Acute arterial occlusions of the small vessels of the hand and forearm: treatment with regional urokinase therapy

PURPOSE

Arterial occlusions of the small vessels of the forearm and hand may have the same consequences as arterial occlusions in the distal lower extremity. There is limited reported experience with the regional thrombolytic therapy in this setting. The authors reviewed their experience with thrombolytic therapy in acute and subacute arterial occlusions of the distal upper extremity to further clarify its role.

MATERIALS AND METHODS

Twelve patients with acute or subacute arterial occlusions of the forearm and hand who had ischemic digits and were treated with regional urokinase infusion were identified retrospectively. Their medical and radiology records were reviewed.

RESULTS

All 12 patients demonstrated angiographic improvement and 11 patients demonstrated clinical improvement after treatment. Tissue necrosis in four patients led to partial amputation of one digit in two patients and three digits in two patients. Three of these patients had category III ischemia at presentation. The level of resulting amputation was altered in all but one patient. Vasospasm was noted frequently but responded to vasodilators. No significant complications occurred.

CONCLUSIONS

When therapeutic alternatives are limited to anticoagulation and expectant amputation, regional urokinase infusion can optimize distal runoff, obviate or improve the options for distal surgical bypass, and limit tissue loss.

Modulation of cyclophosphamide activity by O6-alkylguanine-DNA alkyltransferase

PURPOSE

The human medulloblastoma cell line D283 Med (4-HCR), a line resistant to 4-hydroperoxycyclophosphamide (4-HC), displays enhanced repair of DNA interstrand crosslinks induced by phosphoramide mustard. D283 Med (4-HCR) cells are cross-resistant to 1,3-bis(2-chloroethyl)- -nitrosourea, but partial sensitivity is restored after elevated levels of O6-alkylguanine-DNA alkyltransferase (AGT) are depleted by O6-benzylguanine (O6-BG). Studies were conducted to define the activity of 4-HC and 4-hydroperoxydidechlorocyclophosphamide against D283 Med (4-HCR) after AGT is depleted by O6-BG.

METHODS

Limiting dilution and xenograft studies were conducted to define the activity of 4-HC and 4-hydroperoxydidechlorocyclophosphamide with or without O6-BG.

RESULTS

The activity of 4-HC and 4-hydroperoxydidechlorocyclophosphamide against D283 Med (4-HCR) was increased after AGT depletion by O6-BG preincubation. Similar studies with Chinese hamster ovary cells, with or without stable transfection with a plasmid expressing the human AGT protein, revealed that the AGT-expressing cells were significantly less sensitive to 4-HC and 4-hydroperoxydidechlorocyclophosphamide. Reaction of DNA with 4-HC, phosphoramide mustard, or acrolein revealed that only 4-HC and acrolein caused a decrease in AGT levels.

CONCLUSIONS

We propose that a small but potentially significant part of the cellular toxicity of cyclophosphamide in these cells is due to acrolein, and that this toxicity is abrogated by removal of the acrolein adduct from DNA by AGT.

Multiple DNA repair mechanisms and alkylator resistance in the human medulloblastoma cell line D-283 Med (4-HCR)

PURPOSE

We have previously reported preferential repair of DNA interstrand crosslinks in the 4-hydroperoxycyclophosphamide-resistant human medulloblastoma cell line D-283 Med (4-HCR). We now report further studies that explored the potential mechanisms underlying this repair.

METHODS

Limiting dilution assays and Western, Southern, and Northern blots were used to compare specific differences between D-283 Med (4-HCR) and its parental line D-283 Med.

RESULTS

D-283 Med (4-HCR) was cross-resistant to melphalan and 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU), with O6-alkylguanine-DNA alkyltransferase (AGT) levels of 466+/-164 fmol/mg protein; AGT levels in the parental line, D-283 Med, were 76+/-96 fmol/mg. The increase in AGT activity was not a result of gene amplification. Depleting AGT with O6-benzylguanine partially restored sensitivity to BCNU. Both cell lines were deficient in the human mismatch protein MutLalpha. ERCC4 mRNA and poly(ADP-ribose) polymerase levels were similar in both cell lines, and ERCC1 mRNA levels were 2- to 2.5-fold lower in D-283 Med (4-HCR). Topoisomerase I levels were 2- to 2.5-fold higher in D-283 Med compared with D-283 Med (4-HCR).

