Use of nitric-oxide-eluting polymer-coated coronary stents for prevention of restenosis in pigs

BACKGROUND

Restenosis after angioplasty remains an unresolved problem despite an increase in use of coronary stents. It has been theorized that nitric oxide (NO) exerts several actions that can prevent restenosis. These include inhibition of proliferation of smooth muscle cells, prevention of arterial spasms, and decreasing aggregation of platelets in response to exposure to collagen.

OBJECTIVE

To determine whether NO coated stents decrease restenosis in a pig balloon injury model.

METHODS

We used coronary stents impregnated with a slow-release precursor of NO in the porcine model of restenosis. Tantalum coil coronary stents (Cordis) were coated with a polymer impregnated with a slow-release precursor of NO. Polymer-coated stents without active precursors were used as controls. Oversized stents were mounted on a delivery balloon and subsequently deployed in the right coronary and left anterior descending arteries of each animal.

RESULTS

Repeated recording of angiograms demonstrated that changes in minimum lumen diameter on going from immediately after stenting to 28-day follow-up for the control and NO-eluting-stent groups were similar, namely decreases of 1.89 +/- 0.33 and 2.08 +/- 0.28 mm, respectively. The morphometric results, showing that severe luminal narrowing occurred for both groups, were similar. The percentage area stenoses were 85 +/- 5% for the control group and 84 +/- 6% for the NO-eluting group. Histology demonstrated that profuse formation of neointima and an inflammatory cell infiltrate occurred.

CONCLUSIONS

Severe diameter stenosis occurred both for control and for treatment groups. The degree of angiographic stenosis was markedly worse than that previously reported for this model. Sustained release of a precursor of NO did not prevent restenosis in this model. This might have been due to a lack of efficacy of nitric oxide or to a profuse and overwhelming stimulatory effect of the polymer in the coated stents.

Fast skeletal muscle isoforms exhibit the highest incorporation level into myofibrils and stress fibers among members of myosin alkali light chain isoform family

Isoproteins of myosin alkali light chain (LC) were co-expressed in cultured chicken cardiomyocytes and fibroblasts and their incorporation levels into myofibrils and stress fibers were compared among members of the LC isoform family. In order to distinguish each isoform from the other, cDNAs of LC isoforms were tagged with different epitopes. Expressed LCs were detected with antibodies to the tags and their distribution was analyzed by confocal microscopy. In cardiomyocytes, the incorporation level of LC into myofibrils was shown to increase in the order from nonmuscle isoform (LC3nm), to slow skeletal muscle isoform (LC1sa), to slow skeletal/ventricular muscle isoform (LC1sb), and to fast skeletal muscle isoforms (LC1f and LC3f). Thus, the hierarchal order of the LC affinity for the cardiac myosin heavy chain (MHC) is identical to that obtained in the rat (Komiyama et al., 1996. J. Cell Sci., 109: 2089-2099), suggesting that this order may be common for taxonomic animal classes. In fibroblasts, the affinity of LC for the nonmuscle MHC in stress fibers was found to increase in the order from LC3nm, to LC1sb, to LC1sa, and to LC1f and LC3f. This order for the nonmuscle MHC is partly different from that for the cardiac MHC. This indicates that the order of the affinity of LC isoproteins for MHC varies depending on the MHC isoform. Further, for both the cardiac and nonmuscle MHCs, the fast skeletal muscle LCs exhibited the highest affinity. This suggests that the fast skeletal muscle LCs may be evolved isoforms possessing the ability to associate tightly with a variety of MHC isoforms.

The pattern of suicide in Pakistan

There is paucity of information on suicide from Pakistan, an Islamic country in which data collection poses formidable challenges. A variety of social, legal, and religious factors make reporting and diagnosing suicide difficult. Paradoxically, incidents of suicide are regularly reported in newspapers in Pakistan. In the absence of other means these reports serve a useful, though basic information source for suicidal deaths. A 2-year analysis of all such reports in a major newspaper in Pakistan showed 306 suicides reported from 35 cities. Men (n = 208) outnumbered women by 2:1. While there were more single than married men, the trend was reversed in women. The majority of subjects were under 30 years of age and "domestic problems" was the most common reason stated. More than half the subjects used organophosphate insecticides, while psychotropics and analgesics were used infrequently. The study challenges the widely held belief that suicide is a rare phenomena in an Islamic country like Pakistan, and underscores the need for more culture specific research on this important public health problem.

The prevalence and types of coronary artery anomalies in Northern Ireland

Coronary artery anomalies are uncommon, with a reported prevalence ranging from 0.2% to 1.6%. It is important that those who undertake coronary angiographic procedures are aware of the spectrum of these anomalies. Interventional percutaneous coronary revascularisation procedures are widely used in the management of patients with symptomatic coronary atherosclerosis. The presence of a coronary artery anomaly may make these procedures technically challenging. We have reviewed the Cardiac catheterisation database at the Royal Victoria Hospital, Belfast, and report the prevalence and types of these anomalies.

Chloroform-induced conformational changes in the bound pigmentin bilirubin-albumin complexes

Chloroform-induced conformational changes of bilirubin (BR) bound to different serum albumins were studied by circular dichroism (CD) and fluorescence spectroscopy. Addition of a small amount of chloroform ( approximately 20 mM) to a solution containing 20 microM albumin and 15 microM BR changed the sign order and magnitude of the characteristic CD spectra of all BR-albumin complexes except BR-PSA complex which showed abnormal behavior. Monosignate negative CD Cotton effects (CDCEs) of BR complexed with SSA, GSA and BuSA were transformed into bisignate CDCEs in presence of chloroform akin to those exhibited by chloroform free solution of BR-HSA complex, indicating that the pigment acquired right handed plus (P) chirality when chloroform was added to these complexes. Bisignate CD spectra of BR complexed with HSA and BSA showed complete inversion upon addition of chloroform corroborating earlier findings. On the other hand, changes observed with BR-RSA complex were slightly different showing an additional CD band of weak intensity centered around 390 nm though inversion of CDCEs was similar to that of BR-HSA complex. Monosignate CD spectra of BR-PSA complex also showed three CD bands occurring at 409, 470 and 514 nm after chloroform addition. These results indicated significant but different effects of chloroform on the conformation of bound BR in BR-albumin complexes which can be ascribed to the changes in the exciton chirality of bilirubin probably due to altered hydrophobic microenvironment induced by the binding of chloroform at or near the ligand binding site. Chloroform severely quenched the intrinsic tryptophan fluorescence of the protein and shifted the emission maxima towards blue region in all the albumins except PSA. However, quantitative differences in both quenching and blue shift were noted in different serum albumins. This suggests that chloroform probably binds in the close vicinity of tryptophan residue(s) located in subdomain(s) IIA or IB and II both. The fluorescence of BR-albumin complexes was also found to be sensitive to the presence of a small amount of chloroform. But the changes observed in the fluorescence of the bound pigment in presence of chloroform were less marked as compared to the changes in the intrinsic fluorescence of protein per se. Taken together, these results suggest that there is at least one conserved site for chloroform binding in all these albumins which is at or near the BR binding site.

