Immunophenotypic characterisation of carotid plaque: increased amount of inflammatory cells as an independent predictor for ischaemic symptoms

OBJECTIVES

To investigate the inflammatory response within intact carotid plaques from carotid eversion endarterectomy (CEE) to determine the relationship between immunohistological plaque morphology and ischaemic cerebrovascular symptoms.

MATERIAL AND METHODS

Intact CEE plaques from 71 patients with high-grade (>70%) stenosis undergoing CEE (group I, symptomatic, n=42; group II, asymptomatic, n =29) and 12 normal postmortem arteries (control group) were analysed with specific antibodies to inflammatory cells (T-Lymphocytes (CD3, CD4), cytotoxic T-cells (CD8), B-lymphocytes (CD20), natural killer cells (CD57), macrophages (CD68)), endothelial adhesion molecules (ICAM-1 (CD54), P-selectin (CD62P), E-selectin (CD62E), VCAM-1 (CD106) and T-lymphocyte co-stimulatory molecule (CD40)) and procoagulatory modulators (thrombomodulin (CD141), tissue factor (CD142)). Both groups were matched for gender, age, risk factors, degree of carotid artery stenosis. Plaques were measured using a semiquantitative score system in a blinded fashion by two observers. Statistical analysis of the group differences were performed by using the Kruskal-Wallis test and the Multitest Procedure with Permutation-Testing. Significance was taken as a p<0.05.

RESULTS

There were significantly more inflammatory cells, an overexpression of P-selectin and the procoagulatory markers thrombomodulin and tissue factor in symptomatic compared to both asymptomatic plaques and the ones of the control group. In both groups there was no significance for ICAM-1, VCAM-1, macrophages and co-stimulatory molecule CD40. There was also no significance for any factor between the asymptomatic and the control group. However, the differences between the symptomatic and the asymptomatic group were highly significant for all factors.

CONCLUSION

These data suggest that structural changes and inflammatory damage within the individual plaque seems to be a critical step in promoting plaque rupture with embolic sequelae.

Corroded nitinol wires in explanted aortic endografts: an important mechanism of failure?

PURPOSE

To analyze surface alterations and fractures observed in the nitinol stent wires of explanted endovascular grafts used for treatment of abdominal aortic aneurysm.

METHODS

Twenty-one explanted Stentor devices and 1 Cragg stent were received from investigators in Germany and France. After macroscopy and photography, the explants were cleaned and the polyester coating removed. The frame was examined completely by stereomicroscopy, and irregularities were assayed by scanning electron microscopy and energy dispersive x-ray analysis (EDAX). The observed alterations were classified according to stereomicroscopic and electron microscopic morphology.

RESULTS

The mean implantation interval for the endografts was 29.1 +/- 13.2 months (range 5-46). All examined explants, even those retrieved after only a few months in situ, showed pitlike surface damage 10-25 microm in diameter. Larger, irregularly shaped surface alterations were observed in approximately 70% of the explants. Older explants (age >32 months) presented vast regions of decay, with bending of the wire and stress cracks in some areas. EDAX examination revealed decreased nickel concentration in the corroded regions.

CONCLUSIONS

Corrosion of the nitinol wire in endovascular grafts is confirmed. Presumably, the observed pitting and irregularly shaped corrosion defects are the precursors of material failure. They weaken the thin wire, which leads to stress cracks and eventually fracture of the stent wire under circulatory pulsation. Cell-induced electrochemical corrosion and active cellular destruction of surfaces are well-known mechanisms that must be investigated for their possible roles in the corrosion of stent metals.

Corroded nitinol wires in explanted aortic endografts: an important mechanism of failure?

PURPOSE

To analyze surface alterations and fractures observed in the nitinol stent wires of explanted endovascular grafts used for treatment of abdominal aortic aneurysm.

METHODS

Twenty-one explanted Stentor devices and 1 Cragg stent were received from investigators in Germany and France. After macroscopy and photography, the explants were cleaned and the polyester coating removed. The frame was examined completely by stereomicroscopy, and irregularities were assayed by scanning electron microscopy and energy dispersive x-ray analysis (EDAX). The observed alterations were classified according to stereomicroscopic and electron microscopic morphology.

RESULTS

The mean implantation interval for the endografts was 29.1 +/- 13.2 months (range 5-46). All examined explants, even those retrieved after only a few months in situ, showed pitlike surface damage 10-25 microm in diameter. Larger, irregularly shaped surface alterations were observed in approximately 70% of the explants. Older explants (age >32 months) presented vast regions of decay, with bending of the wire and stress cracks in some areas. EDAX examination revealed decreased nickel concentration in the corroded regions.

