Five-year study of medical or surgical treatment in children with severe vesico-ureteral reflux dimercaptosuccinic acid findings. International Reflux Study Group in Europe.

UNLABELLED: The results of serial dimercaptosuccinic acid (DMSA) imaging over 5 years are reported in 287 children with severe vesico-ureteral reflux entered into the European Branch of the International Reflux Study in Children. The children were randomly allocated to medical (n=147) or surgical (n=140) management and DMSA studies were performed during the follow up period at least 6 months after any urinary tract infection. Abnormal images were classified into four types: (1) large polar hypodensity with normal renal outline; (2) peripheral photon deficient defect(s) in a non-deformed kidney; (3) small renal image with normal contour; and (4) peripheral defect(s) with resultant irregularity of the renal outline. The DMSA findings were abnormal at entry in 235 (82%) with no difference in incidence or severity between the two treatment groups. During follow up, deterioration was observed in 25 medically and 23 surgically treated patients and comprised image deterioration alone in 17, image deterioration with corresponding reduction in differential function in 16 and reduction in relative function without image change in 15, with similar distribution between the two treatment groups. Deterioration was more frequent in children entering the study under the age of 2 years and in those with grade IV rather than grade III reflux. These findings, showing no difference in outcome between children managed surgically or medically, are consistent with the radiological results already published. CONCLUSION: In the International Reflux Study the DMSA scintigraphic data showed no difference in outcome between children managed surgically or medically.

Distribution of radioactive microspheres injected into the vertebral artery of the dog.

The aim of the present study was to evaluate the use of the vertebral artery for cerebral blood flow studies. In eight dogs a small catheter was introduced into an unligated a. vertebralis sin. Radioactive microspheres (141Cerium) were injected and detected with a gamma camera. The microspheres were distributed to all parts of the brain. The concentrations were highest in the cerebellum, pons and medulla oblongata, while the total activity was greatest in the cerebrum because of its higher weight. The activity in the extracerebral tissues in the head was found to be less than 5% of the brain activity.

Evidence for a countercurrent exchanger in the intestinal villi of suckling swine.

The possible existence of a countercurrent exchanger (multiplier) in the intestinal villi of suckling swine was investigated with three different methods: (1) Comparing venous appearance of oxygen and red cells in the mesenteric vein after close i.a. injection of a blood sample equilibrated with pure oxygen and containing methaemoglobinaemic red cells. (2) Determining sodium (micrograms) over protein (mg) ratios along villi. (3) Estimating tissue osmolality in the villus tissue from measurements of freezing-point depression. It was observed that oxygen appeared earlier than red cells in the mesenteric vein after i.a. injection. Furthermore, both the chemical measurements of sodium/protein ratios in the villi and the estimations of tissue osmolality indicate that there exists a gradient of osmolalities along the villus length, the villus tip being hyperosmolar as compared to the villus base. We conclude that a countercurrent exchanger (multiplier) exists in the villi of suckling swine. Its possible pathophysiological significance is discussed.

Extravascular arteriovenous oxygen shunting in the cat stomach.

Venous appearance of oxygen and red cells labelled with methaemoglobin was compared in the gastric vascular bed. At 'resting' gastric blood flow the red cells appeared earlier than oxygen after simultaneous close i.a. injection, as would be expected from the intravascular laminar flow profile. However, when lowering arterial inflow pressure to the stomach by partially occluding the coeliac trunk, oxygen often appeared earlier than the red blood cells. When arterial pressure was lower than 50 mmHg this was always the case. This observation is taken to indicate that during these experimental conditions an extravascular shunting of oxygen occurs. It is suggested that this may occur in the submucosal vascular network and/or in the mucosa. The functional implications of such a mechanism are tentatively discussed.

The effect of insulin on the leg and splanchnic balance of glucose and gluconeogenic substrates after cardiac surgery.

The effect of insulin and glucose infusion on the leg and splanchnic balance of glucose and the gluconeogenic substrates lactate, pyruvate, alanine and glycerol was studied in 13 patients directly after cardiac surgery. Insulin was infused continuously at a rate of 1.0 Unit/kg/hr during 1 hour. Sixteen patients served as a control group and received no insulin and glucose infusion. A significant increase in arterial lactate concentration in both the control group (from 1.40 +/- 0.19 to 1.68 +/- 0.24 mmol/l p less than 0.01) and the insulin group (from 1.58 +/- 0.27 to 2.07 +/- 0.22 mmol/l, p less than 0.05) was observed. The arterial pyruvate concentration was significantly increased (from 0.075 +/- 0.019 to 0.105 +/- 0.021 mmol/l, p less than 0.01) and glycerol was significantly decreased (from 0.15 +/- 0.03 to 0.12 +/- 0.03 mmol/l, p less than 0.05) during the insulin and glucose infusion. The alanine concentration was unchanged in both groups. Insulin and glucose infusion was followed by an increased leg uptake of glucose (from 0.15 +/- 0.14 to 1.06 +/- 0.16 mmol/min/100 ml, p less than 0.05), and by a changed splanchnic glucose balance (from -8.2 +/- 2.8 to +4.0 +/- 1.2 mmol/kg/min, p less than 0.01). A net leg release and at the same time a net splanchnic uptake of all gluconeogenic substrates was observed. The insulin and glucose infusion did not significantly change either the splanchnic balance or the leg balance of the gluconeogenic substrates.

