Accuracy of various methods of localization of the orifice of the coronary sinus at electrophysiologic study

The coronary sinus (CS) orifice is an important reference point for determining electrode and, thereby, accessory pathway location at electrophysiologic study. The reliability of fluoroscopic landmarks used to identify the CS orifice is not known. This study compared the accuracy of several fluoroscopic landmarks for identifying the CS orifice with the location defined by radiopaque contrast injection of the CS. Forty patients were studied. Radiographic markers of the CS orifice that were examined included: (1) the point at which the CS catheter prolapsed during advancement, (2) the point of maximum convexity of the CS catheter when a superior vena caval approach was used, (3) the right side of the ventricular septum, and (4) the relation to the underlying vertebrae. The least-significant difference method of multiple comparisons was used for statistical analysis. The point at which the CS catheter prolapsed was the most accurate noncontrast method for determining the location of the CS orifice (p less than 0.05), but was possible without the use of excessive force in only 48% of patients. The point of catheter prolapse was a median of 1 mm (range 0 to 11) from the true location of the os. Errors with other examined landmarks ranged up to 3 cm. Identification of the CS orifice is best performed by radiopaque contrast injection. The point of prolapse during catheter advancement in the CS is an accurate alternative when contrast injection is not feasible. Other noncontrast fluoroscopic landmarks are less reliable and are best avoided.(ABSTRACT TRUNCATED AT 250 WORDS)

Dimensions of the human posterior septal space and coronary sinus

Accurate anatomic localization of accessory pathways during preoperative electrophysiologic study and during operative mapping depends on a knowledge of the dimensions of the posterior septal space and the left free wall. These dimensions were therefore studied in 48 human cadaver hearts. Mean distance from the coronary sinus orifice to the left margin of the posterior septal space was 2.3 +/- 0.4 cm and mean length of the left free wall was 5.0 +/- 1.0 cm. The posterior septal space at the level of the valve anuli extended a mean of 3.4 +/- 0.5 cm around the epicardium. The width of the posterior septum measured in the coronary sinus was related to heart weight and a combination of body weight and patient age (p less than 0.05). The probability of an accessory pathway being located in the left free wall or the posterior septum during catheter mapping was calculated for various distances from the coronary sinus orifice for adults of different ages and body weights. In adults, accessory pathways located in the proximal 1.5 cm of the coronary sinus are almost always in the posterior septum. Those located between 1.5 and 3 cm from the coronary sinus orifice may be in either the left free wall or the posterior septum, and those located greater than 3 cm from the coronary sinus orifice are almost invariably in the left free wall.

A tumor chromosome rearrangement further defines the 11p13 Wilms tumor locus

A sporadic Wilms tumor, WT-21, with an (11;14)-(p13;q23) reciprocal translocation has been identified. The translocation is found in tumor cells, but not in the patients' circulating lymphocytes. Molecular analysis of somatic cell hybrids segregating the derivative translocation chromosomes reveals a submicroscopic interstitial deletion at the translocation breakpoint, as well as a cytologically undetectable interstitial deletion in the nontranslocation chromosome 11, resulting in a homozygous deletion in 11p13. Pulsed-field gel analysis of tumor DNA indicates that the two deletions are indistinguishable, and the homozygously deleted region is less than 875 kb. The homozygously deleted regions of three other sporadic Wilms tumors overlap with the deleted region in WT-21, and the candidate cDNA clone for the 11p13 Wilms tumor gene described by Call et al. (Cell 60, 509-520, 1990) is included in the deleted region. These findings strengthen previous conclusions regarding the obligate location for the 11p13 WT locus and support the suggestion that the Wilms tumor gene has been cloned.