CONCLUSIONS

Corrosion of the nitinol wire in endovascular grafts is confirmed. Presumably, the observed pitting and irregularly shaped corrosion defects are the precursors of material failure. They weaken the thin wire, which leads to stress cracks and eventually fracture of the stent wire under circulatory pulsation. Cell-induced electrochemical corrosion and active cellular destruction of surfaces are well-known mechanisms that must be investigated for their possible roles in the corrosion of stent metals.

Evidence for a gender-related effect of alcoholism on brain volumes

OBJECTIVE

The goal of this study was to compare brain volumes of alcoholic and nonalcoholic men and women and determine if the magnitudes of differences in brain volumes between alcoholic women and nonalcoholic women are greater than the magnitudes of the differences between alcoholic men and nonalcoholic men.

METHOD

The study group included 118 subjects: 79 inpatients 30-60 years of age who were alcohol dependent but had no clinically apparent cognitive impairment or medical illness (43 men and 36 women) and 39 healthy comparison subjects of similar age who were not alcoholic (20 men and 19 women). The volume of intracranial contents was segmented into gray matter, white matter, sulcal CSF, and ventricular CSF from a T(1)-weighted magnetic resonance image obtained after the alcoholic subjects had attained 3 weeks of sobriety.

RESULTS

Alcoholic women had significantly smaller volumes of gray and white matter as well as greater volumes of sulcal and ventricular CSF than nonalcoholic women. The differences in gray and white matter volumes between alcoholic and nonalcoholic men were significant, but the significance of these differences was of a smaller magnitude than the significance of the differences between alcoholic and nonalcoholic women. Direct comparisons of alcoholic men and women showed that the proportion of intracranial contents occupied by gray matter was smaller in alcoholic women than in alcoholic men. The magnitudes of differences in brain volumes adjusted for intracranial size between alcoholic women and nonalcoholic women were greater than the magnitudes of the adjusted differences between alcoholic men and nonalcoholic men.

CONCLUSIONS

These results are consistent with greater sensitivity to alcohol neurotoxicity among women.

Loss of the ClC-7 chloride channel leads to osteopetrosis in mice and man

Chloride channels play important roles in the plasma membrane and in intracellular organelles. Mice deficient for the ubiquitously expressed ClC-7 Cl(-) channel show severe osteopetrosis and retinal degeneration. Although osteoclasts are present in normal numbers, they fail to resorb bone because they cannot acidify the extracellular resorption lacuna. ClC-7 resides in late endosomal and lysosomal compartments. In osteoclasts, it is highly expressed in the ruffled membrane, formed by the fusion of H(+)-ATPase-containing vesicles, that secretes protons into the lacuna. We also identified CLCN7 mutations in a patient with human infantile malignant osteopetrosis. We conclude that ClC-7 provides the chloride conductance required for an efficient proton pumping by the H(+)-ATPase of the osteoclast ruffled membrane.

Effects of high-intensity resistance training on untrained older men. II. Muscle fiber characteristics and nucleo-cytoplasmic relationships

During growth and repair of skeletal muscle fibers, satellite cells become activated, undergo mitosis, and a daughter nucleus becomes incorporated into the muscle fiber to increase myonuclear numbers. An increase in myonuclei appears to be required for this postnatal growth. This study examined whether muscle fibers of elderly men can hypertrophy with strength training and, if so, whether they have the capacity to incorporate nuclei into the fibers. The sarcoplasmic area associated with each myonucleus was calculated in nine elderly men before and after 16 weeks of strength training, and compared to nine elderly control men. Muscle fiber type changes and myosin heavy chain composition were also compared. All major fiber types (I, IIA, IIB) became significantly larger after training, and a transition of type IIB fibers to IIA occurred with training. The area occupied by each fiber type correlated with myosin heavy chain percentage, and both of these changed similarly with strength training. The cytoplasm-to-myonucleus ratio increased, but not significantly (p = .07), with muscle fiber hypertrophy. Number of myonuclei per fiber and myonuclei per unit length of muscle fiber increased, but not significantly. Cross-sectional areas of the muscle fibers in untrained elderly men were much smaller than in untrained young men (when compared with our earlier studies). Training increased the sizes of the elderly muscle fibers to that of the untrained young men. This hypertrophy of muscle fibers by 30% with training resulted in no change in the cytoplasm-to-myonucleus ratio. This suggests that the myonuclear population continues to adapt to growth stimuli in the elderly muscles.

