Unilateral antegrade cerebral perfusion through the right axillary artery provides uniform flow distribution to both hemispheres of the brain: A magnetic resonance and histopathological study in pigs

BACKGROUND

Bilateral antegrade cerebral perfusion (ACP) has decreased in popularity over the past decade because of its complexity and the risk of cerebral embolism. We used magnetic resonance (MR) perfusion imaging to assess flow distribution in both hemispheres of the brain during unilateral ACP through the right carotid artery via a cannula placed in the right axillary artery in conjunction with hypothermic circulatory arrest.

METHODS AND RESULTS

Twelve pigs were randomly exposed to 120 minutes of either bilateral ACP through both carotid arteries (n=6) or unilateral ACP through the right axillary artery (n=6) at pressures of 60 to 65 mm Hg at 15 degrees C, followed by 60 minutes of cardiopulmonary bypass at 37 degrees C. MR perfusion images were acquired every 30 minutes before, during, and after ACP. The brain was perfusion fixed for histopathology. During initial normothermic cardiopulmonary bypass, MR perfusion imaging showed a uniform distribution of flow in the brain. In both the bilateral and unilateral ACP groups, the same pattern was maintained, with an increase in regional cerebral blood volume during ACP and reperfusion. The changes in regional cerebral blood volume and mean transit time were similar in both hemispheres during and after unilateral ACP. No difference was observed between the 2 groups. Histopathology showed normal morphology in all regions of the brain in both groups.

CONCLUSIONS

Both bilateral ACP and unilateral ACP provide uniform blood distribution to both hemispheres of the brain and preserve normal morphology of the neurons after prolonged hypothermic circulatory arrest.

The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients

A retrospective clinical evaluation of patients consecutively treated from multiple centers was performed. The treatment of these patients utilized the bone-added osteotome sinus floor elevation (BAOSFE) procedure with immediate implant fixation. The BAOSFE method employs a specific set of osteotome instruments to tent the sinus membrane with bone graft material placed through the osteotomy site. A total of 174 implants was placed in 101 patients. Implants were of both screw and cylinder shapes with machined, titanium plasma-sprayed, and hydroxyapatite surfaces from various manufacturers. The 9 participating clinicians used autografts, allografts, and xenografts alone or in various combinations, and the type of graft was selected by the individual clinicians. The choice of graft material did not appear to influence survival rates. Loading periods varied from 6 to 66 months. The survival rate was 96% or higher when pretreatment bone height was 5 mm or more and dropped to 85.7% when pretreatment bone height was 4 mm or less. The most important factor influencing implant survival with the BAOSFE was the preexisting bone height between the sinus floor and crest. This short-term retrospective investigation suggests that the BAOSFE can be a successful procedure with a wide variety of implant types and grafting procedures.

Does retrograde warm blood cardioplegic perfusion provide better protection of ischemic areas than antegrade warm blood cardioplegic perfusion? A magnetic resonance study in pig hearts

OBJECTIVE

The purpose of this study was to determine whether retrograde continuous normothermic blood cardioplegic perfusion provides better protection to ischemic areas of the left and right ventricles than does antegrade continuous normothermic blood cardioplegic perfusion. Localized phosphorus 31 magnetic resonance spectroscopy was used to monitor the changes in energy metabolism and intracellular pH in the ventricles of pig hearts.

METHODS

Ten isolated pig hearts received 20 minutes of antegrade continuous normothermic blood cardioplegic perfusion for collection of control (baseline) data, followed by 60 minutes of either antegrade continuous normothermic blood cardioplegic perfusion (n = 5) or retrograde continuous normothermic blood cardioplegic perfusion (n = 5) with occlusion of the left anterior descending and the right coronary arteries. The hearts were then subjected to antegrade continuous normothermic blood cardioplegic perfusion for 20 minutes. The perfusion pressures were maintained between 80 and 100 mm Hg and between 38 and 43 mm Hg during antegrade and retrograde continuous normothermic blood cardioplegic perfusions, respectively. Intracellular pH and creatine phosphate, inorganic phosphate, and adenosine triphosphate levels were measured continuously in each ventricle by means of localized phosphorus 31 magnetic resonance spectroscopy with 2 surface coils.

RESULTS

Both antegrade and retrograde continuous normothermic blood cardioplegic perfusion resulted in a significant increase in inorganic phosphate level and decreases in creatine phosphate level, adenosine triphosphate level, and intracellular pH. No significant differences in these changes were observed between the two groups. The creatine phosphate and adenosine triphosphate levels were significantly lower in the right ventricle than in the left ventricle during retrograde continuous normothermic blood cardioplegic perfusion. On reperfusion, the inorganic phosphate level, creatine phosphate level, and intracellular pH recovered completely; however, no recovery in the adenosine triphosphate level was seen in the ventricles of either group.

CONCLUSIONS

Retrograde continuous normothermic blood cardioplegic perfusion does not provide better protection to ischemic areas of the ventricles than does antegrade continuous normothermic blood cardioplegic perfusion under our experimental conditions.

Retrograde cerebral perfusion results in flow distribution abnormalities and neuronal damage. A magnetic resonance imaging and histopathological study in pigs

BACKGROUND

In the past few years, although significant efforts have been made to assess flow distribution during retrograde cerebral perfusion with microspheres, dye, or hydrogen clearance, flow distribution in real time is still undefined. We used MR perfusion imaging to monitor flow distribution in the brain during and after deep hypothermic circulatory arrest (DHCA) with antegrade or retrograde cerebral perfusion (ACP or RCP).