CONCLUSION

These results, while illustrating the multiple differences between D-283 Med and D-283 Med (4-HCR), do not explain the enhanced DNA interstrand crosslink repair seen in D-283 Med (4-HCR).

Causes of erroneous white blood cell counts and differentials in clinically healthy young northern elephant seals (Mirounga angustirostris)

From 1993 to 1995, approximately 10% of the clinically healthy northern elephant seals (Mirounga angustirostris) at The Marine Mammal Center in California exhibited a large unexplained increase in their white blood cell (WBC) count. In these animals, WBC counts ranged from 28,780 to 125,000/mm3, with a mean of 50,087/mm3. Significant correlations between the leukocytosis and weight gain and day of admittance were identified, but no correlation existed between leukocytosis and general state of health, sex, length of stay, or diet. Bone marrow contamination of blood samples, erroneous automated leukocyte counts, and leukogram changes consistent with subclinical inflammation were the major factors contributing to the elevated WBC counts in these apparently clinically healthy animals.

Young infants' perception of illusory contours in dynamic displays

Ninety-six 4-month-old infants were habituated to one of three computer-generated displays depicting two rod parts above and below an occluding box. In the first display, the surfaces and boundaries of the rod and box were specified by dense surface texture. Their depth segregation was specified by accretion and deletion of background texture and motion shear. In the second display, the unity of the rod parts and box, and their depth segregation, were specified only by illusory contours. In the third display, the boundaries of the rod and box were specified by illusory contours, perceptible only via spatiotemporal integration of accretion and deletion of sparse-background-texture elements. Infants appeared to perceive object unity, and segregate the rod and box surfaces, in all three displays, indicating use of illusory contours to perceive bounded surfaces in depth. The results suggest a cognitive contribution to perception of some illusory contours, abilities which seem to be present by at least 4 months of age.

Effect of anatomic distribution of pulmonary emboli on interobserver agreement in the interpretation of pulmonary angiography

OBJECTIVE

This study examines the anatomic distribution of emboli on pulmonary angiography and attempts to determine the relationship of vessel size to interobserver agreement, two factors having important implications in comparing pulmonary angiography with cross-sectional imaging for pulmonary embolism.

MATERIALS AND METHODS

One hundred twenty-five consecutive pulmonary angiograms were reviewed retrospectively by three interventional radiologists. Initial interpretations were recorded and compared to determine interobserver agreement on a per-patient and per-embolus basis. Discordant interpretations were reviewed by all radiologists for a consensus interpretation.

RESULTS

Unanimous per-patient agreement occurred in 91% (114/125) of initial interpretations. The largest artery containing acute pulmonary embolism was segmental or larger in 24 patients (83% of patients with acute positive findings, 19% of all patients) and subsegmental in only five patients (17% and 4%, respectively). On a per-patient basis, initial interobserver agreement averaged 45% and unanimous consensus agreement was achieved for 79% of patients having isolated subsegmental pulmonary embolism. Consensus readings altered initial per-patient interpretations for 30% of patients having only subsegmental pulmonary embolism; per-embolus interpretations were altered for 37% of all subsegmental emboli.

CONCLUSION

Subsegmental emboli occurring as isolated findings are relatively rare. Approximately one third of subsegmental emboli and one third of patients having isolated subsegmental emboli may be initially misdiagnosed on pulmonary angiography. Objections to cross-sectional imaging for pulmonary embolism based on the inability to detect subsegmental pulmonary embolism when compared with pulmonary angiography should be reexamined with this data in mind.

