[Application of the lower partial sternotomy approach to patients who may need tracheostomy in the early period after cardiac surgery].

Recent good results of cardiovascular surgery have led to expansion of its indication to elderly patients and patients with serious complications. Such patients may have serious respiratory complications after cardiac surgery and need to undergo tracheostomy relatively early in the postoperative period. Although the full sternotomy approach is the standard in almost all cardiac surgeries, superficial and deep sternal infections are rather common after early tracheostomy in full sternotomy patients. The lower partial sternotomy approach is a safer and more useful procedure in patients who will need tracheostomy in the early period after cardiac surgery. We report on 2 patients who were successfully tracheostomized within a week after cardiac surgery, with a review of the literature.

Lath formation mechanisms and twinning as lath martensite substructures in an ultra low-carbon iron alloy.

Lath martensite is the dominant microstructural feature in quenched low-carbon Fe-C alloys. Its formation mechanism is not clear, despite extensive research. The microstructure of an Fe-0.05 C (wt.%) alloy water-quenched at various austenitizing temperatures has been investigated using transmission electron microscopy and a novel lath formation mechanism has been proposed. Body-centered cubic {112}〈111〉-type twin can be retained inside laths in the samples quenched at temperatures from 1050 °C to 1200 °C. The formation mechanism of laths with a twin substructure has been explained based on the twin structure as an initial product of martensitic transformation. A detailed detwinning mechanism in the auto-tempering process has also been discussed, because auto-tempering is inevitable during the quenching of low-carbon Fe-C alloys. The driving force for the detwinning is the instability of ω-Fe(C) particles, which are located only at the twinning boundary region. The twin boundary can move through the ω ↔ bcc transition in which the ω phase region represents the twin boundary.

The relationship of skin color, UVB-induced erythema, and melanogenesis.

The relationship between skin color, delayed erythema, and delayed tanning (DT) elicited by a single exposure of UVB was investigated. Both constitutive and facultative pigmentation were determined by skin reflectance using a melanometer. Skin reflectance using visible light was well correlated to the minimal immediate pigment darkening dose elicited by UVA irradiation, which may relate to epidermal melanin content, a determinant of skin color. Minimal erythemal dose (MED) was well correlated to skin color, but there was less correlation between minimal melanogenic dose and skin color or the MED, since melanogenesis is controlled by genetic factors. DT also correlated to the dose of UVB in terms of MED. A coefficient of the regression line of DT may suggest the tanning capacity of skin. The possibility of detecting mild photosensitivity in individuals from a regression line of the MED on skin color is suggested.

Effects of ethyl p-chlorophenoxyisobutyrate on carbohydrate and fatty acid metabolism in rat liver.

1. Rats were fed on a diet containing ethyl p-chlorophenoxyisobutyrate (0.3%, w/w) for 14 days. 2. The alterations of contents of intermediates in the liver indicate that gluconeogenesis is inhibited at the reaction(s) between 3-phosphoglycerate and fructose 1,6-diphosphate. The [nad+]/([nadh] ratios in cytoplasm and mitochondria were increased about 3- and 4-fold, respectively. Marked increases in the contents of CoA and its thioesters were found. 3. Hepatic fatty acid synthesis increased about 3-fold. There was no evidence of inhibition of the acetyl-CoA carboxylase [EC 6.4.1.2] reaction by the drug.

The effect of tryptophan administration on fatty acid synthesis in the livers of rats under various nutritional conditions.