METHODS AND RESULTS

Thirteen pigs were divided into 2 groups and exposed to 120 minutes of either RCP (n = 7) or ACP (n = 6) at 15 degrees C, followed by 60 minutes of cardiopulmonary bypass (CPB) at 37 degrees C. During DHCA, the brain was perfused antegradely through the common carotid artery or retrogradely through the superior vena cava at pressures of 60 to 70 mm Hg and 20 to 25 mm Hg in the ACP and RCP groups, respectively. Esophageal temperature was monitored continuously. MR perfusion images were acquired every 30 minutes before, during, and after DHCA. The brain was perfusion-fixed with formaldehyde solution for histopathology at the completion of each experiment. During initial normothermic CPB, MR perfusion imaging showed a nearly uniform distribution of flow in the brain. The same pattern was maintained with a significant increase in regional cerebral blood volume during ACP and reperfusion in the ACP group. RCP provided little or no detectable blood distribution to the brain, resulting in poor reperfusion of many areas of the brain on reflow with CPB at 37 degrees C. The total area suffering poor reperfusion was significantly higher in the RCP group than the ACP group. Histopathology showed no morphological changes in any area of the brain in the ACP group, whereas varying severity of neuronal damage was observed in different regions of the brain in the RCP group.

CONCLUSIONS

ACP preserves uniform blood distribution and normal morphology of brain tissue after prolonged DHCA. RCP provides very little blood to the tissue of the brain. A 120-minute period of RCP results in abnormal flow distribution and neuronal damage during reperfusion. The damage resulting from shorter periods of RCP remains to be assessed.

Impact of unified procedures as implemented in the Canadian Quality Assurance Program for T lymphocyte subset enumeration. Participating Flow Cytometry Laboratories of the Canadian Clinical Trials Network for HIV/AIDS Therapies

The objective of the Canadian Quality Assurance Program (CQAP) is to provide the most reproducible and accurate T-cell subset enumeration for individuals living with HIV who are enrolled in the Canadian Clinical Trial Network for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) Therapies (abbreviated as CTN). The Canadian National Laboratory for Analytical Cytology, within the Laboratory Centre for Disease Control, is part of the Health Protection Branch of Health Canada. For the past eight years, the Laboratory for Analytical Cytology has been responsible for delivering a bilingual quality assurance program for CD4 T-cell enumeration. This federal program, which integrates biotechnology transfer with quality assessment, was achieved through the organization of workshops focused on technology transfer and essential skill-building techniques. Two training sessions were conducted for the CTN flow cytometer operators. The first introduced the concept of window of analysis, to demonstrate the practical benefits of unified quantitative fluorescent measurement. As a follow-up to the first workshop, participants performed a series of quantitative assays that monitored the expression of CD69, an early activation marker. This quantitative fluorescence protocol was performed with acceptable inter-laboratory variation using modified commercial kits. The second workshop focused on a absolute count method based on a single platform. Four preserved whole-blood preparations were tested with this approach. The combined effort reduced inter-laboratory variation. The direct impact was monitored as related to the frequency of participation. Over the years, the standard deviation of average accumulated variation decreased dramatically with increased frequency of participation, from 10% to <4%.

Differential roles for disulfide bonds in the structural integrity and biological activity of kappa-Bungarotoxin, a neuronal nicotinic acetylcholine receptor antagonist

kappa-Bungarotoxin, a kappa-neurotoxin derived from the venom of the banded Krait, Bungarus multicinctus, is a homodimeric protein composed of subunits of 66 amino acid residues containing five disulfide bonds. kappa-Bungarotoxin is a potent, selective, and slowly reversible antagonist of alpha3 beta2 neuronal nicotinic acetylcholine receptors. kappa-Bungarotoxin is structurally related to the alpha-neurotoxins, such as alpha-bungarotoxin derived from the same snake, which are monomeric in solution and which effectively antagonize muscle type receptors (alpha1 beta1 gamma delta) and the homopentameric neuronal type receptors (alpha7, alpha8, and alpha9). Like the kappa-neurotoxins, the long alpha-neurotoxins contain the same five conserved disulfide bonds, while the short alpha-neurotoxins only contain four of the five. Systematic removal of single disulfide bonds in kappa-bungarotoxin by site-specific mutagenesis reveals a differential role for each of the disulfide bonds. Removal of either of the two disulfides connecting elements of the carboxy terminal loop of this toxin (Cys 46-Cys 58 and Cys 59-Cys 64) interferes with the ability of the toxin to fold. In contrast, removal of each of the other three disulfides does not interfere with the general folding of the toxin and yields molecules with biological activity. In fact, when either C3-C21 or C14-C42 are removed individually, no loss in biological activity is seen. However, removing both produces a polypeptide chain which fails to fold properly. Removal of the C27-C31 disulfide only reduces the activity of the toxin 46.6-fold. This disulfide may play a role in specific interaction of the toxin with specific neuronal receptors.

Adenoma characteristics at first colonoscopy as predictors of adenoma recurrence and characteristics at follow-up. The Polyp Prevention Study Group

BACKGROUND & AIMS

All patients with colorectal adenomas may not require identical follow-up. We aimed to determine if adenoma characteristics at initial colonoscopy could predict adenoma recurrence or characteristics at follow-up.

METHODS

The number of adenomas and the size, type, and degree of atypia in 479 patients in a polyp prevention trial were evaluated as predictors of the same characteristics at follow-up using odds ratios (ORs) with 95% confidence intervals (CIs). Multiple logistic regression analysis was performed to determine if several baseline characteristics were simultaneously associated with outcome.

RESULTS

Although several characteristics were significant predictors of recurrence univariately, by multivariate analysis, multiple adenomas at follow-up were more likely when patients had > or = 3 baseline adenomas (OR, 2.25; 95% CI, 1.20-4.21) or at least 1 tubulovillous adenoma (OR, 2.12; 95% CI, 1.12-4.02). No specific characteristic was associated with recurrence of high-risk polyps (> or = 1 cm, villous, severe atypia). Seventy percent of patients with 1 or 2 baseline adenomas had no recurrence, and only 3.3% had any adenomas of clinical concern.

