Esophageal pressure and apnea hypopnea index in sleep-disordered breathing

Severity of negative esophageal pressure (Pes) and apnea hypopnea index (AHI) were investigated in six cases of upper airway resistance syndrome (UARS) and 11 cases of obstructive sleep apnea syndrome (OSAS). The severity of negative Pes was represented by the highest peak (Pes Max) and the number of increased episodes (more than 13.5 cmH2O) per h (NPesI13.5). There was no significant correlation between Pes indices and AHI. Pes Max and NPesI13.5 were not different among severe OSAS (AHI > 30), mild OSAS (AHI < 30) and UARS. Apnea hypopnea index failed to represent the severity of negative Pes, which is an important aspect of the pathophysiology of sleep-disordered breathing.     

Statistical Analysis of Factors Affecting the Outcome of Patients with Ruptured Distal Anterior Cerebral Artery Aneurysms

Summary  The clinical factors affecting the outcome of patients with ruptured distal anterior cerebral artery (ACA) aneurysms were analyzed using multiple logistic regression analysis.  The medical records were reviewed of 52 patients (57 aneurysms) with ruptured distal ACA aneurysms operated on by the same neurosurgeon over 25 years. The standard policy was early surgery for patients in Hunt and Kosnik grades I to IV. Age, sex, Hunt and Kosnik grade, timing of operation, size of aneurysms, number of aneurysms, association of intracerebral haemorrhage (ICH), intraventricular haemorrhage, and azygos ACA, use of temporary clipping , occurrence of premature rupture, and presence of psychiatric change were investigated. Univariant analysis disclosed that clinical grade (P=0.0006), size of aneurysm (P=0.005), and size of ICH (P=0.012) affected the outcome of patients. Multiple logistic regression analysis found that Hunt and Kosnik grade (P=0.010) and timing of operation (P=0.033) affected the outcome. There was no significant relationship between long-term outcome and clinical factors, although a close relationship was found with Hunt and Kosnik grade (P=0.071).  Clinical grade and timing of the operation affected the outcome of patients with ruptured distal ACA aneurysms. Patients harboring ICH of over 3 cm diameter in poor grades should also be carefully treated.     

Clinical review of 39 cases with ectopic ureteroceles

BACKGROUND: There are many controversies surrounding the management of ectopic ureteroceles (EUC). The aim of this study is to review our cases with EUCs and to show our policy of choice of treatments of EUCs. METHODS: The medical records of 39 patients with EUCs treated at Kobe. Children's Hospital from 1978 to 1998 were reviewed retrospectively. Patients' age, affected site, presentation, treatment, and postoperative course were recorded. RESULTS: The age at presentation ranged from 0 month to 13 years (mean; 6 years). The left EUCs were found in 15 patients, the right in 17 patients, and the bilateral in 7 patients. The EUCs with duplicated system of the kidney were involved in 35 cases (42 kidneys) and single system in 4 cases (4 kidneys). The most common mode of presentation was urinary tract infection (n = 24) followed by abdominal distention (n = 6) and fetal ultrasonography (n = 6). One patient presented with incontinence and in two patients EUCs were discovered incidentaly. Thirty-five cases (42 kidneys) were followed up over six months. In these cases diversion including nephrostomy and ureterostomy was performed in 5 kidneys, heminephrectomy and/or excision of the EUC and ureteral reimplantation in 8 kidneys, nephrectomy in 3 kidneys, pyeloureterostomy in 2 kidneys, excision of the EUC and ureteral reimplantation in 10 kidneys, and transurethral incision (TUI) of the EUC in 14 kidneys. After these treatments the second surgery was totally required in 15 kidneys(36%) including 7 kidneys in which TUI was performed. Furthermore, in two kidneys the third operation was performed. CONCLUSIONS: Reoperation was required in about one-third of patients with ectopic ureteroceles. It is easy to perform TUI, however the rate to reoperation is high.     

Estimation of photoparoxysmal response elicited by half-field visual stimulation

We examined photoparoxysmal responses (PPRs) elicited by half-field visual stimulation with deep-red flicker light to determine the neurophysiological features of photosensitive epilepsy (PSE). EEG revealed two types of PPRs. One had the focal spike in the occipital region and the other in the temporo-occipital region at the contralateral hemisphere. The equivalent current dipoles of these types were located at the occipital cortex and the inferior temporal (IT) cortex, respectively. These cortices comprise one of the main pathways in the visual system, and they play important roles in color discrimination. Thus, we propose that the visual system, especially the occipital cortex and the IT cortex, might be involved in the generator mechanism of PSE.     

Repeated procedure after radical surgery for tetralogy of Fallot

BACKGROUND: Although the immediate results of radical operation for tetralogy of Fallot are excellent, long-term follow-up has shown that the number of repeated procedures has increased in many institutions. We describe patients who underwent a second or third procedure after radical operation for tetralogy of Fallot. METHODS: Between April 1981 and August 1996, we operated on 44 patients for the second time and on 4 for the third time after radical operation for tetralogy of Fallot. Indications for a second and third procedure included right ventricular outflow tract obstruction in 38 patients, infective endocarditis in 4, and isolated residual ventricular septal defect in 3. RESULTS: One patient died after concomitant replacement of the pulmonary and tricuspid valves. Three patients who underwent sternotomy more than twice (before the second or third operation) underwent accidental cardiovascular trauma during this procedure (30%). Moreover, when patients underwent more than two sternotomy procedures before the repeated operation for tetralogy of Fallot, the total bypass time, interval between cessation of the cardiopulmonary pump to completion of the operation, amount of blood transfusion, and length of intensive care unit stay were significantly higher compared with those who underwent less than two sternotomy procedures (p < 0.05). Right ventricular outflow tract obstruction was the main indication for a second operation. After the second operation for right ventricular outflow tract obstruction in 35 patients, the preoperative right ventricle to left ventricle pressure ratio decreased significantly (from 0.75 +/- 0.13 to 0.51 +/- 0.12; p < 0.0001). However, the right ventricle to left ventricle pressure ratio did not significantly decrease in patients who underwent a third procedure to treat right ventricular outflow tract obstruction. CONCLUSIONS: The surgical results of a second procedure after radical operation for tetralogy of Fallot were acceptable. However, the risk of accidental cardiovascular trauma during dissection was high among patients who underwent sternotomy more than twice before repeat operation.     

Long-term effect of polystan monocusp ventricular outflow patch after right ventricular outflow tract reconstruction

Forty-eight patients who underwent right ventricular outflow tract reconstruction with Monocusp Ventricular Outflow Patch (MVOP) fifty-five times and survived surgery, were reviewed in this study. Mean age at surgery was 6.4 years-old and mean follow-up interval was 75.2 months. There was no late death, however reoperation was performed 7 times. Freedom from reoperation rate was 97.2% and 80.7% after 5 and 10 years after surgery, respectively. The main cause for reoperation were right ventricular outflow obstruction RVOTO (5 cases). All of the RVOTO occurred at the distal end of the anastomosis. However, there was no RVOTO in patients who underwent RVOTR with MVOP during the past ten years. So, we considered the cause of RVOTO a technical problem. Pulmonary regurgitation was one to two degree early after surgery, and had worsened by almost two or three degrees more than 5 years after surgery. Moreover, five of six patients who underwent cardiac catheterization more than 10 years after surgery had three degrees of pulmonary regurgitation as well as a large CTR. In conclusion, according to long-term results, especially more than 10 years post operatively, pulmonary regurgitation was the most important problem.