Transnasal transesophageal echocardiography: a modified application mode for cardiac examination in ventilated patients

In 42 endotracheally intubated patients, we examined the utility of a miniaturized monoplane probe for transnasal transesophageal echocardiography (TEE). Transnasal TEE was prospectively evaluated in 26 deeply and 16 mildly sedated patients receiving topical anesthesia with lidocaine jelly 2%. The patients with deep sedation were additionally examined with transoral monoplane and multiplane TEE. Transnasal esophageal insertion of the TEE probe was successfully performed in 90% of patients. Endotracheal malpositioning was corrected in two patients. Nasal bleeding required treatment in another patient. Topical anesthesia was adequate in 82% of mildly sedated patients. Left ventricular short- and four-chamber long-axis views of good quality were obtained with transnasal (transoral) monoplane TEE in 76% (81%) and 92% (96%) of patients (differences not significant). Compared with conventional multiplane TEE, transnasal monoplane TEE missed diagnoses in 19% of patients. The relative error (mean +/- SEM) of quantification with transnasal TEE was <9% +/- 2% for ventricular diameters and <7% +/- 2% for cross-sectional area measurements, with a bias of 0.5 +/- 3.8 cm2 and 0.1 +/- 2.4 cm2 (mean +/- 2 SD) for left ventricular end-diastolic and end-systolic short-axis areas. The relative error in measuring intracardiac flow velocities was >40%, but systolic to diastolic peak velocity ratios at the valvular site were determined with an error <4% +/- 3%. Transnasal monoplane TEE can be performed even in mildly sedated patients with an endotracheal tube without further need for analgesia or sedation. The technique is as useful as conventional transoral TEE to image standard tomographic planes for quantification, but it is less suited for comprehensive echocardiographic diagnosing.

IMPLICATIONS

Transnasal insertion of a miniaturized monoplane transesophageal echocardiography (TEE) probe was studied in endotracheally intubated patients. Nasal passage was well tolerated even by patients with only mild sedation. Imaging quality was similar to conventional transoral monoplane TEE with larger transducers, but technical restraints cause a deficit in complete cardiac diagnosing obtained with multiplane TEE.

RARalpha antagonist Ro 41-5253 inhibits proliferation and induces apoptosis in breast-cancer cell lines

Ro 41-5253 is a RARalpha-selective antagonist that binds RARalpha but does not induce transcriptional activation and does not influence RAR/RXR heterodimerization and DNA binding. This retinoid inhibits proliferation and induces apoptosis in MCF-7 and ZR-75.1 estrogen-receptor-positive breast-carcinoma cells in a dose-dependent way. The anti-proliferative effect is more evident in ZR-75.1 cells than in MCF-7 cells and is probably mediated by anti-AP1 activity, a mechanism known to be implied in the action of several retinoids. In the induction of apoptosis also ZR-75.1 cells are more sensitive to treatment with Ro 41-5253 than MCF-7 cells. In ZR-75.1 cells an apoptotic/hypodiploid DNA peak is already evident after 2 days of incubation, whereas in MCF-7 cells it appears only after 4 days. The highest percentage of apoptotic cells, for both cell lines, is reached after 6 days of treatment. The apoptosis pathway is p53-independent and bcl-2 downregulation seems to be correlated with an increase in TGF-beta1 protein. The MDA-MB-231 estrogen-receptor-negative cell line is poorly responsive to Ro 41-5253 treatment, both in terms of proliferation inhibition and apoptosis induction. Ro 41-5253 has proliferation-inhibiting and apoptosis-inducing properties that are not mediated by transcriptional activation from retinoic-acid response elements. This retinoid antagonist seems to be a compound that exerts an anti-tumor activity but does not induce the toxic side effects of retinoids and might, therefore, be considered as a candidate for cancer therapy.