CONCLUSIONS

Number and type of baseline adenomas predict recurrent adenomas, but the recurrence is rarely of clinical concern. Patients with 1 or 2 tubular adenomas constitute a low-risk group for whom follow-up might be extended beyond 3 years.

The relationship between irritable bowel syndrome and psychiatric illness. A family study

Although irritable bowel syndrome (IBS) is a common disorder among gastrointestinal clinic outpatients, it continues to be a diagnosis of exclusion. In treatment-seeking populations, IBS has been frequently associated with psychiatric illness, and this co-occurrence has added to controversy about the validity of the IBS diagnosis. This study is a preliminary effort to examine the nature of this relationship by using the family study design. The probands consisted of 20 patients with IBS and 20 patients who had undergone laproscopic cholecystectomy. Their first-degree relatives were interviewed to obtain lifetime diagnoses of functional gastrointestinal and psychiatric syndromes. Significantly more IBS probands had lifetime psychiatric illness than the cholecystectomy probands. The lifetime prevalence of IBS as well as other functional gastrointestinal syndromes was not significantly different between the groups of relatives. However, significantly more relatives of the IBS probands had lifetime psychiatric illness than the relatives of the cholecystectomy probands. Among the relatives with functional gastrointestinal disorders, significantly more had psychiatric illness. This preliminary study provides support for a relationship between IBS and psychiatric illness by the finding of an increased prevalence of psychiatric disorders among the relatives of patients who have IBS.

Does retrograde warm blood cardioplegia provide equal protection to both ventricles? A magnetic resonance spectroscopy study in pigs

BACKGROUND

The degree of protection provided to the right ventricle during retrograde continuous normothermic blood cardioplegia (RCNBC) remains controversial. The purpose of this study was to determine whether RCNBC is able to provide "adequate" nutritive flow to both ventricles to prevent ischemic metabolism in normal swine hearts. Localized 31P magnetic resonance spectroscopy (MRS) was used to monitor the changes in energy metabolism and intracellular pH (pHi) in each ventricle separately.

METHODS AND RESULTS

Isolated normal swine hearts received 20 minutes of antegrade continuous normothermic blood cardioplegia (ACNBC) for collection of control (baseline) data, followed by 20 minutes of RCNBC. This protocol was repeated four times in five hearts and twice in two hearts. Perfusion pressure was maintained between 70 to 85 and 38 to 43 mm Hg during ACNBC and RCNBC, respectively. pHi, creatine phosphate (PCr), inorganic phosphate (Pi), and ATP were measured continuously in each ventricle during ACNBC and RCNBC, using localized 31P MRS with two surface coils. RCNBC resulted in a significant increase in Pi (LV 222% and RV 244% of the baseline levels, respectively) and a decrease in PCr (left ventricle [LV] to 68% and right ventricle [RV] to 31% of the baseline levels, respectively) in both ventricles relative to ACNBC. The PCr level was significantly lower in the RV than in the LV (31% versus 68%, P<.001) during RCNBC. In one series of experiments (n=5) where ACNBC and RCNBC were alternated every 20 minutes (ACNBC, RCNBC, ACNBC, RCNBC, ACNBC) for a total of 100 minutes, Pi and PCr recovered completely. A continuous and significant decrease in ATP was observed in the RV, and no recovery of ATP was found when switching from RCNBC to ACNBC. No significant decrease in ATP was observed in the LV. pHi remained unchanged in both ventricles during alternate ACNBC and RCNBC.

CONCLUSIONS

Energy metabolism in the RV is less well preserved than in the LV during RCNBC. A combination of ACNBC and RCNBC seems to provide good cardiac protection as measured by the recovery of cardiac energetics and pHi.

Feeding mechanism and functional morphology of the jaws of the lemon shark Negaprion brevirostris (Chondrichthyes, Carcharhinidae)

This study tests the hypothesis that preparatory, expansive, compressive and recovery phases of biting behavior known for aquatically feeding anamniotes are conserved among extant elasmobranch fishes. The feeding mechanism of the lemon shark Negaprionbrevirostris is examined by anatomical dissection, electromyography and high-speed video analysis. Three types of feeding events are differentiated during feeding: (1) food ingestion primarily by ram feeding; (2) food manipulation; and (3) hydraulic transport of the food by suction. All feeding events are composed of the expansive, compressive and recovery phases common to aquatically feeding teleost fishes, salamanders and turtles. A preparatory phase is occasionally observed during ingestion bites, and there is no fast opening phase characteristic of some aquatically feeding vertebrates. During the compressive phase, palatoquadrate protrusion accounts for 26% of the gape distance during jaw closure and is concurrent with muscle activity in the dorsal and ventral preorbitalis and the levator palatoquadrati. Hydraulic transport events are shorter in duration than ram ingestion bites. Prey ingestion, manipulation and hydraulic transport events are all found to have a common series of kinematic and motor components. Individual sharks are capable of varying the duration and to a lesser extent the onset of muscle activity and, consequently, can vary their biting behavior. We propose a model for the feeding mechanism in carcharhinid sharks, including upper jaw protrusion. This study represents the first electromyographic and kinematic analysis of the feeding mechanism and behavior of an elasmobranch.

A new technique of coronary artery ligation: experimental myocardial infarction in rats in vivo with reduced mortality

In vivo models of myocardial infarction following coronary artery ligation in the rat still suffer from high early mortality and a low rate of success of myocardial infarction. This study investigated the possibility of reducing early mortality and increasing the rate of myocardial infarction by modifications of surgical techniques. Eighteen rats were divided into two groups: normal control (3 rats) and ligation (15 rats). The major modifications of surgical techniques used in this study include: (1) no exteriorization of the heart, (2) ligation of the origins of the branches rather than the main trunk of the left coronary artery, (3) removal of air from the chest after closure, (4) supplying oxygen immediately after extubation. Following surgery, the rats recovered uneventfully and 11 rats were alive after 16 weeks. One rat, with a large myocardial infarction, died 2 h after surgery. Early mortality (during surgery and 1 week after surgery) was 6.7% with a success rate of myocardial infarction of 85%. The left ventricle in the ligation group showed significant dilation relative to normal and sham-operated control hearts (317% of control hearts, p < 0.001). However, myocardial mass did not increase. The average infarct size was 33%. These results demonstrate that a reduction in early mortality and an increased success rate of myocardial infarction can be achieved by modifications of surgical techniques.

