[Suspected fetal malformation in ultrasound examination: effects on the psychological well-being of pregnant women]

OBJECTIVE

Today's ultrasound technology permits the detection of foetal malformations during pregnancy. This study examined pregnant women's psychological responses to a suspected fetal anomaly and the subsequent course of psychological well-being.

METHOD

86 pregnant women with a suspected fetal malformation were assessed by means of questionnaires three times: before an ultrasound examination at a specialized centre, one to two weeks after the examination, and four weeks after giving birth or after premature termination of the pregnancy. Anxiety (STAI), depression (HADS-D) and feelings towards the child were assessed.

RESULTS

A suspected fetal malformation results in psychological stress with anxiety and depression levels significantly higher than in normal samples. Regardless of either confirmation or rejection of the diagnosis of a malformation, stress decreases significantly after the ultrasound examination at the specialized centre. Only women who decide to terminate the pregnancy prematurely show increasing levels of stress in this period. Four weeks after giving birth or termination of pregnancy the assessed psychological parameters of all participants fall within the normal range.

CONCLUSIONS

A suspected fetal malformation results in immediate psychological stress but not in an enduring psychological disorder. Women facing immediate premature termination of pregnancy exhibited the highest stress levels. The psychosocial distress caused by the diagnosis of a fetal malformation should be taken into consideration in the psychosocial consultation and treatment of concerned women and their partners.

Compression stockings prophylaxis of emergent varicose veins in pregnancy: a prospective randomised controlled study

QUESTIONS UNDER STUDY

To determine the efficacy of compression stockings in preventing emergent varicose veins in pregnancy.

METHODS

A prospective randomised controlled study in the outpatient department of the University Hospital of Zurich, Switzerland, including women with uncomplicated pregnancies <12 weeks at outset of study. A no-stockings control group (n = 15) was compared with two treatment groups: group 1 (n = 12) wore compression class I stockings (18-21 mm Hg) on the left leg and class II stockings (25-32 mm Hg) on the right; in group 2 (n = 15), the compression classes were reversed. Stockings were worn from study entry to term. Endpoints were emergence and worsening of superficial varicose veins, long saphenous vein reflux at the sapheno-femoral junction, and leg symptoms (pain, discomfort, cramps) during pregnancy.

RESULTS

Both classes of compression stockings failed to prevent the emergence of superficial varicose veins. However, long saphenous vein reflux at the sapheno-femoral junction was observed in the third trimester in only 1/27 treated women vs. 4/15 controls (p = 0.047); in addition, more treated women reported improved leg symptoms (7/27 vs. 0/15 controls; p = 0.045). Emergent varicose changes, however, did not differ significantly (7/14 controls vs. 5/12 in group 1 and 8/14 in group 2; 3x3 table, Fisher's exact = 0.94).

CONCLUSIONS

Although compression stockings do not prevent the emergence of gestational varicose veins, they significantly decrease the incidence of long saphenous vein reflux at the sapheno-femoral junction and improve leg symptoms. Our results also suggest that superficial varices and deep venous insufficiency may have a different aetiology.

Compression stockings prophylaxis of emergent varicose veins in pregnancy: a prospective randomised controlled study

QUESTIONS UNDER STUDY

To determine the efficacy of compression stockings in preventing emergent varicose veins in pregnancy.

METHODS

A prospective randomised controlled study in the outpatient department of the University Hospital of Zurich, Switzerland, including women with uncomplicated pregnancies <12 weeks at outset of study. A no-stockings control group (n = 15) was compared with two treatment groups: group 1 (n = 12) wore compression class I stockings (18-21 mm Hg) on the left leg and class II stockings (25-32 mm Hg) on the right; in group 2 (n = 15), the compression classes were reversed. Stockings were worn from study entry to term. Endpoints were emergence and worsening of superficial varicose veins, long saphenous vein reflux at the sapheno-femoral junction, and leg symptoms (pain, discomfort, cramps) during pregnancy.

RESULTS

Both classes of compression stockings failed to prevent the emergence of superficial varicose veins. However, long saphenous vein reflux at the sapheno-femoral junction was observed in the third trimester in only 1/27 treated women vs. 4/15 controls (p = 0.047); in addition, more treated women reported improved leg symptoms (7/27 vs. 0/15 controls; p = 0.045). Emergent varicose changes, however, did not differ significantly (7/14 controls vs. 5/12 in group 1 and 8/14 in group 2; 3x3 table, Fisher's exact = 0.94).

