Fluticasone in mild to moderate atopic dermatitis relapse: A randomized controlled trial.

BACKGROUND: The long-term efficacy of corticosteroids to prevent atopic dermatitis (AD) relapses has partially been addressed in children. This study compared an intermittent dosing regimen of fluticasone propionate (FP) cream 0.05% with its vehicle base in reducing the risk of relapse in children with stabilized AD. METHODS: A randomized controlled, multicentric, double-blind trial was conducted. Children (2-10 years) with mild/moderate AD (exclusion criteria: >30% affected body surface area and/or head) were enrolled into an Open-label Stabilization Phase (OSP) of up to 2 weeks on twice daily FP. Those who achieved treatment success entered the Double-blind Maintenance Phase (DMP). They were randomly allocated to receive FP or vehicle twice-weekly on consecutive days for 16 weeks. The primary study endpoint was relapse rate; time to relapse and severity of disease were also studied. Kaplan-Meier estimates were calculated. RESULTS: Fifty-four patients (29 girls) entered the OSP (23 mild AD) and 49 (26 girls) continued into the DMP. Mean age was 5.5 (SD: 2.8) and 5.1 (SD: 2.3) yrs for FP and vehicle groups, respectively. Four patients withdrew from the DMP (two in every group). Patients treated with FP twice weekly had a 2.7 fold lower risk of experiencing a relapse than patients treated with vehicle (relative risk 2.72, SD: 1.28; p=0.034). FP was also superior to vehicle for delaying time to relapse. Both treatment therapies were well tolerated. CONCLUSION: This long-term study shows that twice weekly FP provides an effective maintenance treatment to control the risk of relapse in children with AD.

[Emergency operation due to complications of cardiac catheterization].

From January 2001 to July 2005, 4,741 cardiac catheterizations were performed on adult patients at our institute. Five of them underwent emergency operation due to complications of cardiac catheterization. The causes of operations were acute coronary occlusion due to coronary arterial dissection in 3 patients and bleeding due to perforation of the coronary artery in 2. Intra-aortic balloon pumping was used preoperatively in 4 patients and percutaneous cardio-pulmonary support in 2. Coronary artery bypass grafting was performed on all patients. Perforation sites of the coronary arteries were closed. One patient died 4 months after surgery, due to neurological damage, but the other 4 patients recovered and have been doing well. As coronary artery disruption is one of the main complications of cardiac catheterization, it is necessary to recognize the risk of hemodynamic derangement and to give prompt and appropriate treatment.

Bidirectional Glenn procedure improves the mechanical efficiency of a total cavopulmonary connection in high-risk fontan candidates.

BACKGROUND: A total cavopulmonary connection (TCPC) is a widely performed surgical procedure for Fontan candidates. High-risk candidates who have undergone the bidirectional Glenn procedure (BDG) before TCPC have shown good results. The exact mechanism of this procedure, however, is still poorly understood. We hypothesized that a volume reduction with BDG improved ventricular contractility, thereby optimizing mechanical efficiency after TCPC. METHODS AND RESULTS: We measured percent normal systemic ventricular end-diastolic volume (%N-EDV), contractility (end-systolic elastance; E(es)), afterload (effective arterial elastance; E(a)), and mechanical efficiency (ventriculoarterial coupling; E(a)/E(es)) on the basis of the cardiac catheterization data before and after TCPC. Eighteen patients who underwent staged TCPC after BDG (staged group) were compared with 29 patients who underwent primary TCPC (primary group). E(es) and E(a) were approximated as follows: E(es)=mean arterial pressure/minimal ventricular volume, and E(a)=maximal ventricular pressure/(maximal ventricular volume-minimal ventricular volume), and E(a)/E(es) was then calculated. The ventricular volume was normalized with the body surface area. A canine experimental model with conductance catheter was used to validate the accuracy of this approximation of E(es) and E(a). %N-EDV decreased after TCPC in both groups. In the staged group, a smaller ventricular volume resulted in better contractility (E(es)). Although afterload (E(a)) increased in both groups, the increment of E(a) was smaller in the staged group. These changes resulted in an improvement of E(a)/E(es) in the staged group, whereas E(a)/E(es) increased in the primary group. CONCLUSIONS: The volume reduction of BDG preceding TCPC allows for any afterload mismatch to be corrected, thereby improving ventricular energetics after TCPC.

[Two-stage repair of the transposition of great arteries with interruption/coarctation of the aorta].

We report on 10 patients who underwent two-stage repair of transposition of the great arteries (TGA) with interruption (IAA) or coarctation (CoA) of the aorta. First, an operation for aortic arch reconstruction was performed: Blalock-Park with pulmonary artery banding (PAB) for IAA (5 patients), subclavian flap with PAB for CoA (4 patients) and end-to-end anastomosis without PAB (1 patient). All survived the first operation and had no significant pressure gradient with good growth of the ascending aorta, except for the 1 case without PAB. Half of the 8 patients who underwent PAB developed migration of the PAB. The arterial switch operation (ASO) was performed 0.7-12.6 (5.6+/-4.7) months after the first surgery. One patient with an abnormal coronary artery tract was lost after ASO. Five developed pulmonary artery stenosis and 1 developed supra-aortic stenosis late after ASO. Two patients need reoperation, 1 for supra-aortic stenosis, and the other for reCoA. Two-stage repair for TGA with IAA/CoA is still a useful method with a good operative result. However, strict follow-up is necessary because of the high frequency of late morbidity.