Antimicrobial susceptibility of bacteria isolated from pinnipeds stranded in central and northern California

Over a 2-yr period (1994-1995), the antimicrobial susceptibilities of 129 bacterial isolates recovered from live stranded California sea lions (Zalophus californianus), harbor seals (Phoca vitulina), and northern elephant seals (Mirounga angustirostris) were studied. Nineteen genera of bacteria were isolated from various sites of inflammation; abscesses and umbilici were the most common sites. Seventy-two percent of the bacterial isolated were gram negative, and the Enterobacteriaceae (Escherichia coli, Proteus spp., Klebsiella spp., Salmonella spp.) accounted for 75% of the gram-negative isolates. All of the gram-positive isolates were either Enterococcus spp. or Staphylococcus aureus. Multiple drug resistance was present in all but one of the bacterial isolates. The gram-positive bacteria were most susceptible to amoxicillin-clavulanic acid (77% of 36 isolates) and least susceptible to lincomycin (18% of 11 isolates). The gram-negative bacteria were most susceptible to amikacin (91% of 91 isolates) and least susceptible to clindamycin (3% of 109 isolates).

Single institution prospective evaluation of the over-the-wire Greenfield vena caval filter

PURPOSE

To assess the technical and clinical success of the over-the-wire (OTW) Greenfield inferior vena caval (IVC) filter.

MATERIALS AND METHODS

Prospective evaluation of the OTW Greenfield filter in 47 patients was performed during the course of 18 months. Technical success and deployment problems were documented. Caval perforation, leg asymmetry, and tilt were evaluated with a postprocedure, noncontrast computed tomographic (CT) scan. Follow-up was performed at 6- and 12-month intervals after the procedure and included a clinical history, chart review, and magnetic resonance (MR) imaging examination of the IVC.

RESULTS

Ninety-one percent of filters were placed without technical difficulties and 100% were successfully deployed. Technical difficulties included sheath kinking prior to deployment (n = 3), initial incomplete filter opening (n = 1), and wire entrapment within the filter (n = 1). Of 38 patients evaluated with CT, there was no case of caval perforation. Twenty-one patients (55%) demonstrated tilt and 14 (37%) had leg asymmetry. Tilting occurred more frequently when the filter was placed from a femoral approach (51%) than from a jugular approach (12%). Of patients with leg asymmetry, the vena cava was narrow in anteroposterior (AP) dimension in five (36%). Of 13 deaths, none were attributed to pulmonary embolism. One patient (2%) had a recurrent pulmonary embolus. Two of 16 patients (12%) with MR imaging follow-up had documented IVC thrombosis.

CONCLUSIONS

The OTW Greenfield filter has an effective delivery system, with few difficulties encountered during deployment. Filter tilt and leg asymmetry are common. The etiology of leg asymmetry is likely multifactorial but is often associated with a cava with a small AP diameter. Because OTW deployment appears to offer no benefit in centering the filter, the authors have elected to remove the wire prior to filter deployment to avoid possible entanglement. MR imaging follow-up reveals an acceptable incidence of IVC thrombosis.

The role of infrapopliteal MR angiography in patients undergoing optimal contrast angiography for chronic limb-threatening ischemia

PURPOSE

To determine the benefit of infrapopliteal magnetic resonance angiography (MRA) in patients with chronic limb-threatening ischemia who have undergone optimal contrast angiography (CA).

PATIENTS AND METHODS

Thirty-four patients (37 limbs) with limb-threatening chronic lower extremity ischemia underwent MRA and CA of the symptomatic extremity. Selective, vasodilator-enhanced digital subtraction angiography of the infrapopliteal vessels was possible for 34 limbs. Two vascular surgeons retrospectively formulated treatment plans based on CA. They then formulated treatment plans based on CA and MRA together.

RESULTS

CA clearly visualized 495 of 888 vascular segments as patent, while MRA clearly visualized 412 of 888 segments. Treatment plans differed for at least one of two surgeons in eight limbs, but MRA would possibly have improved clinical outcome in only one. The amount of inflow disease did not appear to influence segment visualization or treatment planning. In eight of 11 limbs that eventually required below- or above-knee amputation, CA clearly visualized more vascular segments than MRA. One patient developed renal insufficiency after CA.

CONCLUSION

Most patients undergoing optimal CA for chronic limb-threatening ischemia will not benefit from the addition of MRA. However, MRA should be considered when CA is suboptimal and when it is necessary to conserve contrast material.