CONCLUSIONS

Although compression stockings do not prevent the emergence of gestational varicose veins, they significantly decrease the incidence of long saphenous vein reflux at the sapheno-femoral junction and improve leg symptoms. Our results also suggest that superficial varices and deep venous insufficiency may have a different aetiology.

Localization of individual subunits of protein kinase CK2 to the endoplasmic reticulum and to the Golgi apparatus

The protein kinase CK2 is composed of two catalytic alpha- or alpha'- and two regulatory beta-subunits. In mammalian cells there is ample evidence for the presence of individual CK2 subunits beside the holoenzyme. By immunofluorescence studies using peptide antibodies which allow us to detect the CK2alpha-, alpha'- and beta-subunits we found all three subunits to be co-localized with a 58 KDa Golgi protein which is specific for the Golgi complex. Subfractionation studies using dog pancreas cells revealed the presence of all three subunits of CK2 at the smooth endoplasmic reticulum (sER)/Golgi fraction whereas the rough endoplasmic reticulum (rER) harboured only the catalytic alpha- and alpha'-subunits. We found that the microsomal preparation from dog pancreas cells contained CK2 which phosphorylated a CK2 specific synthetic peptide and which was heparin sensitive. Furthermore, we could immunoprecipitate the CK2alpha-subunit that exhibited a kinase activity which phosphorylated a CK2 specific substrate and which was heparin sensitive. Protease digestion experiments revealed that the CK2 subunits were located on the cytosolic side of the rER and the sER/Golgi complex. Thus, we could demonstrate an asymmetric distribution of the CK2 subunits at the rER and sER/Golgi complex. Since the CK2alpha- and alpha'-subunits exhibit a substrate specificity which is different from the CK2 holoenzyme one might speculate that the asymmetric distribution of the CK2 holoenzyme and the CK2 catalytic subunits may have regulatory functions.

Prenatal diagnosis of a fetus with lumbar myelocystocele

We present a case of a fetal lumbar myelocystocele, a rare congenital malformation, characterized by herniation of the central canal through a bony spina bifida. Routine ultrasound examination at 11 weeks' gestation by the primary obstetrician showed a suspicious cyst on the fetal back. Initially, the suspected diagnosis was a meningocele. After sonographic detection of newly developed fetal brain anomalies at 22 weeks' gestation the patient was referred to us. The enlarged cyst, which floated freely in the amniotic fluid, had a funnel-like appearance and was covered by a very thin layer of skin. With the help of ultrafast fetal magnetic resonance imaging the diagnosis of a fetal myelocystocele was made.

Vascular endothelial growth factor in articular cartilage of healthy and osteoarthritic human knee joints

OBJECTIVE

To determine the levels of vascular endothelial growth factor (VEGF) mRNA and protein expression in normal and osteoarthritic (OA) human articular cartilage, and whether VEGF expression alters during the progression of OA.

METHODS

Sections from normal and OA human knee cartilage were immunotained with a polyclonal antibody recognising VEGF. In addition, total RNA was isolated from normal and osteoarthritic human knee cartilage and analysed by reverse transcriptase-polymerase chain reaction (RT-PCR) for VEGF mRNA expression.

RESULTS

VEGF was found to be present in normal and OA human knee cartilage in all cartilage layers. A significant increase of VEGF immunopositive chondrocytes to up to approximately 82% was detected in severe OA cartilage compared with normal articular cartilage (approximately 56% of immunopositive chondrocytes). RT-PCR analysis showed the expression of VEGF also on the mRNA level.

CONCLUSIONS

VEGF is expressed by articular chondrocytes in normal and OA human knee cartilage. The percentage of VEGF immunopositive chondrocytes significantly increases in late stages of the disease. The VEGF transcript levels encoding all four isoforms shows a big variability in samples from different donors, suggesting a distinct regulation of the expression of the four VEGF isoforms in normal and OA cartilage.

Different preparation methods to obtain platelet components as a source of growth factors for local application

BACKGROUND

Autologous platelet components were recently used as part of tissue-engineering strategies in oral and maxillofacial surgery. Various preparation methods were investigated to define standardized blood bank components and to collect data on the growth factor content of human platelets before and after storage.