High-molecular-weight kininogen preadsorbed to glass surface markedly reduces neutrophil adhesion

Adsorbed proteins on biomaterial surfaces determine whether cells adhere, but rheological variables are also critical. Neutrophil adhesion under well-defined radial flow conditions was studied on glass preadsorbed with plasma proteins or plasma protein domain fragments. Fibrinogen, low-molecular-weight kininogen (LK), high-molecular-weight kininogen (HK), cleaved HK (HKa), and recombinant HK domains 3 and 5 (D3 and D5H) were used. The number of adherent cells on the HK and HKa surfaces was less than 10% that found on the fibrinogen absorbed surface. The degree of spreading was minimal and detachment of adherent neutrophils was observed. HK and HKa contain binding sites for both anionic surfaces and neutrophils in the same domain (D5H). When adsorbed to surfaces, HK and HKa did not have the neutrophil binding sites available and therefore exhibited an anti-adhesive effect. Although D5H contains anionic surface binding sites, its small molecular size required a higher number of adsorbed molecules to cover the surface before a significant decrease in cell adhesion was observed. Since LK and D3 do not possess specific anionic surface binding sites, the adsorption of these proteins on glass was very low compared to HK and HKa. Thus, extensive cell adhesion and spreading were observed on the surfaces partially covered with preadsorbed LK and D3.

Primary structure of guinea pig plasma prekallikrein

A full length guinea pig plasma prekallikrein (PK) cDNA was cloned from a liver cDNA library. The nucleotide sequence with 2242 bp was analyzed and the amino acid sequence with 618 residues was deduced. Kallikrein was purified from guinea pig plasma and cleavage site in the activation was determined. The amino acid sequence around the cleavage site -368Ile-Asp-Ala-Arg-Ile-Val-Gly-375Gly- differed from that of the human PK -368Thr-Ser-Thr-Arg-Ile-Val-Gly-375Gly-. Protease substrates containing penta-peptides which mimicked the sequence of the cleavage sites from P3 to P2' of guinea pig Hageman factor (HF) and PK were synthesized, and kinetic analyses of the hydrolysis by guinea pig activated HF (HFa) and kallikrein were carried out. The combination between HFa and the PK mimicking peptide provided the best kinetics. These results in part explain why the cascade activation of PK by HFa is predominant in the guinea pig system.

Immunoregulatory effects of N9-benzyl- and N7-benzyl-8-bromoguanines

In this study we investigated the effects of two guanine derivatives, 9-benzyl- (I) and 7-benzyl-8-bromoguanines (II) on the proliferation of human T-cell leukemia and T-cell lymphoma, normal human peripheral blood mononuclear cells (PBMC), and mouse Th1 (pGL10) and Th2 (D10.G4.1) clones. We also assessed their effects on cytokine production (IL-3, IL-10 and IFN-gamma) in PBMC, T-cell lymphoma, HUT78 (IL-2), and murine Th1 (IL-2) and Th2 (IL-4 and IL-5) clones. These compounds were synthesize as analog of known inhibitors of purine nucleoside phosphorylase (PNP) 8-amino-9-benzylguanine. These compounds suppressed proliferation of human leukemia MOLT-4 cells, human cutaneous lymphoma HUT78 cells and normal PMBC. Compound II was a significantly more potent inhibitor than compound I. Exogenous recombinant human IL-2 reversed the anti-proliferative effects of both compounds on HUT78 cells. These compounds had low toxicity to human EBV-transformed B-lymphocytes. Both compounds suppressed the production of IL-2 by activated human HUT78 cells, IFN-gamma by PBMC and did not affect IL-3 and IL-10 production in PBMC. Compound I inhibited anti-CD3-activated IL-2 secretion from the murine Th1 clone. The murine Th2 clone was less sensitive to both compounds as compared with Thl. The production of IL-4 and IL-5 by this clone was not suppressed. Thus, it has been shown that not only 9-substituted guanines but also their 7-isomers selectively inhibit T-cell functions and both selectively inhibit Th1-related cytokines secretion.

Effect of lysine modification on the conformation and indomethacin binding properties of human serum albumin

In order to study the involvement of lysine residues of human serum albumin (HSA) in the binding of indomethacin, HSA was treated with different molar excess of acetic anhydride, succinic anhydride and O-methylisourea which resulted in differently modified preparations: 30%, 62% and 87% acetylated, 20%, 34%, 64% and 78% succinylated and 21%, 43% and 86% guanidinated HSAs. All the preparations were found to be homogeneous with respect to charge as well as size as judged by polyacrylamide gel electrophoresis and gel filtration on a Seralose-6B column. Hydrodynamic and circular dichroic results showed that pronounced conformational changes (both tertiary and secondary structures) were induced in the maximally acetylated (87%) and succinylated (78%) preparations. On the other hand, guanidinated preparations showed no expansion in the hydrodynamic volume. The percent decrease in alpha-helical content was 34% for 87% acetylated, 31% for 78% succinylated and 10% for 86% guanidinated HSAs. A significant increase in the values of Stokes radii and frictional ratios (from 3.43 nm and 1.29 for native HSA to 4.07 nm and 1.52 for 87% acetylated and 4.35 nm and 1.60 for 78% succinylated HSAs, respectively) was also noticed in these highly modified preparations. Fluorescence quench titration results obtained at pH 7.4 and ionic strength 0.15 showed that only 54.1% and 64.7% binding of indomethacin at 4:1 drug/protein molar ratio was retained by 87% acetylated and 78% succinylated HSAs, respectively, as compared to 91% retention in binding in 86% guanidinated preparation. No reversal in the binding of drug to 87% acetylated and 78% succinylated HSA preparations was observed on increasing the ionic strength to 1.0. Therefore, it seems that one or two critical lysine residue(s) that can form salt linkage with the carboxyl group of indomethacin, was (were) probably modified in these preparations. A small decrease in the binding of drug to the guanidinated preparation also confirms the involvement of positive charge, probably contributed by lysine residue(s), in the binding of indomethacin to HSA.

Aprotinin inhibits thrombin formation and monocyte tissue factor in simulated cardiopulmonary bypass

BACKGROUND

Aprotinin reduces perioperative bleeding after open heart surgery, primarily by inhibiting fibrinolysis. In addition, the drug has both procoagulant and anticoagulant effects that involve complex reactions of coagulation proteins and cells that are incompletely understood. This study tests the hypothesis that aprotinin has an anticoagulant effect on the extrinsic coagulation pathway.

METHODS

Human heparinized blood was recirculated through a membrane oxygenator with and without high concentrations of aprotinin (18.4 microM). Serial plasma samples were obtained at intervals up to 240 minutes.

RESULTS

Aprotinin significantly reduced the progressive increase in prothrombin fragments (F1.2) and thrombin-antithrombin complex beginning immediately. Aprotinin also significantly reduced monocyte expression of tissue factor and Mac-1. Aprotinin did not significantly reduce factor VII or factor VIIa.

CONCLUSIONS

During simulated cardiopulmonary bypass, aprotinin immediately inhibits kallikrein and thrombin formation via the intrinsic coagulation pathway. Later, aprotinin inhibits monocyte expression of tissue factor and the extrinsic coagulation pathway. The ability of aprotinin to inhibit monocyte tissue factor provides a means to reduce thrombin formation in blood aspirated from the wound during open heart surgery.

Suicide and attempted suicide in Pakistan

Suicide and attempted suicide are understudied subjects in Pakistan, an Islamic country where they are considered criminal offenses. National suicide statistics are not compiled nor are suicide mortality statistics reported to the World Health Organization (WHO). Although there are strong religious sanctions against suicide, there are no clear principles against attempted suicide in Islam. Despite this, Pakistan, like many other Islamic countries, has punitive laws against attempted suicide. This has led to both suicide and attempted suicide being underdiagnosed and underreported. Data on suicide and attempted suicide are also difficult to obtain. This article gives an overview of the current state of suicide and attempted suicide in Pakistan, in the context of existing religious and legal factors, high-lighting the main findings of the few studies carried out over the last 50 years. It is important that researchers in Islamic countries like Pakistan not be deterred by the apparent low rates of suicide in these countries, but conduct further research in this important yet neglected public-health problem.