Factors affecting the development of pneumothorax associated with thoracentesis

This study is a retrospective survey of the variables that may influence the development of pneumothorax after thoracentesis. In a 30-month period, a computer search of hospital records identified 342 thoracenteses, of which 154 were done with conventional techniques by the clinical services, and 188 were done with sonographic guidance. Other factors surveyed included the patients' age, sex, underlying pulmonary disease, and overall clinical condition; the size of the effusion; the type of tap (diagnostic or therapeutic); the amount and type (exudate or transudate) of fluid acquired; and the size of the needles used. The technique used was the most significant single risk factor affecting the development of pneumothorax (18% for clinical vs 3% for sonography-guided thoracenteses). The incidence of pneumothorax decreased when a smaller amount of pleural fluid was aspirated (mean, 246 ml aspirated from patients who did not vs 472 ml from those who did develop pneumothorax) and when thin needles were used (4% pneumothorax with 20-gauge or smaller and 18% with larger than 20-gauge needles). The other factors surveyed did not influence the development of pneumothorax. Our results show that sonography-guided thoracentesis is complicated by pneumothorax significantly less often than is thoracentesis done with conventional techniques. Use of the smallest possible needle and aspiration of the smallest possible amount of fluid will also result in fewer cases of pneumothorax.

Permanent junctional reciprocating tachycardia misdiagnosed as 'cardiomyopathy'

In a nine-year-old female, cardiac failure was erroneously attributed to idiopathic cardiomyopathy and cardiac transplantation was planned. The actual cause of cardiac failure was permanent junctional reciprocating tachycardia (PJRT), a rare form of supraventricular tachycardia. The diagnostic error was discovered before transplantation was performed and the arrhythmia was treated surgically. This resulted in return of near normal cardiac function.

Rapid DNA sequencing based upon single molecule detection

We are developing a laser-based technique for the rapid sequencing of 40-kb or larger fragments of DNA at a rate of 100 to 1000 bases per second. The approach relies on fluorescent labeling of the bases in a single fragment of DNA, attachment of this labeled DNA fragment to a support, movement of the supported DNA fragment into a flowing sample stream, and detection of individual fluorescently labeled bases as they are cleaved from the DNA fragment by an exonuclease. The ability to sequence large fragments of DNA will significantly reduce the amount of subcloning and the number of overlapping sequences required to assemble megabase segments of sequence information.

What is the best method for assessing the long-term outcome of surgery for accessory pathways and atrioventricular junctional reentrant tachycardias?

The success of surgery for supraventricular tachycardia (SVT) is evaluated by a variety of methods in different hospitals. Unfortunately, the predictive values of these methods are not known. We therefore compared the various methods in 261 patients undergoing surgery for SVT at Westmead Hospital since 1981. Surgical outcome was assessed by early tests during the first week after surgery (serial 12-lead electrocardiograms, telemetric monitoring of the electrocardiogram, and electrophysiological study performed using epicardial wires); later tests at 6 months after surgery (12-lead electrocardiograms and electrophysiological study); and symptomatic review done by telephone interview at a median of 34 months after surgery. Early tests were obtained in 97%, later tests were obtained in 76%, and symptomatic review was obtained in 98% of patients. All of the examined tests were inaccurate methods of surgical assessment compared with the late electrophysiological study. A large proportion of the patients proven to be surgical failures at the late electrophysiological study were not detected by early tests (83%), by later electrocardiograms (66%), or by symptomatic assessment (41%). Accurate assessment of surgical outcome requires a late electrophysiological study to permit comparison of surgical techniques. Late electrophysiological study also provides accurate information on the current risks and benefits of proposed surgery for communication to patients to enable them to make an informed decision on future treatment. Most patients are willing to have a late electrophysiological study and usually benefit from clarification of their true surgical outcome.