FMRI visualization of brain activity during a monetary incentive delay task

Comparative studies have implicated striatal and mesial forebrain circuitry in the generation of autonomic, endocrine, and behavioral responses for incentives. Using blood oxygen level-dependent functional magnetic resonance imaging, we sought to visualize functional activation of these regions in 12 normal volunteers as they anticipated and responded for monetary incentives. Both individual and group analyses of time-series data revealed significant activation of striatal and mesial forebrain structures (including insula, caudate, putamen, and mesial prefrontal cortex) during trials involving both monetary rewards and punishments. In addition to these areas, during trials involving punishment, group analysis revealed activation foci in the anterior cingulate and thalamus. These results corroborate comparative studies which implicate striatal and mesial forebrain circuitry in the elaboration of incentive-driven behavior. This report also introduces a new paradigm for probing the functional integrity of this circuitry in humans.

Percutaneous tracheostomy by forceps dilation: report of 162 cases

A prospective, observational clinical study evaluated the safety of percutaneous single-step dilatational tracheostomy over a 43-month period. One hundred and sixty-two patients were deemed suitable for the procedure. The mean duration of tracheal intubation prior to tracheostomy was 6 days. The mean duration of the procedure was 9.3 min. Intra-operative complications occurred in 27 patients (16.6%), most of which were minor technical difficulties without morbidity. Postoperative complications, some of which were associated with morbidity, occurred in 16 patients. There were two deaths secondary to premature decannulation, one case of severe bleeding and five pneumothoraces. Long-term complications were assessed in 81 patients; there were four tracheal stenoses requiring surgery or laser therapy and seven patients with granulation tissue at the stoma site which did not require treatment. Forceps dilatational percutaneous tracheostomy appeared to be a convenient bedside procedure. However, complications do occur and further studies should address late sequellae, such as tracheal stenosis.

[Investigations on the fermentation quality of silage from low-nitrate green forage]

In 3-year-experiments green forage from Dactylis glomerata and Festuca species, produced by differentiated cutting frequencies, was ensiled under laboratory conditions. The forage was almost without nitrate. Because of the higher content of water-soluble carbohydrates the fermentability coefficients of Festuca species were above of Dactylis glomerata. The fermentability coefficients of both plant species were inferior in the second and third cut, even if the first cut was delayed until July. Despite of similar fermentability coefficients of the two plant species silages contained different amounts of lactic and butyric acid. The portion of lactic acid amounted to 52 to 57% and 60 to 73% of total acids, the proportion of butyric acid 30 to 35% and 18 to 25% for Dactylis glomerata and Festuca species, respectively. According to the high fermentability coefficients silages free of butyric acid would be expected, however, by both species butyric acid always was formed, in some cases at high concentrations. In the contrary the amounts of ammonia, acetic acid and alcohol as well as the pH-value were almost extremely low. It can be concluded that the quality of silages produced of green forages with low nitrate cannot be assessed adequately by the current evaluation key.

Determination of trace anions in organic solvents

Ion chromatography along with matrix elimination was used to reliably determine trace levels of anionic contaminants in organic solvents. A 5-ml sample volume was injected directly into the instrument without any sample pretreatment. High-purity deionized water was used to deliver the sample to a preconcentration column, where the anions of interest were retained while the organic matrix was rinsed to waste. A sodium carbonate eluent eluted concentrated anions from the preconcentration column and separated them on a 2-mm pellicular anion-exchange column. The separated anions were detected by suppressed conductivity. This method was used to determine the anionic contaminants of isopropanol, acetone and N-methylpyrrolidone. Method detection limits for chloride, nitrate, sulfate and phosphate were all lower than 1 microg/l.

Determination of trace anions in concentrated weak acids by ion chromatography

Ion-exclusion chromatography (ICE) followed by ion chromatography (IC) was used for the determination of trace anionic contaminants in concentrated weak acids. The ICE separation was used as a pretreatment step to isolate the contaminant anions of strong acid from the excess of matrix ions. Then a fraction containing the analyte ions was separated using IC with suppressed conductivity detection. Microbore-ion-exchange columns were chosen to address the increased purity requirements for use of these concentrated acids in semiconductor applications. The chromatographic conditions were optimized for determining trace chloride, sulfate, phosphate, and nitrate in concentrated 24.5% (v/v) hydrofluoric acid; trace chloride, sulfate, and nitrate in concentrated 85% (w/w) phosphoric acid and trace chloride and sulfate in concentrated 0.7% (v/v) glycolic acid. Method detection limits for the anions of interest were below 100 micrograms/l.