Surgical removal of subfoveal choroidal neovascularization in age-related macular degeneration

OBJECTIVE

To assess the results of surgical excision of subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration (AMD).

DESIGN

Retrospective, interventional, noncomparative case series.

PARTICIPANTS AND INTERVENTION

Sixty-four consecutive patients undergoing surgical removal of AMD-related subfoveal CNV were studied. The surgical method included a small retinotomy, subretinal tissue plasminogen activator (t-PA), perfluoro-n-octane, and air-fluid exchange.

MAIN OUTCOME MEASURES

Final visual acuity was the main outcome measure; surgical complications and recurrence rates were also assessed.

RESULTS

Preoperative visual acuity ranged from 20/100 to 1/200, with a mean of 20/400. Average follow-up was 19 months. The best acuity achieved after surgery ranged from 20/20 to hand motions, with a mean of 20/200. Final visual acuity ranged from 20/50 to light perception, with a mean of 20/400. Final acuity was improved 3 or more lines in 19 eyes (30%) (median, 5 lines), stable in 27 eyes (42%), and 3 or more lines worse in 18 eyes (28%) (median, 4 lines). Factors associated with greater visual improvement included poorer initial acuity, larger CNV size, and smaller subretinal hemorrhage. Analysis of groups similar to Macular Photocoagulation Study subgroups A through D showed an average improvement of 1 line for group C (visual acuity, 20/200 or worse; CNV larger than 2 disc areas). Other preoperative, intraoperative, and postoperative factors, including recurrence and retinal detachment, did not have a significant effect on final visual outcome.

CONCLUSIONS

After surgical excision of AMD-related subfoveal CNV, vision improved or stabilized in the majority of patients. Surgery may be of greatest value for patients with poorer vision, larger subfoveal CNV, and minimal hemorrhage. Further evaluation of this technique should be accomplished via completion of a controlled, randomized multicenter study.

Viral ski inhibits retinoblastoma protein (Rb)-mediated transcriptional repression in a dominant negative fashion

The mechanism by which the viral oncogene ski (v-ski) transforms chicken embryo fibroblasts is currently unknown. Recently, the c-ski gene product (c-Ski) was found to bind to N-CoR (nuclear hormone receptor co-repressor), an element implicated in transcriptional repression mediated by multiple transcriptional repressors including the nuclear hormone receptors and Mad. c-Ski is required for transcriptional repression mediated by Mad involved in negative regulation of cellular proliferation. v-Ski abrogates Mad-induced transcriptional repression in a dominant negative fashion. Here we report that v-Ski also inhibits transcriptional repression mediated by Rb, another tumor suppressor gene product. Rb forms a complex with c-Ski, Sin3A, and histone deacetylase (HDAC) via direct binding to c-Ski and HDAC. c-Ski is required for the transcriptional repression mediated by Rb. These results suggest that inhibition of Rb activity contributes, at least partly, to transformation by v-Ski.

Ski is a component of the histone deacetylase complex required for transcriptional repression by Mad and thyroid hormone receptor

The N-CoR/SMRT complex containing mSin3 and histone deacetylase (HDAC) mediates transcriptional repression by nuclear hormone receptors and Mad. The proteins encoded by the ski proto-oncogene family directly bind to N-CoR/SMRT and mSin3A, and forms a complex with HDAC. c-Ski and its related gene product Sno are required for transcriptional repression by Mad and thyroid hormone receptor (TRbeta). The oncogenic form, v-Ski, which lacks the mSin3A-binding domain, acts in a dominant-negative fashion, and abrogates transcriptional repression by Mad and TRbeta. In ski-deficient mouse embryos, the ornithine decarboxylase gene, whose expression is normally repressed by Mad-Max, is expressed ectopically. These results show that Ski is a component of the HDAC complex and that Ski is required for the transcriptional repression mediated by this complex. The involvement of c-Ski in the HDAC complex indicates that the function of the HDAC complex is important for oncogenesis.

Involvement of protein kinase A in histamine-mediated inhibition of IL-2 mRNA expression in mouse splenocytes

The release of histamine from mast cells and basophils during allergic reactions can regulate functions of T cells and may influence the nature of the immune response to a given antigen. The effects of histamine on T lymphocytes are associated with its binding to H2-receptors linked with adenylate cyclase, elevation of cAMP levels and activation of cAMP-dependent protein kinase (PKA). In this report we explore the role of PKA in histamine-mediated effects on IL-2 mRNA expression and IL-2 protein secretion. Fresh isolated mouse splenocytes (C57Bl/6) were pretreated with histamine (10(-4) M) for 1 h in the presence or absence of Rp-cAMPS (50 microM), an inhibitor of PKA regulatory subunit. The cells were then washed thoroughly and activated with plate-bound anti-CD3 (5 microg/ml), or PHA (1:100) or PMA + ionomycin (10 ng/ml, 1 microg/ml) for 6 h. Pretreatment with histamine inhibited IL-2 mRNA expression and secretion in cells activated with anti-CD3 or PMA, but not in cells activated with PMA + ionomycin. Rp-cAMPS prevented histamine-mediated suppression and did not itself affect IL-2 production. These results provide evidence that histamine affected IL-2 production when the cells were activated via the T cell receptor (TCR)/CD3 complex, but did not interfere with signal transduction pathways downstream of PKC leading to production of IL-2. These effects of histamine on IL-2 secretion and mRNA expression were mediated via PKA.

Enoxaparin suppresses thrombin formation and activity during cardiopulmonary bypass in baboons

OBJECTIVE

This study tests the hypotheses that enoxaparin, a low molecular weight heparin and potent inhibitor of factor Xa, alone or in combination with standard heparin, inhibits thrombin formation and activity and modulates complement activation and neutrophil elastase release during cardiopulmonary bypass in baboons.

METHODS

After preliminary studies to determine doses and possible species differences to anticoagulants and protamine, 27 anesthesized baboons had normothermic cardiopulmonary bypass with standard, unfractionated, porcine intestinal heparin, enoxaparin, or a combination of heparin and enoxaparin. Protamine in appropriate doses was used to reverse anticoagulation. Blood samples were obtained at 6 time points. Activated clotting times were monitored; template bleeding times were measured before and up to 24 hours after cardiopulmonary bypass.

RESULTS

Hemodynamic measurements were not affected by the anticoagulant. Activated clotting times remained above 400 seconds throughout bypass, and no clots were observed. The anticoagulant did not alter platelet count, aggregation to adenosine diphosphate, release of beta-thromboglobulin, release of neutrophil elastase, or complement C3b/c and C4b/c. Enoxaparin alone, but not in combination, significantly reduced plasma levels of prothrombin fragment F1.2, fibrinopeptide A, and thrombin-antithrombin complexes but prolonged template bleeding times for more than 24 hours.

CONCLUSION

Enoxaparin significantly reduces thrombin formation and activity during cardiopulmonary bypass but does not suppress complement activation and neutrophil elastase release and is not adequately reversed by protamine after bypass.