Predisposing factors of renal dysfunction following total correction of tetralogy of Fallot in the adult.

A retrospective study of 21 adult patients with tetralogy of Fallot (TOF) was undertaken to determine the predisposing risk factors of renal dysfunction following total correction of the disease. Five of the 21 patients exhibited moderate-to-severe postoperative azotemia and an additional five exhibited mild azotemia. Significant risk factors for postoperative renal dysfunction found in routine preoperative examinations were as follows: arterial oxygen saturation of less than 90%, cardiothoracic ratio (CTR) of greater than 50%, mean electrical axis of the QRS complexes of greater than +120 degrees, S wave in Lead V6 of greater than 7 mm, R/S voltage ratio in Lead V6 of less than 2, and negative T wave in Lead V6. In addition, preoperative cardiac catheterization data showed that the patients exhibiting postoperative azotemia had more severe pulmonary stenosis, a smaller pulmonary-to-systemic flow ratio (Qp/Qs), and a larger left ventricular cavity than nonazotemic patients. The incidence of postoperative low cardiac output state (LOS) was significantly higher in the azotemic patients. These findings suggest that a combination of the severe form of TOF and a large left ventricle increase susceptibility to LOS and postoperative renal dysfunction. The cause and the clinical significance of the large left ventricular cavity in adults with TOF are discussed.

New technique in the transfer of an anomalously originated left coronary artery to the aorta.

A 21-month-old girl with an anomalous origin of the left coronary artery underwent a transfer of the left coronary artery to the aorta using a new technique of coronary prolongation. Because the anomalous left coronary artery arising from the left anterior aspect of the pulmonary trunk was too short to reach the aorta, a simple transfer of the left coronary artery to the aorta was deemed impossible. Therefore, a transfer was performed with the help of a coronary prolongation technique using the cuff of the pulmonary trunk and an aortic flap. The new route of the left coronary artery was established anterior to the pulmonary trunk. Postoperative angiography showed a patent left coronary artery without any narrowing or kinking, as well as an improved contractility of the left ventricle. Postoperative cardiac scintigraphy showed a decreased ischemic area. This technique is thus considered applicable when the orifice of the anomalous left coronary artery is too distant from the aorta for a direct anastomosis.

Coenzyme Q10: the prophylactic effect on low cardiac output following cardiac valve replacement.

A randomized, prospective study of the effectiveness of preoperative administration of coenzyme Q10 on the prophylaxis of postoperative low cardiac output state was performed in 50 patients with acquired valvular diseases necessitating valve replacement. There were 25 patients in the treatment group and 25 in the control group. Patients in the treatment group received 30 to 60 mg of coenzyme Q10 orally for six days before operation. Preoperative clinical variables, operative procedures, total cardiopulmonary bypass time, and aortic cross-clamping time were similar for the two groups. Postoperatively, mild to severe low cardiac output state developed in 28 of 50 patients (56%) and necessitated the administration of considerable amounts of inotropic agent. The treatment group showed a significantly lower incidence of low cardiac output state during the recovery period than the control group (p less than 0.05). These results suggest that preoperative administration of coenzyme Q10 will increase the tolerance of human hearts to ischemia during aortic cross-clamping.

Surgical management of aortopulmonary window.

OBJECTIVE: Aortopulmonary window is a rare congenital malformation involving a window-like communication between the ascending aorta and the pulmonary artery. Here, we present our experience regarding the surgical repair of an aortopulmonary window, and also assess the long-term outcome. METHODS: Thirteen children with an aortopulmonary window associated with various congenital lesions underwent a repair of the defect. The age at operation ranged from 3 days to 1 year (median age, 19 days). The patient's weight ranged from 2.1 to 7.0 kg (mean weight, 3.6 kg). The associated lesions included an interrupted aortic arch (5 patients), a ventricular septal defect (2), an atrial septal defect (1), mitral valve regurgitation (1), and tricuspid atresia [Ic] with mitral valve regurgitation (1). The aortopulmonary window was repaired with a cardiopulmonary bypass in 11 patients, and 2 patients were ligated without a cardiopulmonary bypass. RESULTS: One patient associated with tricuspid atresia died (mortality rate of 7.7%). There has been no late death during a mean follow-up of 7 years and 3 months. CONCLUSIONS: The surgical results for an aortopulmonary window are encouraging, even if such patients are associated with major cardiac anomalies and an interrupted aortic arch. Most have shown a good long-term outcome.

[Transvenous monitoring of left atrial and central venous pressure with a double-lumen catheter].