1. Tryptophan was administered to rats under various nutritional conditions: fasted for 24 hr, fasted and refed with glucose or corn-oil, fasted and administered glycerol intramuscularly, and nonfasted. 2. The changes in the contents of glycolytic intermediates in the livers indicated that the phosphoenolpyruvate carboxykinase [EC 4.1.1.32] reaction is inhibited by tryptophan administration in all groups of rats. The inversely related changes in the contents of malate and phosphoenolpyruvate were associated with the accumulation of quinolinate in the livers. The content of quinolinate which exhibited the half-maximal effect on the contents of both metabolites was 0.1-0.2 mumole per g liver. 3. The rate of incorporation of 3H from 3H2O into the total hepatic fatty acids was increased about 2-fold by the administration of this amino acid to the fasted rats. The enhancement of the rate was closely related to the increase in the citrate content. The hyperlipogenesis was also related to the decrease of acetyl-CoA and the increase of malonyl-CoA. The content of long-chain acyl-CoA was not affected. These effects of tryptophan administration on the hepatic fatty acid metabolism were found in all groups of rats. The liver content of glycerol 3-phosphate was decreased by tryptophan administration was markedly increased by glycerol injection. The injection of glycerol into the control and the tryptophan-treated rats produced a marked increase of glycerol 3-phosphate but did not affect the rate of fatty acid synthesis in the livers of either group. 4. It may be concluded that, in the livers of rats under various nutritional conditions, the short-term control of fatty acid synthesis by tryptophan administration is most likely due to the activation of acetyl-coenzyme A carboxylase [EC 6.4.1.2] by citrate.

Unruptured aneurysm of the sinus of Valsalva into the pulmonary artery.

Congenital aneurysms of the sinus of Valsalva are rare lesions. Because the aortic root is central, the aneurysm can rupture into any cardiac chamber, and virtually all combinations of sinus and chamber fistulas have been described. Rupture into the pulmonary artery, however, is very rare. We encountered a 14-year-old boy with conal ventricular septal defect and right coronary cusp prolapse with an unruptured aneurysm of the sinus of Valsalva into the pulmonary artery.

Lichen sclerosus et atrophicus, morphea, and coexistence of both diseases. Histological studies using lectins.

Histological studies using three lectins, lens culinaris agglutinin, soybean agglutinin, and Ulex europaeus agglutinin-I, were carried out in a case of coexistent lichen sclerosus et atrophicus and morphea, five cases of morphea, and two cases of lichen sclerosus et atrophicus. The lectin staining patterns of the formaldehyde-fixed epidermis of patients with morphea were not different from those of normal epidermis, but epidermis of patients with lichen sclerosus et atrophicus showed different staining patterns. Lens culinaris agglutinin stained the basal and the spinous layers of the normal epidermis and that of patients with morphea but stained only the basal cells of the epidermis from patients with lichen sclerosus et atrophicus; epidermal Ulex europaeus agglutinin binding was observed only in the cases of lichen sclerosus et atrophicus. Moreover, in the patient with coexistent diseases, the morphea lesion showed the staining profiles of morphea and the lichen sclerosus et atrophicus lesion showed the staining patterns of lichen sclerosus et atrophicus, respectively.

Utilization of a model lung system to assess the effects of an inspiratory impedance threshold valve on the relationship between active decompression and intra-thoracic pressure.

Use of an inspiratory impedance valve has recently been shown to increase the efficacy of standard and active compression-decompression cardiopulmonary resuscitation. We evaluated the effects of a prototypic impedance valve on the relationship between the active decompression and intra-thoracic pressure using a mechanical model lung system. Intermittent impedance to inspiratory flow of respiratory gases during the decompression phase of active compression-decompression cardiopulmonary resuscitation significantly decreased the intra-thoracic pressure, while the pressure was almost zero cm H2O during the cardiopulmonary resuscitation cycle when the impedance threshold valve was not functioning. Thus, this mechanical model will help in evaluating the valve as well as in optimizing its function by simulating various forms of lung disease.

Laparoscopic lumbar sympathectomy for lower-limb disease.