Analysis of DNA mismatch repair proteins in human medulloblastoma

During replication, the primary function of the eukaryotic DNA mismatch repair (MMR) system is to recognize and correct mismatched base pairs within the DNA helix. Deficiencies in MMR have been reported previously in cases of hereditary nonpolyposis colorectal cancer and sporadic tumors occurring in a variety of tissues including gliomas. Furthermore, recent evidence indicates that the MMR system may be involved in mediating therapeutic sensitivity to alkylating agents. In this study, 22 neoplastic tissue samples from 22 patients who underwent surgical resection for medulloblastoma, a common cerebellar tumor of childhood, were assayed for the presence or absence of MMR polypeptides using Western blot and immunohistochemical techniques. Results from these experiments indicate that the MMR system is not commonly deficient in medulloblastoma.

MR angiography of the portal venous system: techniques, interpretation, and clinical applications

Magnetic resonance (MR) angiography is a noninvasive means of assessing the portal venous system that has potential advantages over currently used modalities. Time-of-flight and phase-contrast MR angiography are useful techniques that differ fundamentally in their means of data acquisition but are comparable in their ability to demonstrate normal anatomy as well as abnormalities of the portal venous system. Occasionally, artifacts caused by respiratory motion, implanted metallic devices or surgical clips, in-plane saturation, or areas of complex flow are seen at MR angiography of the portal venous system. However, most artifacts can easily be identified as such and either remedied or ignored. In addition, the suppression of signal from surrounding soft tissues may result in poor detection of parenchymal lesions. The utility of standard projection angiograms and source images can be increased through the use of intravenously administered contrast material and postprocessing techniques such as partial-volume maximum intensity projection reconstructions and shaded surface renderings. In addition to providing information on portal venous anatomy and portosystemic collateral vessels, MR angiography of the portal vein has clinical application in portal venous thrombosis and stenosis, liver transplantation, and the evaluation and planning of surgical and transjugular intrahepatic portosystemic shunts.

Time-of-flight MR arteriography of below-knee arteries with maximum-intensity-projection reconstruction: is interpretation of the axial source images helpful?

OBJECTIVE

We evaluated the extent to which detailed review of axial source images enhances the interpretation of projectional reconstructions of two-dimensional time-of-flight MR arteriograms of the tibial vessels.

SUBJECTS AND METHODS

Thirty-one patients (34 limbs) with limb-threatening ischemia underwent two-dimensional time-of-flight imaging and contrast-enhanced angiography of the below-knee arteries. Maximum-intensity-projection (MIP) reconstructions of the MR arteriograms were independently interpreted by three observers. The studies were then reinterpreted after detailed review of the axial source images. A consensus reading of each study was performed as well. The observers commented on the patency of 816 vascular segments and graded the extent of disease for 272 vessels. Interobserver agreement and correlation with contrast-enhanced angiography were determined.

RESULTS

On average, the addition of axial images altered the observers' interpretation of MR arteriograms in 13% of segments for patency and in 18% of vessels for grading of disease severity. For determining the patency of vascular segments, mean interobserver agreement was 0.79 without and 0.80 with axial image interpretation, and mean agreement with contrast-enhanced angiography improved from 0.69 to 0.72 with the addition of axial images. When evaluating the extent of disease, correlation between observers improved for all combinations of observers with the addition of axial images, and correlation with contrast-enhanced angiography improved for two of three observers. Based on the consensus interpretation of the MR arteriograms, review of axial images was found to improve agreement with contrast-enhanced angiography in 34 vascular segments. In addition, axial image review correctly altered the number of stenoses identified in 12 vessels. When consensus interpretation identified a vessel as patent without significant stenosis on the MIP images, the MIP-based interpretation was found to be correct in all cases.

CONCLUSION

Review of axial source images provides limited benefit to interpretation of MR arteriograms of the distal lower extremity in patients with peripheral vascular disease. Although selective review of axial source images may be appropriate, axial images can improve interpretation when MIP images are complicated by the presence of patient motion, difficult anatomy, or artifacts. Axial image review may also be appropriate when a significant stenosis is identified on the MIP images.