We developed a new method to monitor left atrial pressure in the patients undergoing open heart surgery. The advantages of our method are 1) freedom from complications relating its removal (eg. bleeding) because of its transvenous insertion, and 2) simultaneous monitoring of both right and left atrial pressures by a single catheter. We designed to place the second port of a two-lumen central venous catheter 5 or 7 cm proximal to the tip. The catheter is inserted into the right atrium before surgery and the tip is advanced in the left atrium through the foramen ovale intraoperatively. We used this catheter in 16 infants and children, and found that effective hemodynamic monitoring was obtained without any complications. We recommend this method for the postoperative management of open heart surgery in the pediatric patients.

[Mitral valve replacement 41 years after right pneumonectomy].

Mitral valve replacement was performed successfully on a 68-year-old patient who had undergone right pneumonectomy and thoracoplasty 41 years earlier. Preoperative pulmonary function tests revealed poor results; the forced vital capacity was 950 ml (28.0% of the predicted value) and the forced expiratory volume in 1 second was 750 ml (28.9% of the predicted value). Despite such poor pulmonary function, the patient tolerated the operation well and led uneventful course. Careful perioperative management to prevent pulmonary edema and aggressive postoperative pulmonary toilet to facilitate recovery of the pulmonary function seem important.

Fluticasone in mild to moderate atopic dermatitis relapse: a randomized controlled trial

BACKGROUND: The long-term efficacy of corticosteroids to prevent atopic dermatitis (AD) relapses has partially been addressed in children. This study compared an intermittent dosing regimen of fluticasone propionate (FP) cream 0.05% with its vehicle base in reducing the risk of relapse in children with stabilized AD. METHODS: A randomized controlled, multicentric, double-blind trial was conducted. Children (2-10 years) with mild/moderate AD (exclusion criteria: >30% affected body surface area and/or head) were enrolled into an Open-label Stabilization Phase (OSP) of up to 2 weeks on twice daily FP. Those who achieved treatment success entered the Double-blind Maintenance Phase (DMP). They were randomly allocated to receive FP or vehicle twice-weekly on consecutive days for 16 weeks. The primary study endpoint was relapse rate; time to relapse and severity of disease were also studied. Kaplan-Meier estimates were calculated. RESULTS: Fifty-four patients (29 girls) entered the OSP (23 mild AD) and 49 (26 girls) continued into the DMP. Mean age was 5.5 (SD: 2.8) and 5.1 (SD: 2.3) yrs for FP and vehicle groups, respectively. Four patients withdrew from the DMP (two in every group). Patients treated with FP twice weekly had a 2.7 fold lower risk of experiencing a relapse than patients treated with vehicle (relative risk 2.72, SD: 1.28; p = 0.034). FP was also superior to vehicle for delaying time to relapse. Both treatment therapies were well tolerated. CONCLUSION: This long-term study shows that twice weekly FP provides an effective maintenance treatment to control the risk of relapse in children with AD

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Pain perception and fibromyalgia.

INTRODUCTION: Although psychological factors and self-regulation processes rarely cause pain they have enough importance to exacerbate pain and contribute to its maintenance. Nevertheless, pain perception and associated beliefs can influence its confrontation and the sensation of intensity. Pain perception in fibromyalgia acquires special relevance due to an abnormal sensitivity to digital pressure on the so-called "tender points". This constitutes the main factor for its differential diagnosis. METHOD: The aim of the present study is to determine differences in pain perception and associated beliefs that appear between a group of patients with fibromyalgia (n = 36), a control group with chronic pain with objectified non-inflammatory locomotion apparatus pathology (n = 44) and a control group with healthy subjects (n = 31). Pain perception and beliefs concerning pain were assessed using Spanish versions of the following self-reports: West Haven Yale Multidimensional Questionnaire (WHYWP) and Pain Perceptions and Beliefs Inventory (PBAPI). RESULTS: Results show that the difference between patients with chronic pain is not related to pain global perception, but rather to greater perception of pain as more incapacitating when carrying out every day activities in fibromyalgic patients. In this sense, these people use escape-avoidance strategies in their every day lives believing that pain incapacitates them and therefore that physical activity should be avoided. CONCLUSIONS: Measurement of pain perceptions and beliefs could be considered relevant for assessment and for intervention programs on pathologies associated with chronic pain.

[A successful case of localized aortic dissection associated with bicuspid aortic valve].

It is known that bicuspid aortic valve is a risk factor of aortic dissection in Europe and America, but there is no report of the case in Japan. A 47-year-old male teacher of senior high school had an abrupt onset of chest pain. Aortogram showed localized dissection of the ascending aorta and moderate degree of aortic regurgitation. Cold cardioplegic arrest with moderate systemic hypothermia was used under cardiopulmonary bypass. The aortic valve was bicuspid and localized transverse intimal dissection was also found above left-sided commissure. As both cusps were soft and not degenerative, mattress sutures were used to support the prolapsed cusps against the outer aortic wall. The ascending aorta was replaced with a prosthetic vascular graft. Postoperative clinical course was uneventful and he is doing well two years after the surgery. The bicuspid aortic valve and aortic dissection were also discussed.