A case of pseudo-Bartter's syndrome due to intestinal malrotation

Intestinal malrotation presenting beyond the neonatal period is associated with a multiplicity of symptoms, which are often non-specific and, consequently, are associated with delays in diagnosis. Pseudo-Bartter's syndrome, which mimics the manifestations of Bartter's syndrome, can be caused by a severe chloride deficiency secondary to vomiting, diarrhea, perspiration, diuretic abuse and so on. We describe a 6 year old boy who had been admitted to hospital three times during the preceding year. The patient lapsed into a critical condition with profound hypochloremia and hypokalemic metabolic alkalosis induced by extremely massive vomiting. The attacks of vomiting were spasmodic and self-limited. During the episodes of vomiting he fulfilled the criteria of pseudo-Bartter's syndrome, including hyperreninemia, hyperaldosteronism and normal blood pressure, but in the intervals between attacks he was completely asymptomatic. At the third admission, examination supported an overall clinical picture of bowel obstruction, which was confirmed by radiographic examination. Laparotomy revealed a midgut volvulus with intestinal malrotation. After surgery he made a good recovery and was symptom-free. In this patient, the high degree of hypochloremia and hypovolemia activated the renin-angiotensin-aldosterone system, then aldosterone promoted intensive reabsorption of sodium and excretion of potassium into the urine. Consequently the diagnosis of pseudo-Bartter's syndrome was establish on the basis of an extreme decrease in urinary chloride and an increase in urinary potassium concentration. It is relatively rare for vomiting due to intestinal malrotation to induce pseudo-Bartter's syndrome. The importance of considering this rare diagnosis in such cases is discussed.

Angiotensin blockade and the progression of renal damage in the spontaneously hypertensive rat

The pathophysiological role of angiotensin II in the development of renal sclerosis was investigated in 5/6-nephrectomized, 12-week-old male spontaneously hypertensive rats. After 1 week of a control period, nephrectomized rats received one of the following treatments for 4 weeks: the selective nonpeptide angiotensin II type 1 receptor antagonist TCV-116 (1 mg/kg per day), the angiotensin converting enzyme inhibitor delapril (30 mg/kg per day), hydralazine (15 mg/kg per day), or vehicle. Urinary protein and albumin excretions and systolic blood pressure were determined every week. Rats with reduced renal mass treated with vehicle had a poor survival rate (30%). Although TCV-116, delapril, and hydralazine treatment significantly improved the survival rate for 4 weeks, hydralazine failed to improve proteinuria and albuminuria as well as the decline in renal function compared with delapril or TCV-116. Histological examination revealed that both TCV-116 and delapril protected glomeruli from sclerosis, whereas hydralazine did not improve histological findings (5%, 7%, and 30% of glomeruli were affected, respectively). These results indicate that angiotensin II plays a dominant role through its type 1 receptor in the pathogenesis of renal deterioration by hypertension.

Osteosarcoma of the patella. A case report

A 34-year-old woman complained of pain and swelling in the left patella. Because of roentgenogram showed hardly any destruction of the patella, she was not initially treated for a bone tumor. The clinical course followed the initial symptoms of a respiratory disorder with pulmonary metastatic foci. A bone tumor was first suspected after aspiration cytology of a lung tumor mass. A left patellectomy was performed to relieve the pain and confirm the diagnosis. The pain was relieved by the operation, but respiratory failure set in and progressed rapidly. The patient died three days later. Histologic examination showed that the tumor tissue consisted of atypical cells, spindle to polygonal in shape. The marrow space of the patella was predominantly occupied by neoplastic cartilaginous tissue. The pathologic diagnosis was primary chondroblastic osteosarcoma of the patella.

Body composition measurement by electrical bio-impedance method to establish the effect of daily physical training in adolescents

As part of an ongoing study on the effect of daily physical training on adolescents, body composition (percentage fat) was measured using the electrical bio-impedance method in a sample of Japanese students aged 15 years (77 sedentary males, 137 active males, 66 sedentary females and 54 active females), who were selected on the basis of their answers in a questionnaire about physical activity in a cardiac study involving 227.361 high school students. Subjects were divided into 4 weight categories (underweight, normal weight, overweight and severe overweight) using an obesity index. ECG and ultrasound cardiography (UCG) were used for all subjects to measure their left ventricular mass (LVM), which was taken as an indicator of the effect of training. Among the 4 weight category groups, a significant difference in the percentage of fat between sedentary and active subjects was found in the normal weight category of males. Correlation between the percentage of fat and the obesity index was significant in both sedentary and active subjects of both the genders, but correlation coefficients were lower for active subjects than for sedentary ones. The percentage of fat tended to be very low in subjects with increased LVM. Additionally, a significant difference in the amount of fat was found between runners and soccer players in active males with normal weight. These results suggest that there were differing degrees of the effect of training on reducing body fat and that this effect is most notable in males with normal weight.(ABSTRACT TRUNCATED AT 250 WORDS)