Preoperative embolization of anastomoses of the jugular bulb: an adjuvant in jugular foramen surgery

We describe the technique of preoperative embolization of the inferior petrosal sinus/anterior condylar vein complex and the posterior condylar vein in three patients undergoing skull base surgery that required opening of the jugular bulb. Contrary to the usual situation, essentially no blood was lost during the operation, resulting in decreased surgical time and reduced risk to the lower cranial nerves.

Methylator resistance mediated by mismatch repair deficiency in a glioblastoma multiforme xenograft

A methylator-resistant human glioblastoma multiforme xenograft, D-245 MG (PR), in athymic nude mice was established by serially treating the parent xenograft D-245 MG with procarbazine. D-245 MG xenografts were sensitive to procarbazine, temozolomide, N-methyl-N-nitrosourea, 1,3-bis(2-chloroethyl)-1-nitrosourea, 9-aminocamptothecin, topotecan, CPT-11, cyclophosphamide, and busulfan. D-245 MG (PR) xenografts were resistant to procarbazine, temozolomide, N-methyl-N-nitrosourea, and busulfan, but they were sensitive to the other agents. Both D-245 MG and D-245 MG (PR) xenografts displayed no O6-alkylguanine-DNA alkyltransferase activity, and their levels of glutathione and glutathione-S-transferase were similar. D-245 MG xenografts expressed the human mismatch repair proteins hMSH2 and hMLH1, whereas D-245 MG (PR) expressed hMLH1 but not hMSH2.

Effect of the method of killing, interval between killing and neck cutting and blood vessels cut on blood loss in broilers

1. Broiler chickens were killed using 90% argon in air, or 30% carbon dioxide and 60% argon in air or 120 mA per bird in a waterbath with a 50 Hz alternating electric current. Ventral or unilateral neck cutting was performed at 1, 3 or 5 min after killing. In addition, a group of broilers was stunned with 120 mA per bird in a waterbath using 1500 Hz alternating current and were bled out-with a ventral neck cut within 20 s from stunning. 2. Blood leaving the neck wound was collected in a bin placed on an electronic balance and a computer program calculated the cumulative blood loss up to 100 s after neck cutting. 3. Bleed-out was significantly affected by killing method and time of neck cutting. Broilers killed with the carbon dioxide-argon mixture bled-out less than those killed with argon or 50 Hz electric current. When compared with the 1 min neck cutting interval, a delay of 3-or 5 min resulted in a lower bleed-out. High frequency electrical stunning and ventral neck cutting within 20 s resulted in a slightly higher bleed-out than those recorded for the killing methods. However, within argon killing, a delay of 3 or 5 min in ventral or unilateral neck cutting had no significant effect on the bleed-out. In broilers killed with the carbon dioxide-argon mixture a 3 min delay in ventral neck cutting or a 5 min delay in unilateral neck cutting resulted in lower bleed-out. 4. Neck cutting of broilers within 5 min after argon killing or 3 min after killing with the carbon dioxide-argon mixture would result in a satisfactory bleed-out.

Welfare implications of gas stunning pigs: 3. The time to loss of somatosensory evoked potentials and spontaneous electrocorticogram of pigs during exposure to gases