STUDY DESIGN AND METHODS

Apheresis platelets (AP), buffy coat-derived platelets (BCP), platelets prepared by tube method (TP), and highly concentrated samples prepared from AP and from BCP were evaluated for standard quality criteria of platelet components and for their concentration of transforming growth factor (TGF)-ss1, platelet-derived growth factor (PDGF)-AB, and PDGF-BB. AP were stored for 5 days. On Days 3 and 5, these components and freshly prepared, highly concentrated samples were evaluated for the same measures.

RESULTS

Platelet concentration in TP was lower than that in the other groups (p<0.05). However, the concentrations of PDGF-AB, PDGF-BB, and TGF-ss1 were comparable in the three groups. TP showed higher spontaneous CD62 expression than did AP and BCP. The three preparation procedures resulted in significantly different WBC contamination, with the highest levels in TP. For the whole series of measurements, there was a strong correlation between growth factor levels and platelet concentration (p<0.05), which was due to the face that the growth factor content of concentrated platelet samples was tenfold that of AP, BCP, and TP. In TP, the WBC concentration was correlated with PDGF levels (p<0.05). After 5-day storage, the mean levels of PDGF-AB, PDGF-BB, and TGF-ss1 were 57.1, 43.0, and 72.0 percent of the initial values in AP. Overall, multiple regression analysis revealed the following factors influencing the measured growth factor concentrations: platelet concentration, baseline CD62 expression, lactate production, and WBC contamination.

CONCLUSION

Various methods enable the preparation of platelet components and of highly concentrated components for local use according to standard blood banking criteria. The obtained components differ, particularly in their WBC content and in vitro platelet activation. These findings are relevant for planning and evaluating further studies of locally usable autologous platelet components.

[Quality of praenatal diagnostic ultrasound - comparison of sonographically detected foetal anomalies with diagnostic findings verified post-partum in Switzerland]

AIM

Comparison of all praenatally detected cases of foetal anomalies to actual diagnostic findings post partum during a one year period in Switzerland.

METHODS

A retrospective questionnaire-based evaluation including the 5 university hospitals and 6 large hospitals in Switzerland as a population-based study. Analysis of all foetal anomalies detected praenatally by ultrasound in the year of 1995 in these centres.

RESULTS

347 cases have been included in the study. 89 % of cases were detected using screening methods. (2/3) were referred by obstetrical practitioners and GPs. 62 % of the pregnancies were completed and 33 % terminated, while the rest resulted in abortion or stillbirth. In terminated pregnancies there was a 82 % agreement between praenatal and postmortem findings. Sonographic results and clinical/post-mortem diagnosis were in agreement about the presence of major foetal anomalies in 18 % of cases. Additional minor anomalies unperceived by sonography, however, were seen post mortem. There was no false positive case.

CONCLUSIONS

Without ultrasound screening almost 90 % of anomalies would have been missed due to the absence of clinical symptoms. The Swiss two-step system for praenatal ultrasound screening, based on screening scans done by the obstetrician and GP in practice, or residents in the public outpatient clinics respectively, and the detailed scan done by a subspecialized perinatologist shows excellent results especially in the subgroup of terminated pregnancies.

Open Tübingen titanium prostheses for ossiculoplasty: a prospective clinical trial

OBJECTIVE

The overall purpose of the study was the evaluation of the efficacy of Tübingen titanium prostheses (TTPs) for ossiculoplasty.

STUDY DESIGN

A two-part clinical study of 216 patients undergoing ossiculoplasty was performed. The first part was a prospective study using TTPs (n = 114). The second part involved study of historical control patients (n = 102) with gold and ceramic prostheses.

INTERVENTIONS

All patients underwent ossiculoplasty.

MAIN OUTCOME MEASURES

Measures included median air conduction thresholds and air-bone gaps.

RESULTS

All patients were per-protocol patients. When the air-bone gap "gold standard" (i.e., < or =10 dB) was investigated in the main speech spectrum, partial TTPs reached this level at 2 kHz in 44% (n = 22) and at 3 kHz in 38% (n = 19). Gold and ceramics revealed significantly lower values. Similar results were obtained for total prostheses. Differences for TTPs and ceramics were statistically significant (Mann-Whitney U test, alpha = 5%).

CONCLUSION

The use of TTPs for ossiculoplasty is an efficient treatment method.