[The study on surface porosity of die stone. Influence of vinyl polysiloxane impression materials]

In this study, the authors have attempted to discover optimum conditions for eliminating all porosity, except what is caused by manual error, in the surfaces of Die Stone. Five vinyl-porisiloxane impression materials, two other kinds rubber impression materials, and two kinds of die materials were used. Die materials were poured at intervals of 0, 15, 30, 60, and 120 minutes after the impression had been removed. Cast-surface porosity was measured by means of SPICCA II. Results 1. Practically surface porosities were not scarcely observed in casts made from any of the impression materials except vinyl silicone rubber. Among the five vinyl-polysiloxane impression materials, Hydrophilic Exaflex produced the least porosity. 2. Porosity in casts made with Provil tended to decrease definitely as pouring time progressed. This tendency occurred with no other materials. 3. When the die material was mixed at a low water-powder ratio, cast-surface porosity was reduced in the case of all materials except President. 4. Concentration of hydrogen gas, which was released from all vinyl-polysiloxane impression materials, decreased with the passing of time. 5. In the case of Provil, a correlation existed between hydrogen-gas concentration and the degree of cast-surface porosity. But no similar correlation was observed in the case of any other vinyl-polysiloxane impression materials.

Diagnosis of arteriosclerosis obliterans by impedance technique with special reference to relative blood flow of the lower extremity

Simultaneous recordings of impedance cardiography of the chest and impedance plethysmography of the lower extremity were performed on 105 limbs with or without arteriosclerosis obliterans (ASO) documented by angiography. The ratios of blood flow to the lower extremity--leg stroke volume/cardiac stroke volume--(LSV/CSV) were 11.2 +/- 3.3% in normal male subjects, 11.1 +/- 5.5% in normal female subjects, and 3.1 +/- 1.2% in lower extremities with ASO, respectively. The normal value (range) for LSV/CSV calculated from the normal groups by the percentile method was between 4.9% and 17.8%, and the diagnostic accuracy of this value was 100% for sensitivity and 97.5% for specificity. LSV/CSV is a good index for the diagnosis of ASO and makes it possible to minimize error when expressed as an absolute value.

Two cases of cystic fibrosis in Japanese children: studies on the essential fatty acid and prostaglandin metabolism

We describe the fatty acid (FA) and prostaglandin (PG) metabolism in two Japanese cases of cystic fibrosis (CF) with or without pancreatic insufficiency (PI). The diagnosis of CF was based on the elevated sweat chloride concentration by pilocarpine iontophoresis. A 1-month-old boy (case 1) showed poor weight gain, steatorrhea and scaly dermatitis, but no respiratory symptoms were noted. He had decreased levels of serum linoleate and arachidonate, and increased palmitoleate and oleate levels, indicating essential fatty acid (EFA) deficiency. Supplementation of fat-emulsion improved his skin lesions and the altered FA pattern within a few months, associated with the definite reduction of the urinary PG F2 alpha levels. Until two years of age, he has been free from respiratory symptoms. A 12-year-old girl (case 2) had had recurrent respiratory tract infections due to Pseudomonas aeruginosa and Staphylococcus aureus for several years, and her pancreatic functions were preserved. The FA patterns of her serum lipid were almost within the normal range. These results indicate that 1) the altered FA composition appeared to be a secondary consequence of PI commonly complicating CF and 2) the correction of the altered FA and PG metabolism might have a beneficial effect on the respiratory function of CF patients with EFA deficiency.

[Study of dynamic counterrolling of the eye--quantitative analysis of effects by visual and vestibular systems]

Dynamic counterrolling of the eye is induced when the head is tilted to one side: it includes cyclorotatory nystagmus, which is affected by visual and vestibular systems. Both of these two ocular movements were measured quantitatively through a video recording system, and the role of visual and vestibular systems in visual stabilization was analyzed. The relationship between the optokinetic and vestibulo-ocular systems was variable in relation to the velocity of head tilting. The optokinetic system contributed more in slow head tilting. As the velocity of head tilting increased, the suppression by the optokinetic system was decreased and eventually the vestibulo-ocular system became more dominant. This suggests that the role of visual and vestibular systems in head tilting is similar to that in head rotation. Visual and vestibular systems seem to work together mutually with some individual variation in stabilizing vision with sensory control in the higher level of the visual cortex.

[Analysis of motor response with respect to the time course in cyclofusion]

Torsional eye movements during cyclofusional responses are recorded objectively and analyzed with respect to the time course of the eye movement until the subject perceives a fused image. Eight subjects whose age ranged from 24 to 35 years old were studied. Torsional disparity was presented stepwise by a synoptiscope. The Number of subjects whose motor response was stepped was less than that of the subjects whose motor response was not stepped. The time course of responses varied in individual. Moreover, the number of the subjects whose motor response showed cyclovergence was less than that of subjects whose motor response showed cycloversion. Fusional cyclovergence is reasonable to bring the disparate images within Panum's area efficiently. However our analysis shows that stepped response and cyclovergence is less in number and the motor response is variable in each individual. Therefore, we do not accept the explanation that the cyclofusional motor response simply brings the disparate images within Panum's area. We speculate that cyclofusional motor response is carried out by a feed-back loop through the cyclofusional sensory input to fuse the disparate images.