Benzodiazepine self-poisoning in Pakistan: implications for prevention and harm reduction

The pattern of all index admissions for benzodiazepine self-poisoning to a university hospital in Karachi, Pakistan are described. Of the 329 medication self-poisoning cases, 84% were benzodiazepine overdoses. Diazepam was the preferred drug in 69% of these cases, with majority ingesting between 20-30 tablets of 5 mg each, 44% bought the benzodiazepine over the counter (OTC) for the purpose of overdose. The preference for benzodiazepines over analgesics (as freely available) may be related to the motives underlying parasuicide acts and their popularity as 'sleeping pills' in Pakistan. Educating the 'chemist' and limiting the number of tablets dispensed at a time are areas to consider in reducing the incidence and harmful effects of benzodiazepine overdoses in Pakistan.

Visualization of serum albumin on electrophoretic gels using the specific ligand bilirubin

Serum albumin, when incubated with bilirubin prior to electrophoresis, was visualized as a yellow-colored band during the electrophoretic run and did not require any staining. Furthermore, free bilirubin served as a tracking dye. A minimum of 20 micrograms of protein was detected very well by this method. The formation of a bilirubin-albumin complex did not affect the electrophoretic mobility as the protein complexed with bilirubin as well as free albumin moved with the same mobility. Only a single protein band was visualized by this method after electrophoresis of human plasma. The method is simple, less time-consuming and may be used in identifying bilirubin-binding proteins in various biological samples.

Development of an indigenous screening instrument in Pakistan: the Aga Khan University Anxiety and Depression Scale

The use of translations of instruments for detecting anxiety and depression continues to be debated. An indigenous screening instrument has been developed in Urdu for anxiety-depression syndromes at the Aga Khan University. It has been developed from the complaints of 150 anxious and depressed patients presenting to a non-speciality clinic and has been validated in 53 patients in a psychiatry clinic. The questionnaire has 25 items, 13 psychlogical and 12 somatic. At a score of 20 it has a sensitivity of 66%, a specificity of 79%, a positive predictive value of 83 and a negative predictive value of 60. In comparison with available instruments in Urdu, comprising of either psychological or somatic items, this scale includes both, which increases its reliability for use as a screening instrument by Community Health Workers in a primary health care setting, in epidemiologic work in Pakistan and in transcultural psychiatric research.

Coronary flow reserve may predict myocardial recovery after myocardial infarction in patients with TIMI grade 3 flow

BACKGROUND

The aim of the study was to determine whether the recovery of global and regional left ventricular function after successful percutaneous transluminal angioplasty (PTCA) could be predicted by measuring coronary flow reserve before performing the intervention.

METHODS AND RESULTS

Thirty-two patients underwent PTCA 6.9 +/- 3.4 days after a recent myocardial infarction. Coronary flow reserve was determined in the infarct-related artery before PTCA by using an intracoronary Doppler tipped wire. Global and regional wall motion were determined by 2-dimensional echocardiography before the Flowire study and again 7 weeks after the angioplasty. Whereas the global and regional wall motion score indices improved in 20 patients (recovery group), they deteriorated or did not change in 9 patients (nonrecovery group). Coronary flow reserve distal to the lesion in the infarct-related artery was significantly higher in the recovery group (1.43 +/- 0.57 vs 0.98 +/- 0.70, P = .0001). Coronary flow reserve distal to the lesion in the infarct-related artery was < 1.1 in patients whose global or regional left ventricular function did not improve at follow-up, whereas flow reserve ranged between 1.1. and 1.8 while patients in whom left ventricular function improved.

CONCLUSIONS

These results suggest that the absence of inducible coronary flow reserve may predict failure of left ventricular systolic function to improve between the first and sixth week after infarction. Measurement of flow reserve with a Flowire at the time of diagnostic angiography after recent myocardial infarction may ultimately prove helpful in deciding whether to proceed with revascularization.

Three noncontiguous peptides comprise binding sites on high-molecular-weight kininogen to neutrophils

The binding of high-molecular-weight kininogen (HK) to neutrophils (polymorphonuclear leukocytes, PMN) is required for the stimulation of aggregation and degranulation by human plasma kallikrein as well as the displacement of fibrinogen from this cell surface. The putative receptor for HK is the leukocyte integrin alphaMbeta2, and domains 3 (D3) and 5 (D5) of HK form its binding site. To further map the binding sites on HK for PMN, we used D3 recombinant exon products and designed peptides from D3 and D5. In D3, a heptapeptide, Leu271-Ala277, from exon 7 product, and a peptide, Cys333-Cys352, from exon 9 product can inhibit binding of kininogen to PMN. Two contiguous peptides from D5 in the histidine-glycine-rich region, Gly442-Lys458 and Phe459-Lys478, each inhibit the binding of HK to PMN. This study has thus delineated three noncontiguous surface-oriented sequences on HK, which together comprise all or most of the binding site for human PMN.

The profile of the cytokines secreted during the generation of T-helper cells from atopic asthmatic subjects

This study investigated cytokine release by T-cell lines from atopic and nonatopic individuals in the presence of specific aeroallergen. Cell lines from atopic and nonatopic individuals secreted IL-2 for less than 14 and more than 21 days, respectively. All of the atopic, but not the nonatopic, cell lines exhibited a biphasic peak in IL-4 and IL-5 secretion. Flow cytometry revealed that, after 35 days, 89.3% of the atopic cells were T helpers and 73.2% were activated. Only 7.4% of the nonatopic cells displayed activation markers. In conclusion, T-cell differentiation may be controlled by other factors in addition to stimulation by aeroallergens.

Gender differences in nonfatal suicidal behavior in Pakistan: significance of sociocultural factors

Suicidal behavior is an understudied subject in Pakistan. A variety of social, legal, and religious factors make reporting and data collection on suicide and nonfatal suicidal behavior difficult. To study the problem, a retrospective case-note analysis was carried out in which the sociodemographic and clinical characteristics of 262 female and 185 male suicidal individuals admitted to a university hospital in Karachi, Pakistan, are compared. Three quarters of the suicidal persons were under the age of 30 years. Compared to men, women were younger and more often married. Both women and men tended to use self-poisoning with benzodiazepines, but more women used organophosphate insecticides. In Pakistani society, legal, social, and economic discrimination predisposes women to psychological distress and subsequent suicidal behavior. The study highlights the need for culture-specific research on suicidal behavior in Pakistan.

In vitro effects of smokeless tobacco extract on tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) production, and on lymphocyte proliferation

The use of smokeless tobacco (moist snuff) products is associated with mucosal lesions, gingival recession, attachment loss, and oral cancer. Despite numerous reports on the general toxic effects of smokeless tobacco extract, little information is available regarding the specific effects of smokeless tobacco on immune response. Inflammatory cytokines released as a result of smokeless tobacco-induced irritation may play a role in the development of oral mucosal lesions at habitual tobacco placement sites in smokeless tobacco users. Consequently, the purpose of this study was to determine whether an aqueous extract of smokeless tobacco (STE) affects the secretion of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), and the proliferation of lymphocytes. A macrophage cell line (J774-A1) was used to measure the effects of STE on tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) secretion. Mouse splenocytes were used to assess the effects of STE on lymphocyte proliferation. We found that STE at low concentrations enhanced the production of both TNF-alpha and IL-1beta. Furthermore, STE at similar concentrations enhanced mitogen-induced murine splenocyte proliferation. Overall, these data suggest that smokeless tobacco upregulated two key proinflammatory cytokines and also induces lymphocyte proliferation.