Quantum mechanical repulsion of exciton levels in a disordered quantum well

Spatially resolved photoluminescence spectra of a single quantum well are recorded by near-field spectroscopy. A set of over four hundred spectra displaying sharp emission lines from localized excitons is subject to a statistical analysis of the two-energy autocorrelation function. An accurate comparison with a quantum theory of the exciton center-of-mass motion in a two-dimensional spatially correlated disordered potential reveals clear signatures of quantum mechanical energy level repulsion, giving the spatial and energetic correlations of excitons in disordered quantum systems.

[Psychological aspects of ultrasound examinations during pregnancy]

The acceptability of ultrasound examinations during pregnancy has been documented in many studies. Yet there is little empirical evidence for the postulated psychological benefits of ultrasound examinations. Although seeing the baby is most often rated as a moving experience, there are no proven long-term effects of ultrasound visualization on bonding with the fetus or on pregnant women's health-related maternal behaviour. There is evidence to support the notion that attenuated anxiety and stress immediately following the examination are likely artefactual - a reflection of increased anxiety before real-time scan. Review of the literature indicates no evidence as to whether antenatal detection of fetal abnormalities leads to improvement in coping or only prolongs the phase of psychological stress and mourning. This articles provides an overview of current research on psychological effects of prenatal ultrasound examination.

A mobile mass spectrometer for comprehensive on-line analysis of trace and bulk components of complex gas mixtures: parallel application of the laser-based ionization methods VUV single-photon ionization, resonant multiphoton ionization, and laser-induced electron impact ionization

A newly developed compact and mobile time-of-flight mass spectrometer (TOFMS) for on-line analysis and monitoring of complex gas mixtures is presented. The instrument is designed for a (quasi-)simultaneous application of three ionization techniques that exhibit different ionization selectivities. The highly selective resonance-enhanced multiphoton ionization (REMPI) technique, using 266-nm UV laser pulses, is applied for selective and fragmentationless ionization of aromatic compounds at trace levels (parts-per-billion volume range). Mass spectra obtained using this technique show the chemical signature solely of monocyclic (benzene, phenols, etc.) and polycyclic (naphthalene, phenathrene, indol, etc.) aromatic species. Furthermore, the less selective but still fragmentationless single photon ionization (SPI) technique with 118-nm VUV laser pulses allows the ionization of compounds with an ionization potential below 10.5 eV. Mass spectra obtained using this technique show the profile of most organic compounds (aliphatic and aromatic species, like nonane, acetaldehyde, or pyrrol) and some inorganic compounds (e.g., ammonia, nitrogen monoxide). Finally, the nonselective ionization technique laser-induced electron-impact ionization (LEI) is applied. However, the sensitivity of the LEI technique is adjusted to be fairly low. Thus, the LEI signal in the mass spectra gives information on the inorganic bulk constituents of the sample (i.e., compounds such as water, oxygen, nitrogen, and carbon dioxide). Because the three ionization methods (REMPI, SPI, LEI) exhibit largely different ionization selectivities, the isolated application of each method alone solely provides specific mass spectrometric information about the sample composition. Special techniques have been developed and applied which allow the quasi-parallel use of all three ionization techniques for on-line monitoring purposes. Thus, a comprehensive characterization of complex samples is feasible jointly using the characteristic advantages of the three ionization techniques. Laboratory applications show results on rapid overview characterization of mineral oil-based fuels and coffee headspace. The first reported field applications include timely resolved on-line monitoring results on automobile exhausts and of waste incineration flue gas.

Temporary granulomatous inflammation following collagen implantation

Injections of bovine collagen are a common procedure for correction of folds in the face. However, this therapy is not free from side effects. We present a patient in whom a granulomatous inflammation occurred following implantation of this material. We therefore now insist on an observation interval of 4 weeks between test injection and actual treatment, as is recommended by the manufacturer.

Paired comparison of apheresis platelet function after storage in two containers

Platelet quality after storage strongly depends on the pre-storage quality as well as on the storage conditions determined by the storage container. In this paired study, we evaluated two different containers (MedSep CLX and Delmed DPL-110). The Fresenius AS104 cell separator was used to prepare 17 platelet concentrates that were split and distributed into the containers to be compared. Cell counts, blood gas analysis, morphological scores, glucose and lactate levels, platelet activation, and platelet aggregation were measured before splitting at the day of preparation and after storage at day 3 and day 5. At day 3, there was no significant difference between the two bags apart from increased lactate and decreased pCO(2) concentrations in the CLX bags. At day 5 there were significantly higher lactate concentrations, pO(2) levels, and aggregation after stimulation in the CLX group, while the glucose and pCO(2) concentrations were significantly lower in these platelet concentrates as compared to the DPL-110 group. However, these parameters did not influence the functional parameters tested. While the platelet quality decreased during storage in all bags, the functional changes were nearly identical in both bags tested. We conclude that both bags are equivalent for 5-day storage of platelet concentrates.