Finance issue brief: insurance reform

Individual and small group market reforms are intended to increase access to health insurance. The majority of the working uninsured are employed by small businesses, prompting state legislatures to make changes in the small group market. Many states did this on their own; however to ensure that health insurance was reaching the most people possible, the federal government enacted the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This act required states without extensive law in the small group and individual insurance market to enact laws to comply with provisions such as guaranteed issue, guaranteed renewal, preexisting conditions, portability and nondiscrimination. It also delved into other areas, including long-term care, inpatient care after childbirth, medical savings accounts and mental health parity.

Finance issue brief: mandated benefits

By enacting legislation to mandate a health insurance benefit, legislators require health plans to provide coverage for particular treatments, screenings, prescriptions and providers. During the 1998 state legislative sessions, several new and somewhat controversial mandates emerged at the forefront of discussion, including coverage for contraceptives, general anesthesia for dental procedures and newborn hearing screening. In 1999, all three of these mandates and others have gained speed as some sessions hit their midpoints and many adjourn.

Finance issue brief: women's health: a legislative overview of selected mandates

From pregnancy to breast cancer screening and osteoporosis prevention, women have a need for a gender-specific set of health services. Dialogue that once occurred only between women and their physicians has evolved into debate between representatives from the insurance industry and state legislators. Therefore, women's health issues have risen on the legislative agenda, illustrated by the increased volume of bills introduced and enacted during the past five years.

Phospholipase A2: its usefulness in laboratory diagnostics

Phospholipase A2 (PLA2) is an enzyme that catalyzes the hydrolysis of membrane phospholipids. This article reviews the source and structure of PLA2, the involvement of the enzyme in various biological and pathological phenomena, and the usefulness of PLA2 assays in laboratory diagnostics. Of particular importance is the role of PLA2 in the cellular production of mediators of inflammatory response to various stimuli. Assays for PLA2 activity and mass concentration are discussed, and the results of enzyme determinations in plasma from patients with different pathological conditions are presented. The determination of activity and mass concentration in plasma is particularly useful in the diagnosis and prognosis of pancreatitis, multiple organ failure, septic shock, and rheumatoid arthritis. A very important result is the demonstration that PLA2 is an acute phase protein, like CRP. Indeed, there is a close correlation between PLA2 mass concentration and CRP levels in several pathological conditions. Although the determination of C-reactive protein is much easier to perform and is routinely carried out in most clinical laboratories, the assessment of PLA2 activity or mass concentration has to be considered as a reliable approach to obtain a deeper understanding of some pathological conditions and may offer additional information concerning the prognosis of several disorders.

[The use of curare-like agents in resuscitation]

OBJECTIVE

To analyse current data on use of neuromuscular blocking agents (NBA) in the intensive therapy unit (ITU) patients and to propose practice guidelines.

DATA SOURCES

We did a Medline search of French and English language articles on NBA administration in ITU patients from 1960 to 1998. Data were also selected from our own collection of articles and books.

STUDY SELECTION

Original articles, clinical cases, letters to the editor and review articles were considered.

DATA EXTRACTION

Data on pharmacology of NBA in the ITU patient were extracted, as well as data on administration patterns and cost.

DATA SYNTHESIS

The indications for myorelaxation in ITU patients include either short term use, as in anaesthesia, or long term administration for facilitation of mechanical ventilation, control of increased intracranial pressure, status epilepticus, tetanus and oxygen demand in case of muscular hyperactivity, diagnostic and therapeutic procedures facilitation. A beneficial effect of NBA on the prognosis of the disease for which these agents have been used is not yet proven. Suxamethonium, because for its short onset time and duration of action, is the agent of choice for endotracheal intubation if myorelaxation is required. Among the benzylisoquinolines, atracurium and besilate of cisatracurium are convenient agents in ITU patients, whereas mivacurium is of no special interest. Among the aminosteroids, pancuronium and vecuronium are the most often used agents in the ITU. Rocuronium has not yet been extensively assessed. Myorelaxants carry risks for morbidity and mortality. The difficulty to assess the neurological status and the level of sedation is a recognised adverse effect. An accidental disconnection from the circuit and the resulting asphyxia is nowadays recognised without delay by the ventilator. NBAs increase the rate of bronchopulmonary infections. Cardiovascular complications include extreme bradycardia or sinus arrest following vecuronium administration, and cardiac arrest after suxamethonium injection mainly in burned or traumatised patients. Conversely to anaesthesia, NBAs do not carry a significant risk for anaphylactic or anaphylactoid complications in the ITU. Tachyphylaxis occurs mainly in burns and other pathologies modifying acetylcholine receptors. Neuromuscular complications include myopathy from steroids, postparalytic syndrome, deconditioning syndrome and intensive care polyneuropathy. Prolonged curarisation after discontinuation of NBA administration has a multifactorial origin and must be differentiated from neuromuscular complications. For prolonged neuromuscular blockade, pancuronium, vecuronium and atracurium are the agents of choice. The association with an adequate sedation is essential. Assessment of depth of neuromuscular blockade is not based on clinical symptoms but on train-of-four (TOF) twitch monitoring. A convenient basic relaxation is usually obtained with the suppression of the two last responses to TOF.