Retrograde cerebral perfusion provides limited distribution of blood to the brain: a study in pigs

OBJECTIVE

The objective of this study was to investigate flow distribution during retrograde and antegrade cerebral perfusion with India ink as a marker.

METHODS

Ten pigs received cerebral perfusion with a solution containing 50% filtered India ink for 5 minutes either antegradely through both internal carotid arteries at a flow of 180 to 200 ml/min (n = 5) or retrogradely via the superior vena cava at a flow of 300 to 500 ml/min (n = 5). The brains were then fixed for quantitative measurement of the density of ink-filled capillaries (reported as a percentage of the total selected area). The assessment was done with the use of an in-house software program.

RESULTS

In the antegrade cerebral perfusion group, the intracranial arterial and venous systems were completely filled with ink. The gray matter was colored uniformly black, and light coloring was observed in the white matter. During retrograde cerebral perfusion, the majority of ink was returned to the inferior vena cava, and only a small amount of ink was found in the innominate artery draining from the brain. Massive ink filling was observed in the sagittal sinus and other venous sinuses in all the pigs. Vessels on the surface of the brain and large vessels in the brain were also well filled with ink. However, only 10% of capillaries were filled with ink during retrograde cerebral perfusion relative to the number observed with antegrade cerebral perfusion.

CONCLUSIONS

Retrograde cerebral perfusion supplies a limited amount of blood to brain tissue, which flows mainly through superficial and large deep cerebral vessels.

Nucleotide sequence of the ermE distal flank of the erythromycin biosynthesis cluster in Saccharopolyspora erythraea

A 7023 nucleotide BamHI fragment immediately upstream of the eryK gene of the erythromycin (Er) biosynthesis cluster in Saccharopolyspora erythraea was sequenced. Computer-assisted analysis of this sequence reveals the existence of seven ORFs that display the codon preferences typical of actinomycete genes. Six of these show homology to known genes: an esterase, a transposase, a peptidyl-prolyl cis-trans isomerase, a subtilisin inhibitor-like protein, and two genes involved in bacterial cell wall biosynthesis. All the ORFs are transcribed toward the Er biosynthetic gene cluster (in the same direction as eryK). From the predicted functions of the putative ORF products none of these genes appear to be involved in the biosynthesis of Er. The eryK gene thus most likely defines one end of the Er biosynthetic gene cluster.

Symptomatic pleural collection of cerebrospinal fluid caused by a ventriculopleural shunt

We report a case of symptomatic pleural collection of cerebrospinal fluid caused by a ventriculopleural shunt in a 4-year-old child. Since ventriculopleural shunts are not commonly used in the management of hydrocephalus, primary physicians must be aware of this potential complication.

Beyond hyperkalemia: beta-blocker-induced cardiac arrest for normothermic cardiac operations

BACKGROUND

Four experimental protocols were carried out to assess the ability of esmolol to induce and maintain reversible cardiac arrest under continuous normothermic (37 degrees C) perfusion.

METHODS AND RESULTS

In the first protocol, 8 perfused rat hearts were subjected to 20, 60, 90, and 120 minutes of esmolol arrest, after which positive and negative first derivative of pressure, heart rate, left ventricular developed pressure, and left ventricular end-diastolic pressure were evaluated. Arrest was achieved 45 to 60 seconds after beginning the infusion of esmolol. Mechanical arrest was achieved before electrical arrest. In the second protocol, dose-response curves were obtained using isolated (Langendorff) rat and rabbit (n = 6) hearts. The concentrations of esmolol varied from 0.084 to 6.7 mmol/L and from 0.12 to 1.45 mmol/L in the rat and rabbit heart experiments, respectively. In the third protocol, the effects of 20 minutes of normothermic (37 degrees C) ischemia on the function of isolated rat hearts perfused with esmolol-containing Krebs solution were compared with those using high-potassium (25 mmol/L) Krebs solution. Group A subjects (n = 9) received the ischemic injury after being perfused (and arrested) for 20 minutes with either esmolol or potassium (KCl, 25 mmol/L). Group B subjects (n = 10) received the same ischemic insult before being perfused with either esmolol or potassium. Esmolol-treated hearts showed better recovery than those receiving potassium, in terms of +/- dP/dt (p < 0.01), left ventricular systolic pressure (p < 0.01), and left ventricular developed pressure (p < 0.009). Finally, the fourth protocol was done to evaluate the effects of esmolol in a clinically relevant experimental model. Pigs were divided into esmolol (n = 6) and potassium (n = 5) groups and subjected to normothermic cardiopulmonary bypass and a 1-hour period of cardiac arrest. Twenty minutes after stopping infusion of the cardioplegic agents, all animals were weaned off bypass. There were no statistically significant differences between the groups.

CONCLUSIONS

Esmolol hydrochloride can be used as effectively as potassium for inducing and maintaining predictable and reversible cardiac arrest during normothermic cardiac operations.

The effect of circulatory arrest and retrograde cerebral perfusion on microtubule-associated protein 2: an immunohistochemical study in pig hippocampus

Microtubule-associated protein 2 (MAP2) immunohistochemical labeling in the hippocampus was studied to assess the protective effect of brain perfusion during surgery requiring hypothermic circulatory arrest in 24 pigs exposed to anesthesia alone (control), 120 min of complete circulatory arrest at 15 degrees C, min of retrograde cerebral perfusion at 15 degrees C, or 120 min of anterograde cerebral perfusion at 15 degrees C. Pigs were reperfused for 60 min and sacrificed. In the control anterograde perfusion groups, the intensity of MAP2 labeling was similar in all regions of the hippocampus. Circulatory arrest and retrograde perfusion resulted in significant reduction of MAP2 labeling (28% and 38% respectively of control, P < 0.001) of neurons in the CA1 region. MAP2 labeling may be useful for assessing early damage in the hippocampus in this model.