BACKGROUND: The standard procedure for sympathectomy is open surgery. The oblique retroperitoneal approach is popular because it provides good visibility, albeit at the expense of requiring a long skin incision. Chemical sympathectomy has been introduced as a less invasive means of achieving sympatholysis; however, this method is also associated with a significant incidence of incomplete block and transient denervation. Laparoscopic surgery is a new approach that simplifies various surgical procedures. The aim of our report was to evaluate the benefits of endoscopic retroperitoneal surgery for lumbar sympathectomies. METHODS: Between March 1997 and April 2000, seven patients underwent laparoscopic lumbar sympathectomy in our department (all men, with an average age or 45.1 years). The predominant presenting symptoms were unilateral pain at rest and lower-extremity coldness. Symphaectomy was performed using a retroperitoneal approach on six patients and an anterior transperitoneal approach on one patient. After laparoscopic lumbar sympathectomy, skin thermometry was carried out on all patients. RESULTS: The postoperative skin temperature of the affected leg rose to 36.6 +/- 0.5 degrees C, as compared to 33.8 +/- 0.8 degrees C preoperatively. After laparoscopic lumbar sympathectomy, none of the patients complained of neuralgia. All patients achieved sustained symptomatic relief, and no major postoperative complications were noted. CONCLUSIONS: Lumbar sympathectomy can be performed laparoscopically. Currently, our standard technique is the retroperitoneal approach. More clinical experience and long-term follow-up will ultimately determine if this will become the procedure of choice. However, we believe that a learning period is necessary for this technique to be fully mastered.

A surgical case of atypical aortic coarctation using cardiopulmonary bypass.

We report a 44-year-old woman with atypical aortic coarctation accompanied by cerebral artery disease. She was hospitalized for vertigo. An extra-anatomic bypass between the ascending aorta and abdominal aorta was performed using partial cardiopulmonary bypass under moderate hypothermia to reduce the after load of the left ventricle and maintain cerebral blood flow and cerebral perfusion pressure. The postoperative course was uneventful and there was no postoperative neurological deficiency.

Human papillomavirus DNA in cell lines derived from malignancies.

The presence of high-risk types of human papillomavirus (HPV) 16, 18 and 33 in cell lines established from several malignancies including 5 of cervical cancer and 6 of head and neck cancer was studied. HPV DNA, either type 16 or 18, was detected by polymerase chain reaction, and by Southern blot hybridization in all of the cell lines derived from cervical cancers. The hybridization patterns of HPV DNA after endonuclease digestion differed among cell lines, suggesting that all of these cell lines were independent isolates. Accordingly, high-risk types of HPV DNA seem to be ubiquitous in cervical cancer. HPV DNA was not detected in the cell lines derived from head and neck cancers or from any other malignancies besides cervical cancer in this study.

Strut fracture of Björk-Shiley convexo-concave valve in Japan--risk of small valve size--.

BACKGROUND: The Björk-Shiley convexo-concave (BSCC) prosthetic valve was introduced in 1979. Between 1979 and 1986, approximately 86,000 BSCC valves were implanted. By December 31, 1994, 564 complete strut fractures had been reported to the manufacture. We experienced a case of an outlet strut fracture and investigated the risk of BSCC prosthetic valve fractures in Japan. METHODS AND RESULTS: To investigate the risk factor of a strut fracture in Japan, we investigated published cases of strut fractures. Between 1979 and 1986, 2021 BSCC valves were implanted in Japan. By January 31, 2000, 11 complete strut fractures of 60-degree BSCC valves including our case had occurred. The patients were eight males and three females. The average age at valve replacement was 42.4+/-8.1 years, and nine of eleven (81.8%) were patients < 50 years-old. The average age of the patients when the BSCC valve fractured was 47.7+/-6.4 years, and eight of eleven (72.7%) were patients <= 50 years old. All patients were implanted in the mitral position. The sizes of the BSCC valve were 27 mm (n=5) (45.5%), 29 mm (n=3) (27.2%), and 31 mm (n=3) (27.2%). Four patients died and seven patients survived. CONCLUSIONS: Although only 11 BSCC valve struts fractured and statistical analysis could not be performed, our findings suggest that the high risk group for a strut fracture in Japan is young male patients with a mitral valve, >= 27 mm in size with BSCC models manufactured before March 1982. When following-up patients with BSCC models manufactured before March 1982, the possibility of a strut fracture in all BSCC valve sizes should be kept in mind.