Lipoprotein lipase mediates the uptake of glycated LDL in fibroblasts, endothelial cells, and macrophages

The nonenzymatic glycation of LDL is a naturally occurring chemical modification of apolipoprotein (apo)-B lysine residues by glucose. Once glycated, LDL is only poorly recognized by lipoprotein receptors including the LDL receptor (LDL-R), the LDL-R-related protein (LRP), and scavenger receptors. Glycated LDL (gLDL) is a preferred target for oxidative modifications. Additionally, its presence initiates different processes that can be considered "proatherogenic." Thus, LDL glycation might contribute to the increased atherosclerotic risk of patients with diabetes and familial hypercholesterolemia. Here we investigate whether lipoprotein lipase (LPL) can mediate the cellular uptake of gLDL. The addition of exogenous LPL to the culture medium of human skin fibroblasts, porcine aortic endothelial cells, and mouse peritoneal macrophages enhanced the binding, uptake, and degradation of gLDL markedly, and the relative effect of LPL on lipoprotein uptake increased with the degree of apoB glycation. The efficient uptake of gLDL by LDL-R-deficient fibroblasts and LRP-deficient Chinese hamster ovary cells in the presence of LPL suggested a mechanism that was independent of the LDL-R and LRP. In macrophages, the uptake of gLDL was also correlated with their ability to produce LPL endogenously. Mouse peritoneal macrophages from genetically modified mice, which lacked LPL, exhibited a 75% reduction of gLDL uptake compared with normal macrophages. The LPL-mediated effect required the association of the enzyme with cell surface glycosaminoglycans but was independent of its enzymatic activity. The uptake of gLDL in different cell types by an LPL-mediated process might have important implications for the cellular response after gLDL exposure as well as the removal of gLDL from the circulation.

No benefit from post-caesarean wound drainage

AIM OF THE STUDY

A prospective randomized controlled trial to determine the benefit of caesarean wound drainage in 305 low-risk pregnant women.

METHODS

Pregnant women at low risk of haemorrhage undergoing caesarean section in the Department of Obstetrics, University Hospital, Zurich, between June 1998 and July 1999 were randomised after informed consent into a no-suction group (n = 154) without post-caesarean wound drainage versus a control group with wound drainage (subfascial and subcutaneous) (n = 151). Outcome measures were perioperative decrease in haemoglobin (Hb), postpartum fever (> 38.5 degrees C for > 2 days), sonographic haematoma and other complications requiring revision, cumulative opiate dose adjusted to body weight, length of hospitalisation and operation time.

RESULTS

305 patients completed the study. Decrease in Hb and the rates of fever, haematoma and revision were similar in both groups. However, cumulative opiate dose was lower in the no-suction group (4.5 +/- 1.8 vs 2.8 +/- 1.4 injections, p = 0.0001), and hospital stay was shorter (6.5 +/- 2.4 vs 7.4 +/- 2.8 days, p = 0.0058), as was operation time (32.7 +/- 11.3 v 36.1 +/- 10.5 min; p = 0.0071).

CONCLUSIONS

Routine post-caesarean wound drainage is not only useless but cost-ineffective. In the light of our results, wound drainage may be questioned and should be analysed generally.

No benefit from post-caesarean wound drainage

AIM OF THE STUDY

A prospective randomized controlled trial to determine the benefit of caesarean wound drainage in 305 low-risk pregnant women.

METHODS

Pregnant women at low risk of haemorrhage undergoing caesarean section in the Department of Obstetrics, University Hospital, Zurich, between June 1998 and July 1999 were randomised after informed consent into a no-suction group (n = 154) without post-caesarean wound drainage versus a control group with wound drainage (subfascial and subcutaneous) (n = 151). Outcome measures were perioperative decrease in haemoglobin (Hb), postpartum fever (> 38.5 degrees C for > 2 days), sonographic haematoma and other complications requiring revision, cumulative opiate dose adjusted to body weight, length of hospitalisation and operation time.

