler waveform in the hepatic vein became pulsatile in two cases. In the remaining case, a remarkable recovery of both graft perfusion and clinical findings was achieved via combined hepatic vein and portal vein angioplasty. We conclude that balloon angioplasty is an effective alternative to surgery for post-transplant vascular stenosis and that Doppler ultrasound is useful in monitoring graft circulation.

Kinetic analysis of impaired work-cost performance in jaundiced rabbit liver.

Impairment of energy metabolism was studied in jaundiced rabbit liver by kinetic analysis of energy transfer function. Free cytosolic ADP (ADPf), as calculated from the measured components of the glyceraldehyde-3-phosphate dehydrogenase and 3-phosphoglycerate kinase/lactate dehydrogenase reactions, decreased from the control value of 48.1 to 37.0 microM at 24 h after bile duct ligation. The maximal velocity (Vmax) of ATP synthesis, as measured by state 3 respiration of isolated mitochondria, decreased from the control value of 62.1 to 38.3 nmol ATP synthesized per min per mg mitochondrial protein, while the Michaelis constant for ADP (Km) decreased from the control value of 19.2 to 12.8 microM. ATP synthesis velocity in vivo }v: Vmax/[1 + (Km/[ADPf])], as calculated by Vmax, Km and ADPf, decreased from the control value of 44.4 to 28.5 nmol ATP synthesized per min per mg mitochondrial protein. Delta v/delta ADPf(delta v/delta ADPf: Vmax.Km/(Km + [ADPf])2), which indicates work-cost performance of the liver, decreased from the control value of 0.263 to 0.198. Biochemical output of the liver, as measured by hippurate synthesis from benzoate, decreased from the control value of 98.4 to 32.7 mg/h. These results indicate that synergistic decreases in ADPf, Vmax, v and delta v/delta ADPf take place in the course of deterioration of mitochondrial ATP synthesis and work output in jaundiced liver.

An assessment of percutaneous transhepatic biliary drainage in the correction of the metabolic capacity of the jaundiced liver by hippurate-synthesizing test.

Hippurate-synthesizing ability was investigated in patients with jaundice with percutaneous transhepatic biliary drainage (PTBD) in relation to hepatic metabolic capacity. In 16 patients with PTBD because of obstructive jaundice and 11 patients without hepatic disease, 1.77 grams of sodium benzoate was injected and the amount of hippurate synthesized and excreted in the urine collected at 30, 60, 120 and 180 minutes was measured (hippurate test). In patients with jaundice and patients in the control group, an almost linear increase was observed in the level of urinary hippurate after benzoate loading. However, the values of the patients with jaundice at one and two hours after the benzoate loading were significantly lower than those of the patients in the control group. Serum levels of glutamate oxaloacetic transaminase, glutamate pyruvate transaminase, alkaline phosphatase, gamma-glutamyl transpeptidase, total bilirubin and direct bilirubin were significantly decreased during PTBD (p < 0.05). Bilirubin levels were closely correlated with hippurate test values (r = 0.567, p < 0.05). Values were also correlated with the period of PTBD before the hippurate test was performed (r = 0.632, p < 0.05). Recovery in hippurate synthesizing ability was observed when the total bilirubin levels decreased to less than 5 milligrams per deciliter or PTBD was maintained for more than three weeks. Because hippurate synthesis is dependent on adenosine triphosphate supply in the hepatic mitochondria, the value of the hippurate test reflects the metabolic viability of the liver in relation to energy metabolism. It is also suggested that the steady maintenance of PTBD for three weeks or more with a decrease in total bilirubin level less than 5 milligrams per deciliter is necessary for full recovery of the metabolic capacity of the jaundiced liver.