Protein kinase A inhibitors reverse histamine-mediated regulation of IL-5 secretion

Histamine and IL-5 are important autacoid mediators involved in the etiology of allergic diseases. IL-5 is the main factor of eosinophilic reactions in allergy. It has been suggested that the protein kinase A-dependent (PKA) pathway of signal transduction may play the main role in histamine-induced elevation of interleukin-5 production. This study was designed to investigate the effects of the inhibitors of regulatory and catalytic subunits of PKA on histamine-mediated elevation of IL-5 production. In our study, histamine at a concentration range of 10(-4)-10(-6) M enhanced IL-5 production in D10.G4.1 cells, a mouse Th2 helper cell line. Pretreatment of this cell line with histamine at a concentration of 10(-4) M for 6-9 h had the maximum stimulatory effects (226-420%) on IL-5 production. Other cAMP-elevating agents including forskolin and Bt2-cAMP produced similar effects. The PKA inhibitors N-[2-(methylaminoethyl]-5-isoquinoline-sulfonamide (H-8) and Rp-diastereomer of adenosine cyclic 3',5'-phosphorothioate (Rp-cAMPS) were used for the inhibition of catalytic and regulatory subunits of PKA, respectively. Pretreatment of D10.G4.1 cells with H-8 at a concentration of 10(-5) M completely prevented the effects of histamine at a concentration range of 10(-6)-10(-4) M. Rp-cAMPS at 10(-5) M also prevented histamine-induced stimulation. Neither inhibitor affected IL-5 production when tested alone. These observations suggest a role for PKA in histamine-mediated increase in IL-5 production.

Does intracoronary thrombus influence the outcome of high risk percutaneous transluminal coronary angioplasty? Clinical and angiographic outcomes in a large multicenter trial. EPIC Investigators. Evaluation of IIb/IIIa Platelet Receptor Antagonist 7E3 in Preventing Ischemic Complications

OBJECTIVES

We sought to evaluate the impact of angiographically visible thrombus on short- and long-term clinical outcomes after percutaneous transluminal coronary angioplasty (PTCA).

BACKGROUND

Intracoronary thrombus is frequently seen on angiography in patients with acute ischemic coronary syndromes or complex lesion morphology, or both, and is often considered to predict a higher rate of complications in patients undergoing PTCA.

METHODS

Prospectively collected data from 2,099 patients undergoing high risk PTCA in the Evaluation of IIb/IIIa Platelet Receptor Antagonist 7E3 in Preventing Ischemic Complications (EPIC) trial were analyzed. In addition to aspirin and heparin, patients were randomized to receive either abciximab bolus and infusion, abciximab bolus alone or placebo. Based on an angiographic core laboratory interpretation, patients were classified into three groups: thrombus absent, thrombus possible or thrombus present. The primary end point at 30 days was the composite of death, myocardial infarction or urgent revascularization. The 6-month end point was the composite of death, myocardial infarction or any revascularization.

RESULTS

Although abrupt closure was most common in patients with thrombus present compared with thrombus absent or possible (13%, 10.0% and 7.4%, respectively), neither the 30-day nor the 6-month clinical end points were different among the three groups (9%, 11% and 11.7%, respectively, and 30%, 34% and 31%, respectively). Most notably, the benefit of treatment with abciximab was present in all three thrombus groups, and the magnitude of benefit was not different among the thrombus groups.

CONCLUSIONS

In high risk patients undergoing percutaneous coronary revascularization, features of thrombus on the preprocedure angiogram do not indicate an augmented risk of adverse clinical outcomes. Abciximab therapy reduces the rate of adverse outcomes regardless of the presence of thrombus and should therefore not necessarily be reserved for patients whose angiograms have features of intraluminal thrombus.

A baboon model for hematologic studies of cardiopulmonary bypass

Objective investigation of new inhibitors of blood protein or cellular systems that are activated during cardiopulmonary bypass (CPB) is impeded by the absence of a satisfactory animal model. Because most baboon hematologic proteins immunologically cross-react with those used for human assays, we developed a robust, reusable baboon model of CPB. Blood samples were obtained from adult baboons at six time intervals before, during, and after 60 minutes of partial CPB at 37 degrees C with peripheral cannulas. Both membrane (n = 7) and bubble oxygenators (n = 7) were investigated. We measured platelet and white blood cell counts; platelet response to adenosine diphosphate and release of beta-thromboglobulin; fibrinopeptide A, prothrombin fragment F1.2, thrombin-antithrombin complex, D-dimer, and plasmin-antiplasmin complex; activated complement (C3b/c and C4b/c); elastase-alpha1 proteinase inhibitor complex; and bleeding times. Adherent glycoprotein IIIa antigen in Triton X-100 washes of the perfusion circuit was also measured. Markers of baboon platelet, complement, and neutrophil activation and thrombosis significantly increased during CPB with bubble oxygenator systems but did not change appreciably in membrane oxygenator circuits. Markers of fibrinolysis, D-dimer, and plasmin-antiplasmin complex did not change with either oxygenator. The baboon model of CPB, when a bubble oxygenator is used, is a robust, reusable animal model for evaluating inhibitors of platelet, complement, and neutrophil activation and thrombosis during and after CPB.

Use of bare-mounted Palmaz-Schatz stents employing the stent saddle technique on the delivery balloon: a single center experience

The major limitations of the Palmaz-Schatz stent stem from the design of its stent delivery system (SDS). The SDS is bulky and has poor trackability in lesions with proximal tortuosity and/or vessel calcification. The use of bare-mounted Palmaz-Schatz stents on low profile balloons represents an alternate approach for lesions that are not accessible for stenting with the SDS. Thus we evaluated the indications, procedural success rate, and in-hospital complications of patients undergoing bare stenting at a single center between 1 October 1995 through 30 September 1996. A total of 363 coronary interventions were performed during this period, including coronary stenting in 194 vessels. In 18 of these 194 vessels, bare-mounted Palmaz-Schatz stents were used. The indications for bare stenting were: inability to deliver the Palmaz-Schatz stent on SDS for suboptimal angioplasty results or acute/threatened abrupt closure; use of half stents; stenting in vessels < 3.0 mm; intermediate disease in the proximal segment that would have precluded optimal visualization of stent placement; and use of guides 7 French or smaller. Bare stenting was successful in 15 of the 18 patients (vessels) in whom it was attempted. There were no deaths, myocardial infarctions, stent thrombosis, repeat interventions, or significant bleeding in patients with successful bare stent delivery. The stents were successfully retrieved in the three patients in whom the stent could not be advanced into the target coronary segment. One of these patients had a propagated spiral dissection prior to attempts at bare stenting and required emergent bypass surgery. The remaining two patients with failed deployment had suboptimal angioplasty results but had an uncomplicated hospital course. Thus bare stenting represents an alternate percutaneous approach to tackle suboptimal procedural results and/or complications in patients who have failed stent deployment with the standard sheathed stent delivery system currently available in the United States.