RESULTS

305 patients completed the study. Decrease in Hb and the rates of fever, haematoma and revision were similar in both groups. However, cumulative opiate dose was lower in the no-suction group (4.5 +/- 1.8 vs 2.8 +/- 1.4 injections, p = 0.0001), and hospital stay was shorter (6.5 +/- 2.4 vs 7.4 +/- 2.8 days, p = 0.0058), as was operation time (32.7 +/- 11.3 v 36.1 +/- 10.5 min; p = 0.0071).

CONCLUSIONS

Routine post-caesarean wound drainage is not only useless but cost-ineffective. In the light of our results, wound drainage may be questioned and should be analysed generally.

Systolic and Diastolic Properties and Myocardial Blood Flow in the Heterotopically Transplanted Rat Heart during Acute Cardiac Rejection

The aim of the study was to characterize the course of systolic and diastolic function, myocardial blood flow, and histologic changes during acute rejection in a model of heterotopic transplantation in rats. For this purpose isogenic Lewis-to-Lewis and allogenic DA (Dark Agouti)-to-Lewis rat cardiac transplants were studied 1 hour and 1, 3, and 5 days, respectively, after heterotopic intraabdominal transplantation. Myocardial tissue blood flow (MBF) was assessed by the hydrogen-clearance method. An implanted balloon was used to measure pressure-volume relations in the transplanted heart. Myocardial water content was determined at the end of the experiments, and histologic examinations were performed. The MBF recovered during the first day postoperatively in both groups and decreased again in the allogenic group after 3 and 5 days (p < 0.05); it remained stable in the isogenic group. Myocardial relaxation was already prolonged in the allogenic group after 3 days and deteriorated further. Left ventricular end-diastolic pressure progressively increased in the allogenic group, whereas it remained unchanged in the isogenic group up to 5 days. After recovery from ischemia, the left ventricular peak systolic pressure was stable in the isogenic group for the entire further observation period, but it significantly decreased in the allogenic group after 5 days (p < 0.05). Myocardial water content showed a significant increase in the allogenic group compared to that in the isogenic group after 5 days. In the allogenic group histologic examination confirmed mild to moderate rejection after 3 days and severe acute rejection after 5 days. Thus, after recovery from ischemia, mild to moderate cardiac rejection was associated with reduced MBF and impaired relaxation. In a typical sequence, generation of edema and impaired diastolic compliance were terminally followed by systolic dysfunction during severe rejection.

Emission of nonchlorinated and chlorinated aromatics in the flue gas of incineration plants during and after transient disturbances of combustion conditions: delayed emission effects

The profiles of different products of incomplete combustion (PIC) in the flue gas of a 1 MW pilot combustion facility were investigated under normal steady-state and disturbed combustion conditions. The behavior of emission profiles after disturbed combustion conditions was investigated in order to obtain a better understanding of emission memory effects. Highly time-resolved, quantitative on-line measurements of several aromatic species down to low ppbv or higher pptv concentrations were performed by a mobile resonance-enhanced multiphoton ionization time-of-flight mass spectrometer. Conventional analytical methods (gas chromatography-mass spectrometry and high-performance liquid chromatography) were also applied for measurement of polycyclic aromatic hydrocarbons (PAH) and polychlorinated dibenzo-p-dioxins and -furans (PCDD/F). The sampling point was located in the high-temperature region of the plant at the outlet of the post-combustion chamber at temperatures between 650 and 880 degrees C, prior to any emission reduction devices. The investigation pointed out that after a short phase of disturbed combustion conditions, e.g., due to process changes, transient puffs, or malfunctions, the composition of combustion byproducts in the flue gas can be changed drastically for a very long time ("memory emission" effect). It is suggested that carbonaceous layers, deposited on the inner walls in the high-temperature zone of the plant, might be responsible for the observed memory emission of some PAH species. Drastic changes in the profiles of the PCDD/F homologues were also observed during memory emission conditions. The PAH memory most likely is due to pyrolytic degradation of the carbonaceous layers, while the altered PCDD/F homologue pattern may be mediated by the high catalytic activity of the freshly formed deposit layers. Finally, it should be emphasized that a rich pattern of aromatic species, including PCDD/F, was found in a temperature regime well above the typical temperature window (approximately 300 degrees C) for de novo PCDD/F formation.