Cerebral protection during moderate hypothermic circulatory arrest: histopathology and magnetic resonance spectroscopy of brain energetics and intracellular pH in pigs

OBJECTIVE

We evaluated the effect of antegrade and retrograde brain perfusion during moderate hypothermic circulatory arrest at 28 degrees C.

METHODS

Phosphorus 31-magnetic resonance spectroscopy was used to follow brain energy metabolites and intracellular pH in pigs during 2 hours of ischemia and 1 hour of reperfusion. Histopathologic analysis of brain tissue fixed at the end of the experimental protocol was performed. Fourteen pigs were divided into two experimental groups subjected to antegrade (n = 6) or retrograde (n = 8) brain perfusion. Anesthesia (n = 8) and hypothermic cardiopulmonary bypass groups (15 degrees C, n = 8) served as control subjects. In the antegrade and retrograde brain perfusion groups, the initial bypass flow rate was 60 to 100 ml x kg(-1) x min(-1). In the antegrade group, the brain was perfused through the carotid arteries at a flow rate of 180 to 210 ml x min(-1) during circulatory arrest at 28 degrees C. In the retrograde group, the brain was perfused through the superior vena cava at a flow rate of 300 to 500 ml x min(-1) during circulatory arrest at 28 degrees C.

RESULTS

The intracellular pH was 7.1 +/- 0.1 and 7.2 +/- 0.1 in the anesthesia and hypothermic bypass groups, respectively. Brain intracellular pH and high-energy metabolites (adenosine triphosphate, phosphocreatine) did not change during the course of the 3.5-hour study. In the antegrade group, adenosine triphosphate and intracellular pH were unchanged throughout the protocol. In the retrograde perfusion group, the intracellular pH level decreased to 6.4 +/- 0.1, and adenosine triphosphate and phosphocreatine levels decreased within the first 30 minutes of circulatory arrest and remained at low levels until the end of reperfusion. High-energy phosphates did not return to their initial levels during reperfusion. Histopathologic analysis of nine regions of the brain showed good preservation of cell structure in the anesthesia, hypothermic bypass, and antegrade perfusion groups. The retrograde perfusion group showed changes in all the regions examined.

CONCLUSIONS

The study shows that moderate hypothermic circulatory arrest at 28 degrees C with antegrade brain perfusion during circulatory arrest protects the brain but that retrograde cerebral perfusion at 28 degrees C does not protect the brain.

Acid-base chemistry of the blood--a general model

This paper describes a general model of acid-base chemistry of the blood which can be used to simulate physiological perturbation of acid-base chemistry on addition or removal of any buffer acid or base. In particular, it is shown how this model can be used to estimate the concentrations of buffer acid or base. In particular, it is shown how this model can be used to estimate the concentrations of buffer acids and bases when blood is equilibrated to a new pCO2, when hydrogen ions H+ are added to the blood, or when two pools of blood with different concentrations of buffer acids and bases are mixed. The ability of the model to represent the addition or removal of any acid or base is a significant increase in functionality above the Siggaard-Andersen nomogram which is limited to simulating the effects of equilibrating the blood to a new pCO2. When used to represent the situation where blood is equilibrated at a new pCO2 the model enables calculation of the amount CO2 removed during equilibration, a further increase in functionality above the Siggaard-Andersen nomogram. In two experimental situations, equilibrating blood to a new pCO2 and addition of H+ ions, the model predictions are shown to be consistent with existing experimental data in the form of the Siggaard-Andersen nomogram.

Neuronal damage after hypothermic circulatory arrest and retrograde cerebral perfusion in the pig

BACKGROUND

Antegrade and retrograde cerebral perfusion during hypothermic circulatory arrest (HCA) has been reported to provide better brain protection during operation than hypothermic circulatory arrest alone. However, the efficacy of these techniques remains to be fully determined, especially when used for prolonged periods. We used a pig model to evaluate the histopathologic consequences of HCA and the potential benefit of cerebral perfusion during HCA.

METHODS

Twenty-two pigs were divided into four groups and exposed to either anesthesia alone, 120 minutes of HCA (15 degrees C), 120 minutes of retrograde cerebral perfusion at 15 degrees C during HCA, or 120 minutes of antegrade cerebral perfusion at 15 degrees C during HCA, and then reperfused for 60 minutes under cardiopulmonary bypass at 37 degrees C. The brains were perfusion fixed at the end of the experiments and examined by light microscopy.

RESULTS

There were no morphologic changes in any areas of the brains in the anesthesia group, and very minor changes in some areas of the brains in the antegrade cerebral perfusion. group. Varying severity of neuronal damage was found in the brains of all the pigs in the HCA and retrograde cerebral perfusion groups. The severity of ischemic damage in the brain showed the following descending order: hippocampus (CA4), caudate nucleus, cerebral cortex, putamen, thalamus, Purkinje cells of the cerebellum, pons, and mesencephalic gray matter. In the hippocampus the order of damage was CA4, CA3, polymorphous layer of the dentate gyrus, prosubiculum, CA2, CA1, and granule cell layer of the dentate gyrus. The damage in the retrograde cerebral perfusion group was less severe relative to the HCA group in many areas (no significance except mesencephalic gray matter).

CONCLUSIONS

These results demonstrate that the pattern of neuronal damage in pigs subjected to HCA and retrograde cerebral perfusion differs from the traditional pattern in that the caudate nucleus and hippocampal CA4 region are the most vulnerable to ischemia-hypoxia. Our results also suggest that antegrade cerebral perfusion prevented ischemic damage to the brain and retrograde cerebral perfusion provided some protection but moderately severe damage occurred.