Effects of docarpamine on hemodynamics after open heart surgery in children.

Docarpamine is a dopamine prodrug which has been selected from a large number of dopamine derivatives in order to develop an orally effective dopamine. The pharmacokinetics after oral administration of docarpamine have not yet been studied in children undergoing open heart surgery. This study examined the effects of docarpamine on hemodynamics and evaluated its safety in 11 children undergoing open heart surgery for congenital heart disease. This study began when the patientOs postoperative condition was stabilized by continuous dopamine infusion into the vein at a rate of 5 micro g/kg/min. The patients were administered 40 mg/kg of docarpamine every 8 hours, and hemodynamics were measured every 4 hours for 16 hours after the initial docarpamine administration. Immediately after the initial docarpamine administration, the dose of dopamine was reduced to 3 micro g/kg/min. Infusion of dopamine was stopped 8 hours after the initial docarpamine administration. Systemic systolic and diastolic blood pressure and heart rate showed no significant changes. Mean right atrial pressure decreased 4 hours after docarpamine administration. Mixed venous oxygen saturation and mean velocity of circumferential fiber shortening increased significantly after docarpamine administration. No significant changes were observed in urine volume. All patients could be weaned from dopamine within 8 hours. No changes were observed in ECG, and no arrhythmia-inducing action was noted. Our study indicates that 40 mg/kg oral doses of docarpamine produce plasma dopamine concentration equivalent to those of a 3 to 5 micro g/kg/min dopamine infusion. Our data suggest that docarpamine is a safe and effective drug for children who have undergone open heart surgery.

Eimeria gozaishoensis n. sp. from the Formosan serow (Capricornis crispus swinhoei).

Eimeria gozaishoensis n. sp. was found in the Formosan serow (Capricornis crispus swinhoei). The oocysts were ovoid, 29.41 +/- 0.58 x 20.77 +/- 0.41 microns with a bilayered wall. A micropyle and micropylar cap were observed, but a polar granule and oocyst residuum were absent. Sporocysts were ovoid, 11.78 +/- 0.30 x 7.60 +/- 0.31 microns, with sporocyst residuum and Stieda body. The new species differs from other known species of the genus by the morphology of oocysts and that domestic goats apparently could not be infected. The sporulation time was 6 to 7 days.

An autopsy case of suicide by hanging with multiple stab wounds of the neck and chest.

We report, from the aspect of 'acting' capability, an autopsy case of suicide by hanging in which multiple deep stab wounds were observed in the neck and chest. A 49-year-old man was found dead in a state typical of hanging. His car was found about 100m away with a blood-stained climber's knife on the seat. Multiple incised and stab wounds were in the neck, with a lesion of the right inner jugular vein. Three penetrating stab wounds of the chest punctured the lungs, with pooling of about 500ml of blood in the left thorax and about 100ml in the right. Two other shallow stab wounds were in the chest. All the above wounds were explainable as self-inflicted. From the autopsy findings and the circumstantial evidence, it was concluded that he walked approximately 100m after stabbing his neck and chest and finally committed suicide by hanging.

Ring fracture of the base of the skull and atlanto-occipital avulsion due to anteroflexion on motorcycle riders in a head-on collision accident.

This report concerns a head-on collision accident of a motorcycle at a very high speed (c. 80-100 Km/h) against a bonnet-type automobile, in which both the motorcyclist and pillion rider were injured at the base of the skull by violent anteroflexion of the head due to the force of inertia. A difference in their injuries was: the motorcyclist sustained a 'ring' fracture and the pillion rider an atlanto-occipital avulsion; dural tear. Anteroflexion without impact on the occiput such as described above seems to be a rare causal mechanism of the 'ring' fracture. In addition, the mode of action of the accelerating forces to the heads of the victims along with their physiques may explain the mechanism which caused the different injuries in this accident.

[Prostacyclin oral internal therapy for severe pulmonary hypertension after total correction of cor triatriatum with partial anomalous pulmonary venous return; report of a case].