Prognostic value of Doppler echocardiographic mitral inflow patterns: implications for risk stratification in patients with chronic congestive heart failure

OBJECTIVES

This prospective study tested whether transmitral flow patterns add incremental value to peak oxygen consumption (VO2) in determining the prognosis of patients with chronic congestive heart failure (CHF) and systolic dysfunction.

BACKGROUND

Peak VO2 is an objective marker of functional capacity and is routinely used as a criterion to identify heart transplant candidates. Diastolic dysfunction limits functional capacity, but its prognostic importance relative to that of peak VO2 is unknown.

METHODS

Peak VO2 and mitral inflow velocities were prospectively measured in 311 consecutive patients (mean age 54 years, 84% male) with impaired left ventricular function (ejection fraction <40%; 88 patients with ischemic and 223 with dilated cardiomyopathy) who were evaluated for heart transplant candidacy.

RESULTS

During a mean follow-up period of 512 +/- 314 days, 65 patients died and 43 patients underwent heart transplantation. Diastolic filling patterns, peak VO2 and left ventricular end-diastolic diameters were independent predictors of cardiac mortality. In patients with peak VO2 < or = 14 ml/min per kg body weight, the outcome was markedly poorer in the presence of restrictive filling patterns as compared with their absence (two-year survival rate 52% vs. 80%). Similarly, despite peak VO2 levels >14 ml/min per kg, the outcome was less favorable in the presence of restrictive filling patterns (two-year survival rate 80% vs. 94%). A risk-stratification model based on the identified independent noninvasive predictors separated groups into those with high (93%), intermediate (65%) and low (39%) two-year survival rates.

CONCLUSIONS

Transmitral flow patterns add incremental value to peak VO2 in determining the prognosis of patients with CHF and impaired systolic function.

Increased soluble Fas in HIV-infected hemophilia patients with CD4+ and CD8+ cell count increases and viral load and immune complex decreases

Previous studies interpreted increases of soluble Fas (sFas) in the plasma during disease progression in HIV-infected patients as evidence of increased apoptosis of CD4(+) lymphocytes. We studied whether sFas and sFas ligand (sFasL) plasma levels are associated with CD4(+) and CD8(+) lymphocyte counts, plasma viral load, and IgM, IgG, C3d, and gp120 complexes on circulating CD4(+) blood lymphocytes in long-term surviving HIV-infected hemophilia patients, most of whom were receiving HAART. Twenty-six hemophilia patients who were infected with HIV in the early 1980s were investigated in 1997, 1998, and 1999. HAART was initiated in 1996 and 1997 in most patients. Lymphocyte subpopulations and immune complex-coated CD4(+) lymphocytes in the blood were investigated by flow cytometry, plasma viral load (HIV-1 mRNA copies/ml plasma) was tested with HIV-1 QT Nuclisens kits, sFas (ng/ml) and sFasL (ng/ml) plasma levels were measured with MBL ELISA kits, and the in vitro response of patient lymphocytes was tested in cell cultures. During the period from 1997 to 1999 we observed an increase in sFas plasma levels (p = 0.003) as well as in CD4(+) (p = 0.004) and CD8(+) (p = 0.023) cell counts; a decrease in IgG (p = 0.047), C3d (p = 0.024), and gp120 (p = 0.001)-coated CD4(+) lymphocytes in the blood; and a decrease in the number of impaired mitogen stimulation assays (p = 0.013). sFas was negatively associated with viral burden (r = -0.662, p = 0.0002) as well as with CD4(+)IgM(+) (r = -0.554, p = 0.004), CD4(+)IgG(+) (r = -0.431, p = 0.031), CD4(+)C3d(+) (r = -0.551, p = 0.041), and CD4(+)gp120(+) (r = -0.430, p = 0.041) blood lymphocytes, CD8(+)DR(+) cell counts (r = -0.700, p = 0.016), and impaired in vitro responses of patient lymphocytes to PHA (r = -0.475, p = 0.016). sFasL was negatively associated with total lymphocyte counts (r = -0.433, p = 0.027), as well as with absolute numbers of CD3(+) (r = -0.492, p = 0.011) and CD8(+) (r = -0.432, p = 0.027) cells. We conclude that, contrary to expectations, sFas plasma levels increased in long-term surviving HIV-infected hemophilia patients receiving HAART, concomitant with increases in CD4(+) and CD8(+) cell counts. Increased sFas may reflect the growing pool of T lymphocytes that recovers because of a decreasing viral burden and a decreasing immune complex load of CD4(+) lymphocytes.