Detection of impaired left ventricular function in coronary artery disease with acceleration index in the first derivative of the transthoracic impedance change

In order to detect impaired left ventricular (LV) function in coronary artery disease (CAD) patients using acceleration index (Ac) of impedance cardiography (ICG), exercise ICG was performed in 29 patients with chest pain but without CAD (Group 1) and 21 patients with CAD (Group 2), and their resting values were compared with 30 healthy controls (Group 3). The acceleration index, which reflects indirectly aortic blood flow acceleration, was calculated as the ratio of dZ/dtmax to its accelerating time (AT). At rest, the values for Ac in Groups 1, 2, and 3 were 23 +/- 10, 15 +/- 6, and 36 +/- 13 omega/s2, respectively. There were significant differences between Group 1 versus 3, 2 versus 3, and 1 versus 2 (all p less than 0.001). At maximal exercise, Ac showed the largest percent change among the various indices used in this study. An increase of 198% for Group 2 was markedly lower than that of 250% in Group 1 (40 +/- 14 vs. 68 +/- 24 omega/s2, p less than 0.001). With a value of less than or equal to 40 omega/s2, Ac can detect the CAD patients, with a sensitivity of 62% and specificity of 90%, superior to stress ECG using CM5 lead. It is concluded that: (1) Ac is the sole index capable of distinguishing not only between the normals and diseased groups, but also between CAD patients and suspected CAD cases at rest. (2) Ac is a remarkably sensitive index for detecting impaired LV function at maximal exercise. (3) Exercise ICG is useful for predicting CAD from the population predisposing to CAD.(ABSTRACT TRUNCATED AT 250 WORDS)

[Non-invasive estimation of aortic flow by local electrical impedance changes]

Aortic flow velocity was measured by catheter-tip flow transducer in 25 patients who underwent left cardiac catheterization for non-invasive estimates by the impedance method. Disk electrodes were attached to the skin at the levels of the second thoracic vertebra in the posterior median line and the V8 lead position for electrocardiography. Alternating current, 350 micro-amperes, 50 KHz constant, was applied to the outer electrode, and impedance changes were detected via the inner electrode. The e wave, or height of the first derivative dz/dt wave of the electrical impedance was lower in cases of old myocardial infarction and higher in cases of aortic valve regurgitation, as compared with the values of the healthy control group. The time lag between the start of the upward deflection and the peak value of the dz/dt wave coincided with that of the aortic flow curve as measured at the aortic arch and descending aorta. These time lags were about 20 to 30 msec as compared with the ascending aortic flow curve, and were -20 to -30 msec as compared with the abdominal aortic flow curve. There was a close correlation between the maximum flow velocity measured at the aortic arch and the height of the e waves. The regression equation was: Y = 0.21X - 1.53, r = 0.88, p less than 0.01. These data suggest that the first derivative of electrical impedance change as obtained by the disk electrode method reflects aortic flow at the arch and descending aorta.

Effects of heat acclimation of distance runners in a moderately hot environment

Five distance runners (H groups) performed a 60 min bicycle exercise at a load of 60--70% VO2max in a moderately hot environment (Ta: 33.5 degree C, 60% RH). Following a period of heat acclimation with bench-stepping at a load equal to about 25--30% VO2max, in a hot environment (Ta: 45--50 degree C, 30--40% RH) for 9 days, the work test was repeated. Two control subjects (R) performed the same work tests with no heat acclimation. Heat acclimation increased performance time. Rectal temperature, mean skin temperature, heart rate, and Na+ concentrations in sweat were lower in H and, with one exception, sweat rate was higher after heat acclimation. All H subjects demonstrated that the linear relationship between sweat rate and rectal temperature was shifted to a lower temperature (threshold shift). This shift correlated with a lowering of resting rectal temperature. The magnitude of the reduction in those two temperatures due to heat acclimation was identical. The observed improvement of work performance in moderate heat following heat acclimation to a higher temperature is attributed to a more efficient thermoregulatory mechanism.

Periodic ACTH discharge

A 9 1/2-year-old girl is presented who had cyclical attacks of abdominal pain, vomiting, emotional disturbance, and marked weight change for two years. Associated findings were facial plethora, hypertension, transient hyperglycemia and glycosuria, elevated plasma ACTH, cortisol, and urinary 17-OHCS excretion, and low plasma osmolality with hyponatremia. Urinary excretion of catecholamines and porphyrin metabolites was not increased. Between episodes, she showed no abnormal clinical signs or laboratory data. The attacks were effectively suppressed with the administration of chlorpromazine. The disorder appears to be due to the periodic release of excessive ACTH; the cause remains unknown.