Splanchnic glucose balance and insulin resistance in the early postoperative phase of cardiac surgery.

The splanchnic balance of glucose was studied in the basal state and at three levels of "clamped" hyperinsulinemia (260 +/- 23, 510 +/- 59, 3875 +/- 367 mU/liter) in 24 patients (43-70 years of age), who had undergone coronary surgery about 1 hr previously. The splanchnic balance of glucose in the basal state was negative in all patients (-1.6 +/- 0.3 mg/kg/min) and was changed into a zero-balance within 30 min when 0.15 or 0.3 U/kg/hr of insulin was infused. At an insulin infusion rate of 1.0 U/kg/hr the net splanchnic glucose balance was turned into a significant positive balance of an average 0.9 +/- 0.3 mg/kg/min.

Cerebral blood flow and metabolism during cardiopulmonary bypass with special reference to effects of hypotension induced by prostacyclin.

Cerebral blood flow and metabolism of oxygen, glucose, and lactate were studied in 43 patients undergoing aortocoronary bypass. Twenty-five patients received prostacyclin infusion, 50 ng per kilogram of body weight per minute, during cardiopulmonary bypass (CPB), and 18 patients served as a control group. Regional cerebral blood flow (CBF) was studied by intraarterially injected xenon 133 and a single scintillation detector. Oxygen tension, carbon dioxide tension, oxygen saturation, glucose, and lactate were measured in arterial and cerebral venous blood. Mean arterial blood pressure decreased during hypothermia and prostacyclin infusion to less than 30 mm Hg. The regional CBF was, on average, 22 (standard deviation [SD] 4) ml/100 gm/min before CPB. It increased in the control group during hypothermia to 34 (SD 12) ml/100 gm/min, but decreased in the prostacyclin group to 15 (SD 5) ml/100 gm/min. It increased during rewarming in the prostacyclin group. After CPB, regional CBF was about 40 ml/100 gm/min in both groups. The cerebral arteriovenous oxygen pressure difference decreased more in the control group than in the prostacyclin group during hypothermia. The cerebral metabolic rate of oxygen decreased in both groups from approximately 2 ml/100 gm/min to about 1 ml/100 gm/min during hypothermia, increased again during rewarming, and after CPB was at the levels measured before bypass in both groups. There was no difference between the groups in regard to glucose and lactate metabolism.

Effects on renal function of treatment with cefoxitin alone or in combination with furosemide.

The glomerular filtration rate measured by 51Chrome-EDTA and serum half life of cefoxitin were followed in patients with preexisting moderate renal impairment. The patients were treated with cefoxitin for two to three weeks because of chronic serious infections. The dose used in patients with an initial clearance of more than 40 mg/ml was 1 g three times daily giving a mean peak concentration of 100 microgram/ml. Seven patients were treated with cefoxitin alone and twelve with cefoxitin and furosemide (80 mg daily orally). The glomerular filtration rate did not change significantly during treatment time. There were no signs of accumulation of cefoxitin as serum half life of the drug remained unchanged both in patients treated with and without furosemide concurrently.

The pressure-flow relations of the canine brain in acute mechanically induced arterial hypertension at different levels of cerebral blood flow.

Cerebral pressure-flow relations were studied in anaesthetized dogs during acute arterial hypertension, induced by compression of the thoracic aorta. In one group of animals steady state measurements were made with the radioactive gas elimination method. In another group the immediate changes of blood flow at a blood pressure change, as indicated by variations in the cerebral venous oxygen saturation, were studied with continuous oximetric analyses of the superior sagittal sinus blood. The initial blood flow was varied by variations of the arterial carbon dioxide tension of injections of papaverine. At low or normal blood flows autoregulation was efficient up to pressures around 180-200 mmHg, while at higher flows the upper autoregulatory pressure limit was found at lower blood pressures. Above the autoregulatory limit-irrespective of the control flow level-there was a rise in blood flow and a decrease in cerebrovascular resistance.