[Postoperative vomiting. A score for prediction of vomiting risk following inhalation anesthesia]

Despite numerous factors are thought to affect postoperative vomiting (PV) recent studies demonstrated that the risk of PV can be predicted by considering just the most important ones. Therefore, the aim of this study was to present the clinically most relevant factors, a risk score based upon those factors and its clinical applicability for other types of surgery.

METHODS

In a prospective study 2220 adult inpatients scheduled for elective surgery were monitored for PV after inhalational anaesthesia over 24 hours. None of the patients received prophylactic antiemetic treatment. Multivariate analyses were performed with data of patients who underwent otolaryngological procedures to identify the major risk factors and to derive a risk score. The applicability of the score in surgical and ophthalmological procedures was tested by linear regression analysis of expected and observed incidences.

RESULTS

In the multivariate model, clinically most important risk factors for PV were female gender, young age, a positive history of postoperative nausea and vomiting or motion sickness, non-smoking and a long duration of anaesthesia, whereas the relative impact of the "type of operation itself" was small. Expected and observed incidences in patients undergoing other types of surgery were strongly correlated (R2 = 0.99, P < 0.001).

CONCLUSION

The risk for PV after inhalational anaesthesia in adults can be predicted using a score which is based on individual risk factors and the duration of anaesthesia only.

A risk score to predict the probability of postoperative vomiting in adults

BACKGROUND

The aim of this study was to identify factors most relevant for postoperative vomiting (PV) and to develop a risk score to predict the probability of PV.

METHODS

Adult inpatients scheduled for elective ear, nose and throat (ENT) surgery under general anaesthesia were offered to participate in a prospective study for PV over 24 h. No prophylactic antiemetics were used. The data of 1137 patients were randomized and split into an evaluation set (n=553) and a validation set (n=584). The evaluation set was subjected to logistic regression analysis to quantify the relative impact of anaesthetic, surgical and individual factors and to develop a risk score. The score was then tested by applying it to the validation set. The area under a receiver operation characteristic (ROC) curve was calculated and the predicted and actual incidences of patients were correlated.

RESULTS

In the evaluation set, patient-related factors (female gender, young age, non-smoking, history of PV or motion sickness) and a high duration of anaesthesia were independent risk factors for PV. The probability of PV could be estimated from the equation: PV=1/(1+exp(-z)) where z=1.28 (gender)-0.029 (age)-0.74 x (smoking)+0.63 x (history of PV or motion sickness)+0.26 x (duration)-0.92. In the validation set this score achieved an area under the ROC-curve of 0.78 and the actual incidence correlated strongly with the predicted risks (R2=0.93, P<0.001).

CONCLUSION

The data suggest that the probability of PV following ENT surgery under inhalational anaesthesia with low-dose opioids can be predicted by a score mainly based upon patient-related risk factors.

The discriminating power of a risk score for postoperative vomiting in adults undergoing various types of surgery

BACKGROUND

Recently, we have demonstrated that the probability of postoperative vomiting (PV) following ENT surgery with inhalational anaesthetics can be predicted using a risk score. This score is based on gender, age, smoking status, history of motion sickness or postoperative nausea and vomiting and the duration of anaesthesia. Therefore, it is of interest whether this score is also accurate in predicting PV in patients undergoing different types of surgery.

METHODS

Inpatients scheduled for bone, vascular, general or eye surgery were included in a prospective survey for PV over 24 h. Data of 1091 patients were analyzed, of which 542 were used for the validation of the previously constructed risk score (Score I). The data of the remaining 549 patients were used to evaluate the risk factors that contribute to PV in this setting and to develop a new score (Score II). The discriminating power of both scores to predict PV was tested in the validation set (n=542) and compared by calculating the area under the receiver operating characteristic (ROC) curves.

RESULTS

The area under the ROC curve of Score I was 0.77 (SD 0.024). Risk factors for PV in the evaluation set were female gender, young age, history of motion sickness or postoperative nausea and vomiting and the type of surgery. The area under the curve of Score II was 0.75 (SD 0.026) and was not significantly different from Score I (P=0.57).