Somatic cell hybrid and long-range physical mapping of 11p13 microdissected genomic clones

Microdissection and microcloning of banded human metaphase chromosomes have been used to construct a genomic library of 20,000 clones that is highly enriched for chromosome 11p13 DNA sequences. Clones from this library have been mapped on a panel of human-rodent somatic cell hybrids that divides the region from distal p12 to proximal p14 into seven physical intervals, A total of 1500 clones has been isolated, 250 clones have been characterized, and 58 clones have been mapped. Six of the clones were used to complete a long-range physical map of 7.5 megabases through the region. Two of the clones are localized to the Wilms tumor (WT) region, three are localized to the aniridia (AN2) region, and two are localized to the region between WT and AN2. The library represents DNA sequences spanning a distance of approximately 13 x 10(6) base pairs, with an average density of one clone per 37,000 base pairs.

Mapping small DNA sequences by fluorescence in situ hybridization directly on banded metaphase chromosomes

A procedure for mapping small DNA probes directly on banded human chromosomes by fluorescence in situ hybridization has been developed. This procedure allows for the simultaneous visualization of banded chromosomes and hybridization signal without overlaying two separate photographic images. This method is simple and rapid, requires only a typical fluorescence microscope, has proven successful with DNA probes as small as 1 kilobase, is applicable for larger probes, and will greatly facilitate mapping the vast number of probes being generated to study genetic disease and define the human genome. Human metaphase chromosomes were prepared from phytohemagglutinin-stimulated lymphocyte cultures synchronized with bromodeoxyuridine and thymidine. Probes were labeled with biotin-dUTP, and the hybridization signal was amplified by immunofluorescence. Chromosomes were stained with both propidium iodide and 4',6-diamidino-2-phenylindole (DAPI), producing R- and Q-banding patterns, respectively, allowing unambiguous chromosome and band identification while simultaneously visualizing the hybridization signal. Thirteen unique DNA segments have been localized to the long arm of chromosome 11 by using this technique, and localization of 10 additional probes by using radioactive in situ hybridization provides a comparison between the two procedures. These DNA segments have been mapped to all long-arm bands on chromosome 11 and in regions associated with neoplasias and inherited disorders.

Proarrhythmic effects of antiarrhythmic drugs

Drugs that are described as antiarrhythmic drugs may actually aggravate arrhythmia in several ways and these are termed proarrhythmic effects. The most common type of proarrhythmia is a paradoxical increase in the frequency of episodes of the target arrhythmia. This type of effect had not been suspected until recently and has not been widely publicized. It is a phenomenon common to all antiarrhythmic drugs when they are used to treat arrhythmias based on a re-entrant mechanism (the most common mechanism of clinical arrhythmias). Different drugs vary in their tendency to produce this type of proarrhythmic response. These differences are explicable in terms of the relative effects of the drugs on refractoriness and conduction times in the re-entrant circuit. Proarrhythmic effects are most important in the treatment of ventricular tachycardias because recurrences are often fatal. Proarrhythmic effects on ventricular tachycardia can now be predicted at electrophysiological study before commencement of long-term therapy, and potentially dangerous treatment can be avoided. The key to proper treatment to proarrhythmia is to recognize that it is a drug-induced problem and to withdraw the offending drug.

Long-range restriction map around 11p13 aniridia locus

Using two random DNA markers, and pulsed field gel electrophoresis, a 1.5-Mb physical map surrounding the 11p13 aniridia locus (AN2) has been assembled. The map was constructed using a combination of single- and double-restriction digests on DNA from normal controls and a patient transmitting familial aniridia. The aniridia patient has a chromosome translocation and the two DNA markers flank the breakpoint. This 11p13 breakpoint lies no further than 100 kb from the DNA marker 1104 (D11S95), located on the centromeric side of the breakpoint. Two CpG islands, separated by 550 kb and flanking the translocation, suggest an upper limit to the size of the gene.