Morphing radiologic images: applications on a desktop computer

OBJECTIVE

Morphing is an image processing technology that transforms one image into another by generating a series of intermediate synthetic images. The ability to perform morphing, once restricted to high-end graphics workstations, is now widely available for desktop computers. We investigated the potential use of morphing for displaying radiographic images.

MATERIALS AND METHODS

Morphing was performed with commercially available software (Morph 2.5; Gryphon Software, San Diego, CA) on a Macintosh (Apple Computer, Cupertino, CA) computer. Images from 26 patients with serial radiologic studies were selected, digitized, and morphed. Key points and key surfaces were identified on the images to improve the quality of the morph movie, a process that took approximately 15 min. The images were then morphed into a continuous Quick Time (Apple) movie lasting 5-7 sec. When a sequence contained more than two images, a single movie incorporating all the images was created. The intervals between segments of the movie were made proportional to the actual time elapsed between the images. Images obtained with different techniques (positron emission tomography and MR imaging) were also morphed. Three observers judged the quality of the morph movies as satisfactory, good, or excellent.

RESULTS

Twenty of the 26 movies were judged to be of good or excellent quality. The movie format allowed the rapid display of multiple images in a concise 5- 7-sec time frame. Moreover, the movie allowed the recognition of several simultaneous processes more easily than was possible with static images. Morphing two images of the same anatomic site using different techniques (MR imaging and positron emission tomography) proved to be a simple method of superimposing images.

CONCLUSION

Morphing is a readily available and easily learned technique for displaying serial studies. The movie format is a more interesting, intuitive, and concise summary of events than can be provided by serial static images. Morphing may be useful for displaying large numbers of serial images in a short time for occasions such as clinical conferences or teaching purposes.

Calcium supplementation and rectal mucosal proliferation: a randomized controlled trial

BACKGROUND

Data from studies using rodents suggest that dietary calcium inhibits bile acid-induced mucosal damage and experimental carcinogenesis in the large bowel. However, in humans, the effect of dietary calcium and calcium supplementation on proliferation and carcinogenesis in the large bowel has been unclear.

PURPOSE

To assess the effect of calcium supplementation on rectal mucosal proliferation in humans, we conducted a multicenter, randomized, placebo-controlled, double-blinded trial.

METHODS

Participants were part of a larger multicenter chemoprevention trial; all were at high risk for large-bowel neoplasia, with at least one large-bowel adenoma removed endoscopically within the 3 months before study entry but with no known polyps remaining. Subjects were randomly assigned to receive daily either 3000 mg of calcium carbonate (providing 1200 mg elemental calcium) or an identical-appearing placebo tablet. During a scheduled endoscopy 6-9 months after random assignment (approximately 1 year after the qualifying endoscopy), rectal mucosal samples were obtained from 333 patients (173 assigned to calcium and 160 assigned to placebo). Proliferating cell nuclear antigen (PCNA) labeling indices (LIs) were computed as the measure of proliferation in specimens from 146 patients receiving calcium and 129 patients receiving placebo. Bromodeoxyuridine (BrdU) labeling was used to measure proliferation in a smaller number of specimens (27 calcium-receiving and 31 placebo-receiving participants). For each scorable crypt having at least one labeled cell (or surrounded by crypts with at least one labeled cell), a crypt LI was calculated as the number of labeled cells divided by the total number of crypt cells. Crypt LIs were averaged to produce a participant's average LI.

RESULTS

The overall unadjusted mean PCNA LIs (+/- SE) were similar in the calcium and placebo groups (3.85% +/- 0.08% versus 3.92% +/- 0.08%, respectively, P = .30). The overall unadjusted mean BrdU LIs (+/- SE) were 3.88% +/- 0.30% in the calcium group and 3.54% +/- 0.21% in the placebo group (P = .54). PCNA labeling indices in the most luminal 40% of the crypt were small but, if anything, were higher in the calcium group. There was no patient subgroup within which calcium had an antiproliferative effect; the overall findings persisted among patients with high and low calcium intake, high and low fat intake, and high and low fiber intake.

CONCLUSIONS

Calcium supplementation does not decrease rectal mucosal proliferation, as measured by PCNA (and BrdU) immunohistochemistry, in patients with previous large-bowel adenomas. This study, therefore, does not provide evidence for an anticarcinogenic effect of calcium.

A 31p-magnetic resonance study of antegrade and retrograde cerebral perfusion during aortic arch surgery in pigs

To evaluate the effect of hypothermic circulatory arrest on brain metabolism, we used 31P-magnetic resonance spectroscopy to monitor brain metabolites in pigs during 2 hours of ischemia and 1 hour of reperfusion. Twenty-eight pigs were divided into five groups. Anesthesia (n = 5) and hypothermic cardiopulmonary bypass groups (n = 5) served as controls. In the circulatory arrest (n = 6), antegrade perfusion (n = 6), and retrograde (n = 6) brain perfusion groups, the bypass flow rate was 60 to 100 ml.kg-1.min-1. In the antegrade group, the brain was perfused via the carotid arteries at a blood flow rate of 180 to 200 ml.min-1 during circulatory arrest at 15 degrees C. In the retrograde group, the brain was perfused through the superior vena cava at a flow rate of 300 to 500 ml.min-1 during circulatory arrest at 15 degrees C. The intracellular pH was 7.1 +/- 0.1 and 7.3 +/- 0.1 in the anesthesia and hypothermic cardiopulmonary bypass groups, respectively. In the circulatory arrest group, the intracellular pH decreased to 6.2 +/- 0.1 and did not recover to its initial value (7.0 +/- 0.1) during reperfusion (p < 0.05 compared with the value obtained from the control groups at the corresponding time). Inorganic phosphate did not return to its initial level during reperfusion. In three animals in this group, levels of high-energy phosphates, adenosine triphosphate and phosphocreatine, recovered partially but did not reach the levels observed before arrest. In the group receiving antegrade perfusion, cerebral metabolites and intracellular pH were unchanged throughout the protocol. During circulatory arrest in the retrograde perfusion group the intracellular pH decreased to 6.4 +/- 0.1 and recovered fully during reperfusion (7.1 +/- 0.1). High-energy phosphates also returned to their initial levels during reperfusion. These studies show that deep hypothermic circulatory arrest with antegrade brain perfusion provides the best brain protection of the options investigated.