CONCLUSION

Score I was accurate in predicting PV in patients after most types of surgery with volatile anaesthetics, which suggests that this score might be useful for other centres as well.

The relation between left ventricular wall stress shortening and preload changes in ventilated patients

The relation between left ventricular end-systolic wall stress (ESWS) and the velocity of circumferential fibre shortening (Vcfs) was examined in four non-random groups with 12 patients each. In group A, preload was increased by the administration of hydroxyethylstarch 30 mL min-1. In group B, preload was reduced by administering nitroglycerine 4.0 +/- 0.8 mg h-1. A change in pulmonary capillary wedge pressure by 3 mmHg was taken to be the end point for preload manipulation. To assess a change in the relation between ESWS and Vcfs, patients in group C received adrenaline at an infusion rate of 4 g min-1. Patients in group D served as the controls. Geometric variables of ESWS and Vcfs were determined by transoesophageal echocardiography. A linear model was used to assess the relation between ESWS and Vcfs within each group by regression analysis, and analysis of covariance performed to detect significance of intragroup and intergroup differences (P < 0.005). No significant changes were found during preload intervention. With adrenaline, Vcfs increased significantly for a given ESWS. It is concluded that the relation between ESWS and Vcfs, in a multiple patient setting, is independent of modest preload changes and may have the potential to indicate inotropic effects.

Relation of echocardiographic preload indices to stroke volume in critically ill patients with normal and low cardiac index

OBJECTIVE

To examine the usefulness of preload indices obtained by transoesophageal echocardiography (TOE) for estimating stroke volume at various levels of cardiac index.

DESIGN

Prospective clinical study.

SETTING

Intensive care unit with surgical patients.

PATIENTS

16 ventilated patients monitored via Swan-Ganz catheterization and TOE.

INTERVENTIONS

Echocardiographic images of left ventricular cross-sectional short-axis areas were analysed for the preload indices end-diastolic area (EDA), stroke area and end-diastolic wall stress. The relation between these indices and stroke volume, calculated from thermodilution cardiac output, was analysed in all patients and in nine patient groups discriminated by various ranges in heart rate (< or = 70 to > 110 beats/min), pulmonary artery occlusion pressure (< or = 8 to > 12 mmHg) and cardiac index (< or = 3.0 to > 4.2 l/min per m2).

MEASUREMENTS AND RESULTS

Overall stroke volume (n = 155) correlated significantly (p < 0.0001) with EDA (r = 0.89) and stroke area (r = 0.80). The correlation with end-diastolic wall stress was non-significant (r = 0.51). Linearity in the relation between stroke volume and EDA or stroke area was independent of variations in heart rate and pulmonary artery occlusion pressure. Stroke volume correlated well with EDA and stroke area, when cardiac index was normal or high, but the relation slightly deteriorated (r = 0.63 to < or = 0.72) when the cardiac index was low. Changes in EDA and stroke area by more than 1, 2 or 3 cm2 were weak predictors for changes in stroke volume greater than 20%.

CONCLUSIONS

Stability of the relation between echocardiographic preload indices and stroke volume emphasize the potential of TOE for continuous preload monitoring in the critically ill.

Comparative disposition, receptor affinity, and teratogenic activity of sulfon arotinoids