Four new DNA markers are assigned to the WAGR region of 11p13: isolation and regional assignment of 112 chromosome 11 anonymous DNA segments

One hundred eighty-three human single copy clones were isolated from the Livermore Laboratory chromosome 11 library (ID code LL11NSO1) and 112 of them were mapped to chromosome 11. Using a panel of somatic cell hybrids segregating chromosome 11 translocations and short arm deletions, 54 of the clones were assigned to one of nine segments on the short arm of chromosome 11; the remainder were assigned to the long arm. Nine of these clones map to 11p13, and four of the nine [57(D11S89), 530(D11S90), 706(D11S93), and 1104(D11S95)] are confined to the same segment within p13 that contains catalase (CAT), the beta subunit of follicle stimulating hormone (FSHB), and the Wilms' tumor-aniridia (WAGR) gene complex.

Two anonymous DNA segments distinguish the Wilms' tumor and aniridia loci

The association of Wilms' tumor with aniridia (the WAGR complex) in children with 11p13 chromosomal abnormalities has been established, but the paucity of molecular probes in 11p13 has hampered identification of the responsible genes. Two new anonymous DNA segments have been identified that map to the WAGR region of 11p13. Both DNA probes identify a cytologically undetectable deletion associated with a balanced chromosome translocation inherited by a patient with familial aniridia, but not Wilms' tumor. The same two DNA segments are also included in the distal p13-p14.1 deletion of another patient, who has aniridia, Wilms' tumor, and hypogonadism, but they are not included in the p12-p13 deletion of a third patient, who does not have aniridia but has had a Wilms' tumor. The discovery of this aniridia deletion and these two DNA segments that physically separate the Wilms' tumor and aniridia loci should facilitate identification of the genes in the WAGR locus, beginning with the aniridia gene.

Factor IXAlabama: a point mutation in a clotting protein results in hemophilia B

Factor IXAlabama is a variant factor IX molecule responsible for a clinically moderate form of hemophilia B. Twenty-five kilobases (kb) of the variant gene, including seven exons coding for the structural protein, were cloned and characterized. The restriction map and the arrangement of coding regions are identical to those of the normal gene. DNA sequence analysis of the coding regions revealed a single base-pair difference between the gene for factor IXAlabama and the normal factor IX gene. An adenine to guanine transition in the first nucleotide of exon d causes the substitution of a glycine codon (GGT) for the normal aspartic acid codon (GAT). This point mutation results in a single amino acid substitution at residue 47 of the zymogen and represents the genetic defect in factor IXAlabama.

Electron donor properties of the antitumour drug amsacrine as studied by fluorescence quenching of DNA-bound ethidium

The effect of the antitumour acridine derivative amsacrine [4'-(9-acridinylamino)methanesulphon-m-anisidide] on the fluorescence lifetime of DNA-bound ethidium has been investigated using a synchronously pumped cavity dumped dye laser producing picosecond pulses for sample excitation and a time-correlated single photon counting detection system. As the proportion of DNA-bound amsacrine on the synthetic DNA polymer poly[deoxyadenylic-thymidylic acid] is increased, the fluorescence decay curve of ethidium can be accurately resolved into two exponential components. The short lifetime component, whose proportion increases with increasing proportions of DNA-bound amsacrine, has a lifetime of between 3 and 4 ns, significantly longer than that of ethidium in aqueous solution (1.63 ns). The magnitude of the long lifetime component decreases from 25.4 to 14 ns with increasing proportions of bound amsacrine. It is concluded that a new fluorescence state of ethidium (lifetime 3-4 ns) is present, probably resulting from reversible electron transfer between ethidium and amsacrine. The ability of various 9-anilinoacridine derivatives to quench the fluorescence of DNA-bound ethidium appears to be related to the electron donor properties of the substituents on the anilino ring, as well as to experimental antitumour activity. The electron donor properties of DNA-bound amsacrine may therefore be relevant to its antitumour action.

The chromosome 11 gene map: genes for growth and development, Wilms' tumor deletions, and cancer chromosome breakpoints

Human chromosome 11 is clearly a model autosome encoding genes and characteristics associated with both normal and abnormal growth and development, and several significant disorders. A fine-structure molecular, genetic, and physical map of this chromosome would add considerably to our knowledge of the organization and control of human genes and to an understanding of normal and abnormal human biology.