Epidemiological use of rectal proliferation measures

Measures of rectal mucosal proliferation have been developed and used in research clinical settings, but their utility for larger-scale epidemiological studies remains uncertain. We assessed the suitability of bromodeoxyuridine (BrdUrd) and proliferating cell nuclear antigen (PCNA)-labeling indices (LIs) in the setting of a multicenter clinical trial of adenoma recurrence. Subjects at participating practices were asked to permit biopsy of normal rectal mucosa during a colonoscopy scheduled for other reasons. PCNA and BrdUrd labeling was performed, and corresponding LIs were computed. In general, subjects were willing to undergo biopsy during their scheduled procedures; less than 10% refused. Specimen preparation for PCNA was acceptable; the mean number of scorable crypts (+/- SE) was 12.99 +/- 0.37. Preparation for BrdUrd labeling was less successful, with a higher proportion of unscorable specimens and a lower mean number of scorable crypts. Among the 54 specimens with both LIs computed, the LI for PCNA was modestly higher than that for BrdUrd LI (4.1 +/- 0.2 and 3.7 +/- 0.2 respectively; P = 0.03). The rank order correlation between the two indices was 0.38). There was variation across centers in the PCNA LIs but few differences according to number of crypts scored. Measurement of rectal mucosal proliferation is feasible among endoscopy patients in large studies if PCNA is used; BrdUrd seems more difficult. The relationship between these two labels requires further study.

Serum creatinine levels during cardiac surgery: absence of effect by aminoglycosides

The literature indicates that the relative nephrotoxicities of the three drugs used in this investigation are gentamicin > tobramycin > or = netilmicin. Serum creatinine levels over time were used in an attempt to elucidate the situation. They varied widely in all three groups and in controls in theatre. No definite trend was shown. Measurements performed for the ICU period showed continued variation. Fluctuations were so great during the perioperative period that the levels were analysed in terms of 44 mumol/litre difference between admission and discharge, ignoring changes between these times. It is now clear that the operative procedure itself is associated with fluctuating serum creatinine levels. The use of these aminoglycosides does not measureably affect the situation adversely over the short period of treatment. The use of nomograms, based on creatinine levels, to set aminoglycoside doses during the perioperative period may therefore be misleading, because of the wide fluctuations shown.

Double blind, placebo controlled trial of metronidazole in Crohn's disease

A double blind study compared the efficacy of metronidazole in two doses (20 mg/kg, 10 mg/kg) with placebo in patients with Crohn's disease. One hundred and five patients participated but only 56 completed the 16 week study -21 were withdrawn for deterioration of symptoms, 17 for adverse experiences, and 11 for protocol violation. Significant improvement in disease activity as measured by the Crohn's disease activity index (metronidazole 20 mg/kg, 97 units; metronidazole 10 mg/kg, 67 units; placebo -1 unit, p = 0.002) and serum orosomucoid (metronidazole 20 mg/kg/day, 49; 10 mg/kg/day, 38; placebo, -9, p = 0.001)) were detected. Changes in C reactive protein concentrations did not achieve significance when all three groups were considered but were significant when all metronidazole treated patients were grouped and compared with the placebo treated patients (0.8 v -0.9, p less than 0.05). Although patients receiving metronidazole 20 mg/kg/day had a greater improvement in disease activity than those receiving 10 mg/kg/day (difference 30 units (95% confidence intervals -27-87), the small sample size may have precluded the detection of statistical significance. Preliminary analysis suggests that metronidazole was more effective in patients with disease confined to the large intestine or affecting both small and large bowel than in those with small bowel disease only. There were no differences in remission rates between metronidazole and placebo treated patients. We conclude that metronidazole warrants further assessment in the treatment of patients with active Crohn's disease.

Reduction of gastrointestinal symptoms following treatment for panic disorder

Symptoms of gastrointestinal distress, including those of irritable bowel syndrome, were reported more frequently by patients with panic disorder than by nonanxious controls. Five of 30 subjects with panic disorder met criteria for irritable bowel syndrome, the onset of which coincided with the onset of panic disorder. Effective treatment for the anxiety disorder was accompanied by a reduction in gastrointestinal symptoms in all subjects.

Persistent beta-adrenoceptor blockade with alkylating pindolol (BIM) in guinea-pig left atria and trachea

The actions of alkylating pindolol (N8-bromoacetyl-N1-3'-(4-indolyloxy)-2'-hydroxypropyl[z]-1,8- diamino-p-menthane; BIM) have been examined on beta-adrenoceptors in guinea-pig left atria and trachea. In organ bath experiments, addition of BIM (greater than or equal to 0.1 microM), followed by washout, produced concentration-dependent rightward shifts of the dose-response curve to cumulative additions of (-)-isoprenaline and oxymethylene-isoprenaline and reductions in the maximal response. The "apparent" pA2 value for BIM was 9.23 +/- 0.20 (slope = 0.98 +/- 0.20). Changes in the maximal density of beta-adrenoceptor binding sites were determined in guinea-pig left atrial membranes using [125I]-cyanopindolol. BIM (0.1, 1.0 and 10 microM) produced 14, 23 and 41% reductions in Bmax with no change in KD. The binding of [125I]-BIM to guinea-pig left atrial membranes had a high non-specific binding component and a pseudo-Hill coefficient less than unity. The "apparent" KD value of [125I]-BIM at beta-adrenoceptor binding sites was 85.7 +/- 57.9 pM.