Zinc status of breastfed and formula-fed infants of different gestational ages

Zinc status in 186 full term and preterm infants was determined at birth, and 3, 6, 9, and 12 months of age along with determination of zinc levels in breast or formula milk to find out if routine zinc supplements are needed during infancy. The leukocyte and plasma zinc levels in all breastfed infants were high at birth and gradually declined reaching lowest values by 4-6 months of age, and improved to normal levels by 9 months following weaning. The preterm infants however, had significantly (P < 0.05) higher leukocyte zinc (213.6 +/- 46.91 micrograms/10(10) cells) at birth compared to term infants. Colostrum of all the mothers had higher zinc concentrations which declined to significantly lower levels in breastmilk by 4-6 months of lactation, corresponding to the age when the breastfed infants had lower zinc levels. The improvement of the levels to normal after weaning suggests that the fall in zinc status during early infancy could be a transient phenomenon which could be reversed by proper weaning, thus strengthening the plea for timely food supplements rather than the need for single nutrient supplements. Formula-fed full term infants had significantly lower leukocyte zinc levels (49.3 +/- 2.59 micrograms/10(10) cells) at 3 months of age compared to breastfed infants of the same age (92.8 +/- 14.04 micrograms/10(10) cells). Even these infants improved their zinc status after weaning on par with breastfed infants. The functional significance of their transient, but low zinc values during early infancy needs to be investigated.

High dose rate intracoronary radiation for inhibition of neointimal formation in the stented and balloon-injured porcine models of restenosis: angiographic, morphometric, and histopathologic analyses

PURPOSE

We examined the effects of intracoronary irradiation delivered at a high dose rate on neointimal hyperplasia after injury induced by two methods: balloon overstretch injury, and stent implantation in a porcine model of coronary restenosis.

METHODS AND MATERIALS

In 34 Hanford miniature swine, a segment of each coronary artery was targeted for injury and treatment. The artery segments were treated with 192Ir at doses of 10 Gy over 4 min (eight animals), 15 Gy over 6 min (nine animals), 25 Gy over 10 min (nine animals) or control (simulation wire only; eight animals). The treated segments were subjected to stent implantation (left anterior descending and right coronary artery) or balloon overstretch (circumflex) injury. Twenty-eight days later, repeat coronary angiography and sacrifice were done. Quantitative coronary angiography, morphometry, and extensive histopathologic analyses were carried out in a blinded fashion.

RESULTS

The change in minimal lumen diameter from postinjury to presacrifice in the stent-injured left anterior descending was -0.79 +/- 0.34 (mean: +/- SD) mm in the control group, compared to -0.43 +/- 0.35 mm in the 15 Gy (p = 0.04) and -0.21 +/- 0.50 mm in the 25 Gy (p = 0.01) groups; and in the balloon-injured circumflex was -0.31 +/- 0.22 mm in the control group compared to -0.03 +/- 0.18 mm in the 10 Gy (p = 0.05) and 0.00 +/- 0.33 in the 15 Gy (p = 0.01) groups. Percent area stenosis in the left anterior descending was 36 +/- 9% in the control group compared to 18 +/- 12% in the 15 Gy (p = 0.003) and 11 +/- 11% in the 25 Gy (p < 0.001) groups; and in the circumflex was 16 +/- 10% in the control groups, compared to 5 +/- 5% in the 15 Gy (p = 0.02) and 2 +/- 2% in the 25 Gy (p = 0.009) groups. Histopathology showed a striking reduction in the amount of neointima in the irradiated arteries compared with control vessels. Other radiation effects were stromal fibrin exudate, thinning of the media, and adventitial fibrosis and leukocyte infiltration in the radiated arterial segments.

CONCLUSIONS

High dose rate intracoronary irradiation with 192Ir effectively inhibits intimal proliferation after stent-induced as well as balloon-overstretch injury. This shorter treatment time (4 to 10 min) may provide a clinically practical approach to the prevention of restenosis after angioplasty.

Effect of factor Xa inhibitors on thrombin formation and complement and neutrophil activation during in vitro extracorporeal circulation

BACKGROUND

Even when large doses of heparin are administered during cardiopulmonary bypass, thrombin is produced. Thrombin is a powerful protease that is associated with the thrombotic and bleeding complications of open heart surgery and is produced by cleavage of prothrombin by factor Xa. This study assessed the ability of a specific inhibitor of factor Xa, recombinant tick anticoagulant peptide (rTAP), alone or in combination with standard heparin and a low-molecular-weight heparin, enoxaparin, to suppress thrombin formation and activity during in vitro extracorporeal circulation.

METHODS AND RESULTS

Fresh, anticoagulated human blood was recirculated for 2 hours in an extracorporeal membrane oxygenator perfusion circuit at 37 degrees C. Four anticoagulant protocols were evaluated; porcine heparin (3.75 U/mL); enoxaparin (17.5 U/mL); rTAP (4 mumol/L); and porcine heparin plus rTAP (2 mumol/L). Blood samples were obtained for analysis from the donor, after anticoagulation, and after 5, 30, 60, and 120 minutes of recirculation. There were no significant differences between groups in platelet count, response to adenosine diphosphate, or prothrombin fragment (F1.2) production. rTAP plus heparin reduced beta-thromboglobulin release; fibrinopeptide A concentrations were significantly higher with rTAP alone. Enoxaparin strongly and significantly inhibited complement C5b9 production and neutrophil elastase release and was associated with significantly increased concentrations of C1-C1 inhibitor and kallikrein-C1 inhibitor complexes.

CONCLUSIONS

rTAP does not reduce thrombin formation or activity during in vitro extracorporeal circulation. Enoxaparin markedly inhibits formation of the complement membrane attack complex and neutrophil elastase release, possibly by accelerating C1 inhibitor activity.

Further evidence of bradykinin involvement in septic shock: reduction of kinin production in vivo and improved survival in rats by use of polymer tailored SBTI with longer t1/2

Involvement of bradykinin in septic shock and its therapeutic endeavor using soybean trypsin inhibitor (SBTI, Kunitz type) were investigated in an in vivo model of septic shock induced by pseudomonal elastase. Pseudomonal elastase injection at 0.5 mg/kg i.v. to guinea pigs resulted in elevation level of bradykinin in the blood from < 1 ng/ml to 25 ng/ml which was accompanied by a drop of mean arterial blood pressure (MABP) (about 45 mmHg). When native soybean trypsin inhibitor (SBTI, Kunitz type, 20 kDa) was injected, into this model, induction of bradykinin generation and hypotension by the bacterial protease treatment was completely obliterated as judged by the both levels of bradykinin and MABP. Specifically, by the treatment with SBTI, bradykinin levels did not increase and the drop of the blood pressure was minimal (< 10 mmHg) in this time frame (< 30 min). We designed and prepared succinylated gelatin-conjugated SBTI (suc-gel SBTI) with enlarged molecular mass (M(r) approximately 110,000) and higher area under the curve of the plasma concentration, which exhibits about 6 times longer plasma half-life (t1/2) and about 4 times larger area under the curve of plasma concentration. Suc-gel-SBTI suppressed the pseudomonal protease-induced shock much more effectively than native SBTI, the conjugate exhibited its effect for more than 3 h, while the native SBTI showed the effect only within 2 h after i.v. injection.