CONCLUSION

The use of NBA in ITU patient should result from a rational decision making procedure, the blockade titrated with a TOF monitor and maintained as superficially and shortly as possible.

Downstream activation of a TATA-less promoter by Oct-2, Bob1, and NF-kappaB directs expression of the homing receptor BLR1 to mature B cells

The chemokine receptor, BLR1, is a major regulator of the microenvironmental homing of B cells in lymphoid organs. In vitro studies identify three essential elements of the TATA-less blr1 core promoter that confer cell type- and differentiation-specific expression in the B cells of both humans and mice, a functional promoter region (-36 with respect to the transcription start site), a NF-kappaB motif (+44), and a noncanonical octamer motif (+157). The importance of these sites was confirmed by in vivo studies in gene-targeted mice deficient of either Oct-2, Bob1, or both NF-kappaB subunits p50 and p52. In all of these animals, the expression of BLR1 was reduced or absent. In mice deficient only of p52/NF-kappaB, BLR1 expression was unaffected. Thus our data demonstrate that BLR1 is a target gene for Oct-2, Bob1, and members of the NF-kappaB/Rel family and provides a link to the impaired B cell functions in mice deficient for these factors.

[Severe form of familial migraine with coma]

The authors report the case of a 43-year-old man experiencing a migraine attack with coma requiring a treatment in an intensive care unit for 9 days. The probable triggering cause as a cerebral arteriography.

[Acute Streptococcus salivarius meningitis after spinal anesthesia]

The case of a 50-year-old woman who experienced an acute Streptococcus salivarius meningitis after a spinal anaesthesia for hysteroscopy is reported. The contamination of the cerebrospinal fluid may occur from a puncture during a bacteriaemia. Contamination from the patient's skin and from the upper airway's flora of the operator seems to be a more plausible cause. Spinal anaesthesia is contra-indicated in the febrile patient. Asepsis is essential during spinal puncture, including wearing a surgical face mask.

"Ocean-to-Ocean Project": a transcontinental external quality assessment trial in clinical chemistry realized throughout Eurasia

More than 800 diagnostic laboratories situated throughout the Eur-Asian continent--from the Pacific Coast up to the North Sea littoral--were involved in a common survey of External Quality Assessment (EQA). It consisted of the simultaneous measurement of up to 30 analytes of 'general' clinical chemistry using the same batch of control material. The laboratories were associated in four EQA institutions: SKZL (The Netherlands), OQUASTA (Austria), SEKK (Czech Republic) and BKKSystem (Community of Independent States). The results demonstrated the feasibility of such a large-scale survey and provided a realistic idea about the state-of-the-art of laboratory diagnosis in these countries: Besides some local specific problems, such as poor quality of water or the forced use of reagents and calibrators from different sources, there are general problems hindering an efficient process of 'harmonization' in laboratory medicine, namely, the high methodological dispersion especially in the case of enzymes and of some organic analytes. At the same time there is a potential necessity for more concentrated implementation of internal quality assessment into the routine work of laboratories.

[Fermentation process during the ensiling of green forage low in nitrate. 2. Fermentation process after supplementation of nitrate, nitrite, lactic acid bacteria and formic acid]

The effect of adding nitrate and nitrite (0.05% and 0.01% N in DM) of two inoculants or formic acid on the ensiling of orchardgrass and a grass-legumes-mixture, both low in nitrate, was proved in two experiments during ensiling starting in an early stage of fermentation silages without additives contained butyric acid, with increasing amounts up to 180 day of storage period. Silages with added nitrate or nitrite (0.1% N in DM) contained no butyric acid despite of a delay in the formation of lactic acid Nitrite was more effective as nitrate (both 0.05% N in DM) to suppress butyric acid fermentation. However, both additives, nitrite and nitrate, increased the lactic acid fermentation. Interpreting this facts it was hypothesized that the clostridia was inhibited by nitrate and nitrite. Addition of inoculants improved the formation of lactic acid, and decreased pH-value in comparison to control silages. The formation of butyric acid was limited, but not suppressed. The effect of inoculants differed in the intensity of fermentation and the formation of by-products of lactic acid fermentation. The effect of formic acid was not sure.