To investigate the relationship between sulfon arotinoid biotransformation and teratogenic activity, the potency of the ethyl (Ro 15-1570) and methyl (Ro 14-9706) arotinoid sulfones and their in vivo disposition in pregnant hamsters were studied. Administration of Ro 15-1570 was teratogenic, but Ro 14-9706 showed no such activity. Total absorbed doses of the ethyl and methyl sulfones (measured as maternal plasma AUC) were very similar. Total delivered dose of Ro 14-9706 to liver and lung was 120-160% that of Ro 15-157, and Ro 14-9706 was transferred in greater amounts to the embryo as well. Placenta AUC for parent sulfon arotinoids was 160-250% that in the embryo. Plasma analyses by HPLC suggested that the ethyl sulfone was oxidized and appeared in maternal plasma as the corresponding sulfinic (Ro 14-9572) and sulfonic (Ro 14-3899) acids, amounting to 10% and 16%, respectively, of the mean maternal ethyl sulfone Cmax value. The concentrations of sulfinic and sulfonic metabolites were always less than the analytical limit of detection in placenta and embryo after maternal ethyl sulfone intubation. Neither the sulfinic nor the sulfonic acid were ever detected in maternal circulation, placenta, or embryo after methyl sulfone intubation. Comparisons of their binding affinities found that neither the ethyl nor the methyl arotinoid sulfone could act as a ligand for cellular retinoic acid-binding protein (CRABP), nor could these compounds bind retinoid nuclear receptors (RAR). Transcriptional activation of RARs was weak and similar for both compounds. The sulfinic and sulfonic acid arotinoids bind and transactivate RARs, and bind CRABP with efficiencies similar to all-trans-retinoic acid. Furthermore, they are active in cultured limb bud chondrocytes. The results suggest that the methyl sulfone (in accord with its lack of activity in cultured limb bud chondrocytes) is of no toxicologic significance in hamster embryo--even after relatively high delivered dose. Teratogenicity of the ethyl sulfone (which shows marked inhibition of chondrogenesis in cultured limb bud) does not appear to depend on measurable concentrations of these sulfinic/sulfonic acid metabolites in the hamster embryo.

Different agonist- and antagonist-induced conformational changes in retinoic acid receptors analyzed by protease mapping

The pleiotropic effects of retinoic acid on cell differentiation and proliferation are mediated by two subfamilies of nuclear receptors, the retinoic acid receptors (RARs) and the retinoid X receptors (RXRs). Recently the synthetic retinoid Ro 41-5253 was identified as a selective RAR alpha antagonist. As demonstrated by gel retardation assays, Ro 41-5253 and two related new RAR alpha antagonists do not influence RAR alpha/RXR alpha heterodimerization and DNA binding. In a limited trypsin digestion assay, complexation of RAR alpha with retinoic acid or several other agonistic retinoids altered the degradation of the receptor such that a 30-kDa proteolytic fragment became resistant to proteolysis. This suggests a ligand-induced conformational change, which may be necessary for the interaction of the DNA-bound RAR alpha/RXR alpha heterodimer with other transcription factors. Our results demonstrate that antagonists compete with agonists for binding to RAR alpha and may induce a different structural alteration, suggested by the tryptic resistance of a shorter 25-kDa protein fragment in the digestion assay. This RAR alpha conformation seems to allow RAR alpha/RXR alpha binding to DNA but not the subsequent transactivation of target genes. Protease mapping with C-terminally truncated receptors revealed that the proposed conformational changes mainly occur in the DE regions of RAR alpha. Complexation of RAR beta, RAR gamma, and RXR alpha, as well as the vitamin D3 receptor, with their natural ligands resulted in a similar resistance of fragments to proteolytic digestion. This could mean that ligand-induced conformational changes are a general feature in the hormonal activation of vitamin D3 and retinoid receptors.

A retinoic acid receptor alpha antagonist selectively counteracts retinoic acid effects

Retinoic acid (RA) exerts its pleiotropic effects on cell growth and differentiation through the activation of a family of transcription factors-the RA receptors (RARs). Three subtypes of these receptors exist, RAR alpha, RAR beta, and RAR gamma. The receptors are differentially expressed in different cell types and stages of development, suggesting that they may regulate different sets of genes. We have identified a synthetic retinoid with the characteristics of a selective RAR alpha antagonist. This antagonist counteracts RA effects on HL-60 cell differentiation and on B-lymphocyte polyclonal activation. Beyond its potential practical relevance, this and other specific antagonists will be useful to dissect the RAR system and to assign to one given receptor each of the many RA-regulated functions.