Neutrophil adhesion on surfaces preadsorbed with high molecular weight kininogen under well-defined flow conditions

The adhesion of neutrophils and other leukocytes to biomaterial surfaces is an important phenomenon in the host response to biomaterials because the number of adherent leukocytes is often related to the inflammatory response after implantation. After adhering to biomaterial surfaces, other leukocyte reactions, such as phagocytosis, respiratory burst, and protease release, may occur and result in the deterioration of the implanted biomaterial and injury to peripheral tissue. This study of neutrophil adhesion quantitatively characterizes neutrophil adhesion under well-defined laminar flow conditions using a radial flow chamber. In this rheologically well-defined system, the fluid shear rate on the surface varies continuously with radial position. This allows the study of shear-dependent behavior of neutrophil adhesion. Exploiting the variable shear rate in the radial flow chamber, the kinetics of neutrophil adhesion was obtained using automated video microscopy and image analysis to recursively acquire cell counts from multiple fields in different radial positions, and to quantify the surface density of neutrophil as a function of time. Neutrophil adhesion was studied on glass preadsorbed with fibrinogen and high-molecular-weight kininogen (HK). At a shear rate of 20 s-1, the number of adherent cells on the preadsorbed fibrinogen surface was similar to that on bare glass, and the number of adherent cells on the HK surface was less than 10% of that on the bare glass. We conclude that surfaces preadsorbed with HK are anti-adhesive to neutrophils.

Parasuicide in Pakistan: experience at a university hospital

There have been few reports of parasuicide from Pakistan, where the act is considered to be a criminal offence and the Islamic religion strongly disapproves of it. In order to address the problem, a retrospective case report analysis of all index cases of parasuicide presenting over a period of 3.5 years to a university hospital in Karachi, Pakistan, was undertaken. Our results showed that most of the subjects were young adults, with married women representing the single largest group. Self-poisoning with medication was the most common method, and benzodiazepines the most frequently used drug. Interpersonal conflict with the opposite sex was the most common precipitating cause. In Pakistani culture, marriage appears to be a significant source of stress for women. Reports based on official police records do not reflect the true picture of the problem in Pakistan.

Phosphodiesterase inhibitors suppress proliferation of peripheral blood mononuclear cells and interleukin-4 and -5 secretion by human T-helper type 2 cells

It has been suggested that interleukin-4 and -5 (IL-4 and IL-5) are instrumental in the control of allergic disease. Elevated levels of IL-4 messenger RNA (mRNA) have been detected in numerous foci of atopic activity, including bronchoalveolar lavage (BAL) fluid from atopic asthmatics and skin of atopic dermatitis patients. IL-5 is important in eosinophil activation, which is a common feature of atopic disease. IL-5 mRNA has been detected in BAL fluid from both atopic and non-atopic asthmatics, indicating that IL-5 may be a common feature of the two disease states. Production of IL-4 and IL-5 by T cells appears to be associated with a high affinity cyclic AMP (cAMP) phosphodiesterase (PDE). This study was designed to compare the effects of PDE inhibitors Ro20-1724 and theophylline on (1) the mitogenic response of peripheral blood mononuclear cells from atopic and non-atopic individuals and (2) secretion of IL-4 and IL-5 by TH(2) cells after activation with PMA and anti-CD3. Both Ro20-1724 and theophylline inhibited proliferation of PBMC in a dose-dependent manner. There was no significant difference between proliferation of PBMC from atopic versus non-atopic donors, but Ro20-1724, a specific PDE IV inhibitor, was more potent at a concentration of 10(-5)M than theophylline in suppressing lymphocyte proliferation. Similarly, both PDE inhibitors suppressed secretion of IL-4 and IL-5 from TH(2)-like cell lines in a dose-dependent manner. In conclusion, as Ro20-1724 and theophylline inhibit proliferation of PBMC and secretion of IL-4 and IL-5 from human TH(2) cell lines, the development of a selective cyclic nucleotide PDE IV inhibitor may provide a promising new approach for asthma prophylaxis.

Surface-bound heparin fails to reduce thrombin formation during clinical cardiopulmonary bypass

The hypothesis that heparin-coated perfusion circuits reduce thrombin formation and activity; fibrinolysis; and platelet, complement, and neutrophil activation was tested in 20 consecutive, randomized adults who had cardiopulmonary bypass. Twenty identical perfusion systems were used; in 10, all blood-contacting surfaces were coated with partially degraded heparin (Carmeda process; Medtronic Cardiopulmonary, Anaheim, Calif.). All patients received a 300 U/kg dose of heparin. Activated clotting times were maintained longer than 400 seconds. Cardiopulmonary bypass lasted 36 to 244 minutes. Blood samples for platelet count, platelet response to adenosine diphosphate, plasma beta-thromboglobulin, inactivated complement 3b, neutrophil elastase, fibrinopeptide A, prothrombin fragment F1.2, thrombin-antithrombin complex, tissue plasminogen activator, plasminogen activator inhibitor-1, plasmin alpha 2-antiplasmin complex, and D-dimer were obtained at these times: after heparin was given, 5 and 30 minutes after cardiopulmonary bypass was started, within 5 minutes after bypass was stopped, and 15 minutes after protamine was given. After cardiopulmonary bypass, tubing segments were analyzed for surface-adsorbed anti-thrombin, fibrinogen, factor XII, and von Willebrand factor by radioimmunoassay. Heparin-coated circuits significantly (p < 0.001) reduced platelet adhesion and maintained platelet sensitivity to adenosine diphosphate (p = 0.015), but did not reduce release of beta-thromboglobulin. There were no significant differences between groups at any time for fibrinopeptide A, prothrombin fragment F1.2, or thrombin-antithrombin complex or in the markers for fibrinolysis: D-dimer, tissue plasminogen activator, plasminogen activator inhibitor-1, and alpha 2-antiplasmin complex. In both groups, concentrations of prothrombin fragment F1.2 and thrombin-antithrombin complex increased progressively and significantly during cardiopulmonary bypass and after protamine was given. Concentrations of D-dimer, alpha 2-antiplasmin complex, and plasminogen activator inhibitor-1 also increased significantly during bypass in both groups. Fibrinopeptide A levels did not increase during bypass but in both groups increased significantly after protamine was given. No significant differences were observed between groups for levels of inactivated complement 3b or neutrophil elastase. Radioimmunoassay showed a significant increase in surface-adsorbed antithrombin on coated circuits but no significant differences between groups for other proteins. We conclude that heparin-coated circuits used with standard doses of systemic heparin reduce platelet adhesion and improve platelet function but do not produce a meaningful anticoagulant effect during clinical cardiopulmonary bypass. The data do not support the practice of reducing systemic heparin doses during cardiac operations with heparin-coated extracorporeal perfusion circuitry.

Primary corneal graft failure. A national reporting system. Medical Advisory Board of the Eye Bank Association of America

OBJECTIVES

To describe a national eye banking registry and to assess the effects of donor age, cause of donor death, time from death to procurement, storage time, and distance between the points of recovery and transplantation on the reported occurrence of primary corneal graft failure.

DESIGN

We performed a retrospective case-control study to estimate the odds ratios of five donor factors for cases of primary graft failure voluntarily reported to a national registry using controls from selected eye banks. We also performed a nested case-control cohort study to compare cases of primary graft failure that occurred in both corneas from the same donor with those of nonmated corneas in which primary graft failure was reported to assess odds ratios for the same donor factors.

PATIENTS

One hundred forty-seven patients developed primary graft failure in penetrating keratoplasty transplantations performed between January 1, 1991, and December 31, 1993. These cases were reported to the Adverse Reaction Registry of the Eye Bank Association of America, Washington, DC. Controls included 7240 donor corneas distributed by nine eye banks during 1992.