Application of molecular genetics to prenatal diagnosis and carrier detection in the hemophilias: some limitations

Prenatal diagnosis and carrier detection in the hemophilias have received much attention in recent years. The error rate in prenatal diagnosis by fetoscopy is less than 1%; fetoscopy is not possible, however, until the second trimester of pregnancy. Carrier detection based on bioassays of plasma has an irreducible error rate (approximately 5%?), because of the "lyonization" phenomenon in heterozygous women, and the final results are always probabilistic. New DNA methods promise to alleviate these difficulties. Prenatal diagnosis can be accomplished in the first trimester. "Lyonization" is bypassed in carrier detection, and the results may sometimes be essentially nonprobabilistic. But the DNA methods have certain limitations of their own which are not widely appreciated. Aside from cost and the necessity to adopt a new technology, there are inherent genetic problems: mothers must be heterozygous for both a disease gene and a marker gene, final results are probabilistic if the marker gene lies outside the disease gene, and multiple marker genes are often in linkage disequilibrium. We have concluded that a clinical unit planning to use the DNA methods must also maintain the conventional methods at a high level of performance.

Structure and function of factor IX: defects in haemophilia B

The genetics of haemophilia B and the structure-function relationships of factor IX interactions with cofactors and substrates have been reviewed. Emphasis has been placed on contributions to our understanding made by analysis of variants. Amino acid substitutions at or near the site of activation lead to inactive factor IX or to factor IX species with decreased clotting activity. Release of the activation peptide is necessary for optimal interaction of factor IX with its cofactors and substrates. Abnormalities in the calcium binding region, whether Gla independent or dependent, also decrease clotting activity. The defects in haemophilia Bm variants somehow affect factor VII-tissue factor interactions with factor X. Other mutations may affect the factor IX heavy chain, probably at or near the active site. Amino acid substitutions may cause conformational changes in factor IX that interfere with other interactions such as with antithrombin III and factor VIII. Recombinant DNA techniques have been employed to analyse normal and abnormal factor IX genes. DNA sequence analysis of factor IX cDNA clones revealed the primary structure of the mature protein and a predicted leader peptide. Knowledge of the primary sequence of factor IX allowed identification of the specific defect in the factor IX Chapel Hill variant. Analysis of normal factor IX genomic clones has determined that the 35 kb gene is composed of eight coding exons and seven intervening sequences. Sequence analysis of the CRM+ variants will identify mutations disrupting the normal interactions of factor IX. Southern analysis of CRM- variants has revealed gross factor IX gene deletions in some cases. Such deletions have been employed for carrier deletion in some families. Restriction fragment length polymorphisms in the factor IX gene have also proven useful for carrier identification. Manipulations of the cloned factor IX gene to make specific mutations in vitro and improvements in the technology for expression of deliberately modified genes will further elucidate the relationships between factor IX structure and function.

Evidence for a prevalent dimorphism in the activation peptide of human coagulation factor IX

We have independently isolated and characterized cDNA and genomic clones for the human coagulation factor IX. Sequence analysis in both cases indicates that threonine is encoded by the triplet ACT as the third residue of the activation peptide. This is in agreement with some earlier reports but in disagreement with others that show the alanine triplet GCT at this position. The discrepancy can thus be accounted for by natural variation of a single nucleotide in the normal population. Amino acid sequence analyses of activated factor IX from plasma samples of four individuals yielded two cases of alanine and two cases of threonine at the third position of the activation peptide. In factor IX from pooled plasma and in factor IX from a heterozygous individual, however, both alanine and threonine were found. Taken together, the findings show that a prevalent nondeleterious dimorphism exists in the activation peptide of human coagulation factor IX.