Changes in the spontaneous electrocorticogram (ECoG) and somatosensory evoked potentials (SEPs) were recorded in 12 pigs in each of three gas killing treatments. The treatments were 90% argon in air with 2% residual oxygen; a mixture of 30% carbon dioxide and 60% argon in air with 2% residual oxygen; or 80-90% carbon dioxide in air. The mean times to loss of SEPs were 15, 17 and 21 s, respectively. The mean time to loss of SEPs recorded during killing with a high concentration of carbon dioxide was significantly longer than those recorded for the other two gas killing treatments (P < 0.05). Slow waves (high amplitude and low frequency) appeared on average 15 s after exposure to argon. In some pigs killed with the carbon dioxide-argon mixture, a decrease in the frequency of electrical activity was apparent, although slow waves did not appear during killing with a higher concentration of carbon dioxide. A suppressed ECoG (reduction in amplitude of signals) was recorded at 22 and 20 s respectively, during exposure to the carbon dioxide-argon mixture and 80-90% carbon dioxide in air, but the onset of ECoG suppression could not be determined exactly during exposure to 90% argon in air. The time to onset of an isoelectric ECoG was 54, 39d and 32 s after exposure to argon, carbon dioxide-argon mixture and a high concentration of carbon dioxide, respectively. The mean time to the onset of an isoelectric ECoG during exposure to argon was significantly longer than that recorded for the other two gas killing treatments (P < 0.05). Based on the time to loss of SEPs, it is concluded that during killing with a high concentration of carbon dioxide, pigs would have to endure a moderate to severe respiratory distress induced with this gas for a considerable period of time prior to the loss of brain responsiveness. Argon-induced anoxia appears to be the first choice from a welfare point of view for killing pigs, based on its lack of aversive properties and its effectiveness in rapidly abolishing brain responsiveness. A mixture of 30% carbon dioxide and 60% argon in air is considered to be more humane than using a high concentration of carbon dioxide, as the time to loss of brain responsiveness is similar to that using 90% argon in air.

Carcase and meat quality in broilers either killed with a gas mixture or stunned with an electric current under commercial processing conditions

1. Carcase and meat quality were evaluated under commercial conditions in 400 broilers either killed with a mixture of 30% carbon dioxide and 60% argon in air or stunned with a 50 Hz AC with clipped sine wave. 2. Compared with electrical stunning, killing broilers with the gas mixture eliminated or substantially reduced the prevalence of carcase and meat quality defects. 3. The results also showed that killing broilers with a mixture of 30% carbon dioxide and 60% argon would enable filleting (deboning) to be performed at 4 h post mortem without adversely affecting the cook loss or texture of breast meat.

Stent deformation and intimal hyperplasia complicating treatment of a post-carotid endarterectomy intimal flap with a Palmaz stent

We report a case of common carotid artery Palmaz stent placement for treatment of an intimal flap after surgical endarterectomy. Despite technical success with an excellent immediate result, a significant stenosis detected by duplex sonographic examination developed at 10 months. This stenosis, the result of stent compression and intimal hyperplasia, illustrates the previously theoretic risk associated with placement of the balloon-expandable stent in a compressible site such as the cervical carotid artery. In addition, we demonstrate that significant intimal hyperplasia may occur after carotid artery stent placement, potentially limiting long-term patency.

Ultrasound screening for anencephaly at 10-14 weeks of gestation

In an ongoing study involving seven hospitals in London and surrounding areas, 55,237 fetuses were examined by ultrasound at 10-14 weeks of gestation. There were 47 fetuses (1 in 1175) with anencephaly which presented with acrania with varying degrees of cerebral degeneration. The first audit of results was performed in April 1995. During the first phase of the study 34,830 fetuses were examined and in eight of the 31 with anencephaly the diagnosis was not made at the 10-14-week scan. Following the audit, 20,407 fetuses were examined and in all 16 with anencephaly the diagnosis was made at the 10-14-week scan (p = 0.03). These findings demonstrate that anencephaly can be reliably diagnosed at the routine 10-14-week ultrasound scan, provided a specific search is made for the sonographic features for this condition.

Transjugular portosystemic shunts in pediatric patients awaiting liver transplantation

Three pediatric patients from 6 to 11 years of age awaiting liver transplantation for end stage liver disease underwent transjugular intrahepatic portosystemic shunt (TIPS) placement for control of variceal bleeding. Two of the three procedures were performed emergently after endoscopic sclerotherapy failed to stop active bleeding. One procedure was performed electively after multiple prior bleeding episodes. The shunts were created from the middle or left hepatic vein to the left portal vein, and none of the subsequent transplant surgeries was complicated by the presence of the stents. No major or minor complications were related to TIPS placement. Two patients underwent concomitant variceal embolization. Bleeding was successfully controlled in each patient. We conclude that TIPS placement in children is technically feasible, does not complicate subsequent surgery, and is useful treating acute variceal hemorrhage in pediatric patients awaiting liver transplantation.