RESULTS

Of the 147 donor corneas that developed primary graft failure, 17 (12%) were obtained from donors who were aged 70 years and older, 39 (27%) came from donors who died of trauma, 13 (9%) had a cadaver time longer than 12 hours, 10 (7%) had a storage time longer than 7 days, and 38 (26%) were distributed outside the eye bank's region. Compared with controls, these donor corneas were more likely to have a storage time longer than 7 days (odds ratio, 2.4; 95% confidence limits, 1.2 and 4.6) and to come from donors aged 70 years and older (odds ratio, 2.4; 95% confidence limits, 1.4 and 4.0). The 22 corneas (15%) in which primary graft failure occurred in both recipients from the same donor were 8.5 times (95% confidence limits, 1.1 and 51.5) more likely to be preserved beyond 1 week than were nonmated corneas with primary failure but were not from significantly older donors. Logistic regression analysis showed that the association between prolonged storage time and primary graft failure in mated corneas remained significant even when the analysis was controlled for other donor factors.

CONCLUSIONS

No clearly defined donor or eye banking factor accounted for most cases of primary graft failure, although prolonged corneal storage and advanced donor age may increase its risk. Ophthalmologists are urged to report to their eye bank all cases of primary graft failure and other adverse events that might be attributable to donor eye tissue.

An eye banking program for selecting donor corneas for surgical distribution

Since fewer donated corneas have become available for surgery, we sought to chart the reasons to exclude them for surgical use over time. Those excluded from surgical use (1991-1994) were plotted using an algorithm based on the reasons for exclusion. Four general categories (universal contraindications [UC], national/local medical criteria [NLMC], serology, and morphology) yielded 13 possible areas. UC and NLMC exclusions for 1993-1994 were higher compared with 1991 and 1992 (p < 0.001). The proportion of corneas excluded for serological reasons decreased (p < 0.001) from 1991 to 1994. Exclusions due to morphology remained the same for all 4 years (p = NS). NLMC eliminate older donors but also exclude younger donors before the tissue reaches the eye bank (p > 0.001). Three of four of the youngest tissues ( < 30 years) are used for surgery, whereas one of five of the oldest ( > 70 years) is used. A quality control algorithm provides a heuristic and logical paradigm for noting changes from year to year. Heightened regulation has counteracted many gains in corneal donation fostered by favorable laws.

Recurrent myocardial infarction with angina and normal coronary arteries

Although it is well recognised that patients with ischemic heart disease can have normal coronary arteries on coronary angiography, most such patients have angina pectoris, whilst a minority have had a previous myocardial infarction. There are few reports of patients with recurrent myocardial infarctions and angina, but with normal coronary arteries on coronary angiography. We describe six patients who had more than one myocardial infarction, confirmed by raised cardiac enzymes and changes on the electrocardiogram. They subsequently developed classical angina and subsequent coronary angiography demonstrated no atherosclerotic coronary artery disease. Coronary artery spasm and diminished coronary reserve may have been contributory factors in these patients.

Capillary perfusion--a study in two groups of radiated patients for cancer of head and neck

Laser Doppler velocitometry is novel non-invasive technique to assess cutaneous microcirculation. Patients undergoing radiation therapy for head and neck cancer with convention and accelerated fraction action were evaluated under normal condition before and after radiation. A total of 70 sites in group A (conventional fractionation) and 35 sites in group B (accelerated fractionation were evaluated. Increase in perfusion was noted in patients undergoing radiation with accelerated fractionation.

Epidemiology of smallpox in west Pakistan. III. Outbreak detection and interlocality transmission. 1971

During one year, 121 outbreaks of variola major were detected in 99 of the 1717 localities within a rural area of West Pakistan with a total population of approximately 1.2 million. Only 19% of the outbreaks, representing 36% of the 1040 investigated cases, were officially reported, although potential strengths in the government surveillance system were also identified. Persistence of smallpox within the area depended on introductions from the outside, and more than one-half of all outbreaks of known source could be ultimately traced to cities. Within the study area, outbreaks with the largest numbers of cases and those in the larger communities were the ones from which smallpox was most frequently transported. The frequency with which variola was introduced into localities was directly related to population size and to the presence of medical care facilities. Trips between localities by infected individuals were extremely rare events. They were made most often during the late fall and winter, primarily during the incubation period of the disease, and did not differ in purpose, means or destination from journeys unassociated with smallpox. Individuals at relatively high risk of becoming introducers included the unvaccinated (primarily children under five), the unschooled and those not native to the area. Vaccination priorities based on these findings could increase the efficiency of smallpox eradication efforts.

Role of alpha-2-macroglobulin and bacterial elastase in guinea-pig pseudomonal septic shock

An essential role of alpha-2-macroglobulin (alpha 2M) was revealed in the prevention of septic shock induced in guinea-pigs by an elastase producing strain (IFO-3455) of Pseudomonas aeruginosa. When bacterial peritonitis was induced by inoculating fibrin-thrombin clot containing viable bacteria at a dose of 10(9) c.f.u./kg body weight, the guinea-pigs (n = 6) died within 7-8 hours due to septic shock. Prior to the shock, consumption of two-thirds of the circulating alpha 2M was observed. When circulating alpha 2M was depleted 4 hours after the bacterial inoculation, the guinea-pigs immediately developed shock and died within one hour. This shock was prevented either with a specific elastase inhibitor, HONHCOCH(CH2C6H5)CO-Ala-Gly-NH2, zincov (6 microM), or with human alpha 2M. Simultaneous depletion of circulating Hageman factor also prevented shock in the alpha 2M-depleted animals. These results indicate that septic shock was induced through activation of the Hageman factor dependent system by the bacteria-produced elastase which survived alpha 2M in the circulation.

Differential effects of histamine on T helper type 2 (TH2) lymphocytes

Histamine inhibits IL-4 secretion from T helper type 2 cells but enhances IL-5 secretion from the same cells. Both of these effects are mediated by H2 receptors. Not all cyclic AMP-elevating agents affect IL-4 and IL-5 secretion. The observations suggest a selective effect of histamine on TH2 lymphocytes. Furthermore, Cl- channels may be involved in histamine-mediated regulation of cytokine secretion. The data suggest that histamine-induced elevation of cyclicAMP may be an important, but probably not the sole, mechanism underlying the selective effects of histamine on cytokine production.

Esophageal countershock: anthropometric determinants of impedance

OBJECTIVE

To examine the use of a novel esophageal electrode system for countershock of atrial and ventricular tachyarrhythmias, with particular regard to the measurement of transesophageal and transthoracic impedances and their association with anthropometric variables.

METHODS

Transesophageal cardioversion was attempted during 131 episodes of arrhythmia in 105 patients (including 109 episodes of atrial fibrillation). The esophageal system also used in 29 patients undergoing electrophysiologic studies for investigation of ventricular tachyarrhythmias. Transesophageal and transthoracic impedances were estimated during passage of a high-frequency, low-amplitude current between the respective electrodes. Impedance estimates were associated with anthropometric measurements using linear regression (least-squares method).

RESULTS

In the group of patients undergoing attempted transesophageal cardioversion, the mean estimated transesophageal impedance of 52.6 +/- 11.7 omega was significantly lower than the mean estimated transthoracic impedance of 63.1 +/- 16.4 omega (n = 104, p < 0.01). For all the patients, transesophageal impedance was associated with weight, body mass index, and chest circumference (all r > or = 0.65, p < 0.01). Transthoracic impedance was associated with the same factors (all r > or = 0.55, p < 0.01).

CONCLUSION

This esophageal electrode system results in lower impedance values for countershock between the esophagus and the cutaneous cardiac apex in comparison with standard transthoracic cutaneous electrode placement. Both techniques are dependent on anthropometric factors.