Maternal death secondary to a dissecting aneurysm of the pulmonary artery

True aneurysms of the pulmonary artery are most frequently associated with congenital heart lesions that have lead to sustained high pulmonary artery flow rates and pulmonary hypertension. A maternal death secondary to a dissecting aneurysm of the pulmonary artery is presented. Death occurred 17 hours postpartum, and the acute dissection may have been precipitated by the high flow rates accompanying parturition or, alternatively, by the Valsalva maneuver. The authors suggest a baseline chest radiograph and electrocardiogram in all women with known or suspected congenital heart disease to evaluate for pulmonary hypertension and pulmonary artery aneurysms. The occurrence of symptoms such as dyspnea or chest pain warrants repeat evaluation with strong consideration being given to right heart catheterization and pulmonary angiography. If a dissecting aneurysm is diagnosed, then emergency surgical repair seems warranted in view of the rapidity with which this condition progresses to death.

Biologic properties of factor-independent nonadherent hematopoietic and adherent preadipocyte cell lines derived from continuous bone marrow culture

Cell lines dependent for growth upon an inducer T-cell synthesized glycoprotein factor interleukin-3 have been derived from continuous mouse bone marrow cultures. These factor-dependent (FD) lines have been shown to be multipotential (erythroid/basophil/neutrophil) or (eosinophil/basophil/neutrophil); or are unipotent basophil or neutrophil granulocyte cell lines. Both classes of cloned FD lines have maintained self-renewal in vitro for several years with absolute growth dependence on freshly added IL-3. In four instances, factor-independent (FI) variant cell lines were derived, one by subculture in medium containing hydrocortisone and 25% horse serum and three by evolution of variants from cloned FD lines. One class of (FI) lines demonstrated adherent fibroblast-like morphology with differentiation to differentiated adipocytes in medium containing 10(-5) hydrocortisone. A second class of cell lines evolved from cloned FD lines and each grew in suspension culture to a saturation density over 10-fold greater than that for the parent FD line (greater than 10(7)/ml) and each contained no detectable hematopoietic cellular differentiation markers by histochemistry or cell surface receptors. In contrast to IL-3 dependent cell lines, (FI) cell lines failed to differentiate to mature granulocyte morphology in diffusion chambers in vivo. The FI cell lines formed no detectable CFUs in vivo, did not reconstitute hematopoiesis in irradiated mice and did not form tumors in vivo. The failure of the (FI) lines to form tumors and lack of detectable hematopoietic differentiation capacity indicates that these lines may represent an intermediate state between normally regulated hematopoietic cellular self-renewal and malignant transformation.

Isoenzyme composition of human plasma monoamine oxidase in normal subjects and in fibrotic liver disease

Hydroxyapatite column chromatography elution profile reveals characteristic differences between monoamine oxidase (MAO) isolated from normal human plasma and from patients with hemochromatosis having hepatic fibrosis. In normal plasma, the alpha form constitutes about 84% of the enzyme, with the remainder in the beta and gamma forms. By contrast, in hemochromatosis there is less alpha form (less than 40%), an additional alpha1 form (about 20%) which was eluted immediately after alpha form, increased beta form (more than 25%), and no significant difference in gamma form. When calculated on the basis of total amount per liter, hemochromatosis is characterized by elevation of beta form (3- to 10-fold) and the presence of alpha1. These results also appear to indicate that the multiple forms separated by hydroxyapatite column chromatography represent true multiplicity of human plasma MAO in vivo.

Etiology of nondisjunction: lack of evidence for genetic control

Evidence for genetic control of meiotic nondisjunction was not found in a religious isolate of Amish in northern Indiana. Sixteen mongols were ascertained, and each had 47 chromosomes without evidence of mosaicism. Through the use of detailed family records, pedigrees were assembled for the propositi. The 16 comparison sibships were matched for maternal age and sibship size and selected at random from the same population. Mean inbreeding coefficients for the parents, grandparents, and great-grandparents were not significantly different between the two groups.