Clinical relevance of the substitution of different brands of sustained-release theophylline

In order to assess whether clinically important changes in serum theophylline concentrations occur when patients switch their brand of slow-release (SR) theophylline, 10 subjects with asthma were administered the same dose of four different SR theophylline formulations for 2-week periods in a random, double-blinded, crossover manner. Analysis of the data revealed significant differences in mean peak-to-trough fluctuations of serum theophylline concentrations between the formulations of SR theophylline, which varied from 60% to 106% of trough concentration (p less than 0.0001, analysis of variance). On at least one occasion in every subject, switching between brands of SR theophylline was responsible for raising the serum theophylline concentrations outside the accepted therapeutic range, and this was associated with symptoms of toxicity in five of the subjects. Worsening pulmonary functions were observed in two of the subjects whose switching resulted in lowered theophylline concentrations. Many of the formulation-related changes in theophylline concentrations appeared to be idiosyncratic and could not be predicted by the overall bioavailability differences between the drugs. These results argue against the open substitution of these formulations and suggest that if patients are switched between different brands of SR theophylline, their serum theophylline concentrations need to be closely monitored.

Water content and NMR relaxation time gradients in the rabbit kidney

Magnetic resonance images were made of rabbits at 1.4 tesla for the purpose of measuring the T1 relaxation times of the kidney in vivo with the animal in different states of hydration. In the normally hydrated animal, the outer cortex has a T1 of about 600 msec and there was a steep T1 gradient with an increase to about 1200 msec at the tip of the inner medulla. The relaxation time gradient was not affected by overhydration with intravenous fluid, but dehydration by withholding water for 24 hours decreased the values in the inner medulla. The T1 and T2 relaxation times and total water content were measured in vitro on tissue samples. The values for both T1 and T2 correlated with the regional renal water content.

Normal values for trabecular and cortical bone in the radius measured by computed tomography

Quantities related to the amount of trabecular bone in the distal radius and cortical bone in the radius mid-shaft have been measured in 262 normal adults of both sexes aged 21-89 years by computed tomography (CT). A special-purpose CT system (ISOTOM) which incorporated a source of 125I (29 keV) was used to make the measurements. The relationships between these quantities and age, weight, height and surface area have been evaluated, and the results have been used to draw conclusions on the significance of values measured in female patients with osteoporosis, Colles' fracture of the wrist and generalised osteoarthritis.

Effects of methyldopa metabolites on amine transmitters and adrenergic receptors in rat brain

Studies of catecholamine concentrations in defined nuclei from the anterior hypothalamic-preoptic regions and the medulla oblongata, known to contribute to cardiovascular control, were measured following acute or chronic methyldopa administration. These studies indicated that methyldopa was enzymatically converted to methyldopamine and methylnorepinephrine, and in some areas to methylepinephrine which replaced endogenous epinephrine. The predominant metabolite was methylnorepinephrine, which accumulated in concentrations higher than endogenous norepinephrine levels. (-)Methylnorepinephrine was found to be 6 times more potent and 75 times more selective for alpha 2-adrenergic receptors than (-) norepinephrine, and it is suggested that this alpha 2-adrenergic receptor action, particularly in the nucleus tractus solitarius, contributes to a major part of the antihypertensive effect of methyldopa.

The involvement of central alpha adrenoceptors in the antihypertensive actions of methyldopa and clonidine in the rat

The antihypertensive effects of methyldopa and clonidine result from agonist activity at alpha adrenoceptor sites within the brain. Methyldopa is converted enzymatically to alpha-methylnoradrenaline in noradrenergic neurones in rat brain and replaces the natural transmitter, noradrenaline. Radioligand receptor studies show that alpha-methylnoradrenaline differs from noradrenaline in being much more selective (70 times) for the alpha 2 subclass of adrenoceptors than noradrenaline and it is likely that the antihypertensive action of methyldopa results from selective activation of alpha 2 adrenoceptors by alpha-methylnoradrenaline in the nucleus tractus solitarius and the anterior hypothalamus. Radioligand studies also show that clonidine is a selective alpha 2 adrenoceptor agonist although it probably interacts with alpha 1 adrenoceptors at higher concentrations. With regard to a withdrawal syndrome after cessation of clonidine treatment, the cardiovascular and behavioural components can now be characterised in a rat model. The components include increases in basal blood pressure and heart rate, as well as increases in cardiovascular reactivity and also increases in rapid eye movement (REM) sleep, body shakes and tremor which is reminiscent of an opiate withdrawal syndrome. Increased central noradrenergic activity is involved in this syndrome and alpha 1 and alpha 2 adrenoceptors mediate opposing effects on the REM sleep rebound component.

Thiomolybdates in rumen contents and rumen cultures

Examination of direct and (Cu)-difference spectra of i) the aqueous supernatants of in vitro cultures of bovine rumen contents incubated with MoO42- and potential sources of S2- and ii) samples drawn directly from the rumen of animals receiving high Mo diets yielded evidence of the presence of thiomolybdates. Only MoS42- was detected in the soluble phase of in vitro cultures. Although intense and variable background absorbance precluded full characterization of thiomolybdate species in samples drawn directly from the rumen, both spectral data and the biochemical and clinical responses of animals given high Mo diets were consistent with the conclusion that MoS42- rather than MoOS32- was the predominant thiomolybdate species present in the aqueous phase. Addition of Ca2+ either to rumen cultures before incubation or as a supplement to diets high in MoO42- content inhibited the appearance of MoS42- in the aqueous phase. Evidence of the sequestration of MoS42- and MoOS32- by particulate or microbial fractions of rumen contents is considered in relation to the inhibitory action of Mo upon Cu absorption by ruminants.