A 37-day-old girl having cor triatriatum with partial anomalous pulmonary venous return was found on emergent admission. Echocardiography and angiography revealed severe pulmonary hypertension with anomalous pulmonary venous return to inominate vein. She still was in respiratory failure after emergent surgical repair because of severe pulmonary hypertension following pulmonary venous obstruction. Prostacyclin is the first Food and Drug Administration (FDA)-approved treatment for advanced primary pulmonary hypertension, which has antithrombotic properties related to its effect on platelets and is a potent vasodilator of both the systemic and pulmonary arteries, and has positive inotropic properties. We started prostacyclin oral internal therapy for her and she recovered from respiratory problems very quickly. Prostacyclin might be effective for pulmonary hypertension before and after surgical repair as primary pulmonary hypertension.

[HANP infusion therapy for early infants with congestive heart failure after surgical repair].

We report about successful case of human atrial natriuretic peptide (HANP) infusion therapy for early infants who developed congestive heart failure after surgical repair of congenital heart diseases at Ehime Prefectural Central Hospital between January, 1998 through January, 2000. Age at operation ranged from 0 day to 38 days (mean 20 days), and body weight ranged from 1.6 kg to 3.5 kg (2.8 kg as mean). Following HANP infusion at incremental doses of 0.05 to 0.24 microgram/kg/min (0.16 microgram/kg/min as mean), urine output and hemodynamics dramatically improved. Urine output increased from 0.75 ml/kg/hr to 2.79 ml/kg/hr (p = 0.0001) and good urinary output was maintained (3.06 ml/kg/hr) even after discontinuation of the infusion. During the infusion, the heart rate decreased from 157 bpm to 150 bpm and the systemic systolic blood pressure increased from 68 mmHg to 78 mmHg. Central venous pressure decreased from 9.3 mmHg to 7.9 mmHg. There were no adverse effects by HANP infusion. These are successful cases of HANP infusion therapy as the initial treatment of post-operative pulmonary hypertension in this age group. Human atrial natriuretic peptide infusion therapy can be used safely and might be useful in some early infants with CHF, although more investigation is needed.

[The effect of milrinone administrated before weaning from cardiopulmonary bypass in adult cardiac surgery].

We investigated the effect of milrinone (phoshphodiesterase III inhibitor) on postoperative hemodynamics in adult eighteen cardiac surgical patients (mean LVEF = 63%). Milrinone was administrated just after the aortic declamping during CPB. Comparing with control group, systemic vascular resistance decreased significantly and sufficient inotropic effect was sustained. In order to keep proper blood pressure much more cathechoramine dose was need when milrinone dose increased during this study. This is supposed that milrinone affected strong vasodilating effect and caused relative hypovolemic condition to the patient who showed good cardiac function. Milrinone causes best efficacy to the patient of poor cardiac function when he showed deconpensation or relatively hypervolemic hemodynamic condition.

[Total anomalous of pulmonary venous connection in infants less than 3 months old].

We examined the surgical results of total anomalous pulmonary venous connection (TAPVC) retrospectively in 6 infants, who were less than 3 months old and underwent a total repair at Ehime Prefectural Central Hospital between May, 1993 through May, 1998, in terms of the pre, peri, and postoperative management, the site of connection, and the surgical procedures. Aged at operation ranged from 1 day to 86 days (mean 39 days), and body weight ranged from 2.4 kg to 5.5 kg (mean 3.4 kg). All 6 patients had echocardiographic diagnosis and cardiac catheterization but one. In operative procedure, cut back method was done in a patient of paracardiac type of Darling's classification and posterior approach was used in total correction for 4 supracardiac and 1 infracardiac type. There were 3 hospital deaths who had poor conditions before operation, but no late deaths. Surgical results of TAPVC might have been improved with advances in non-invasive diagnosis by echocardiography, and pre and perioperative management. And we should take care of these patients of TAPVC in long term period to make sure that they have no pulmonary venous obstruction.