Intergroup RTOG 98–11: A phase III randomized study of 5-fluorouracil (5-FU), mitomycin, and radiotherapy versus 5-fluorouracil, cisplatin and radiotherapy in carcinoma of the anal canal

4009

Background: An ∼65% 5-year disease-free-survival (DFS) rate from 5-FU/mitomycin/radiation for anal carcinoma needs improvement. Methods: A phase III randomized trial compared 5-FU (1,000mg/m2 days 1–4 and 29–32) plus mitomycin (10mg/m2 days 1 and 29) and radiation (45 to 59 Gy) (Arm A) to 5-FU (1,000mg/m2 days 1–4, 29–32, 57–60 and 85–88) plus cisplatin (75mg/m2 on days 1, 29, 57 and 85) and radiation (45 to 59 Gy; start day=57) (Arm B) in anal carcinoma patients. Stratification included gender, clinical N status and tumor diameter. Primary endpoint was DFS. Statistical power was 80% with two-sided test to detect 10% DFS increase for Arm B. Results: Of 682 patients accrued, 598 were analyzable. Most unanalyzed patients’ data are early. Patient characteristics were balanced. Median age was 55 years, women predominated (69%), 27.5% had >5 cm tumor diameter and 26% had clinically N+ cancer. Preliminary 5-year estimated DFS was 56% for Arm A and 48% for Arm B (p=0.28) and 5-year estimated overall survival was 69% for both arms (p=0.24). Men(p=0.04), clinically N+ cancer (p<0.0001) and tumor diameter >5 cm (p=0.005) independently prognosticated DFS in a multivariate analysis. 5-year colostomy rate was 10% for Arm A and 20% for arm B(p=0.12). Grade 3/4 toxicity rates: non-hematologic=76% for Arm A and 75% for Arm B but hematologic=67% for Arm A and 47% for Arm B(p=0.0004). Conclusions: In Intergroup-98–11, induction 5-FU/cisplatin followed by 5-FU/cisplatin/radiation failed to improve DFS compared to the standard treatment, 5-FU/mitomycin/radiation. Supported by RTOG U10 CA21661, CCOP U10 CA37422, Stat U10 CA32115.

No significant financial relationships to disclose.

Development of a new production system for weaned and growing pigs

The design of modem housing systems for farm animals calls for cooperation between scientists within different disciplines. This article describes the design of a new production system for weaned and growing pigs, as well as the analyses and working processes behind its development. The aim of the study was to develop an economically competitive system that also provided better welfare for the animals and a healthier environment for the workers. Analyses were carried out with emphasis on behavioral needs and building design and economy. The resulting system, the "safari system," consists of a number of straw flow pens of increasing size. Pigs are moved to larger and larger pens each week until slaughter. The main advantage is that pigs are not mixed during the growth period and that they are given more space, especially toward the end of the growth period when their space demand is high. Furthermore, the provision of straw for comfort and exploration and of wallow basins for cooling in the pens for the larger pigs were considered significant welfare improvements. An analysis revealed that the safari system would be economically competitive in comparison to traditional intensive systems.

New analysis for the study of the muscle function in the human oesophagus

The aim was to further develop a method for studying the active and passive tissue properties in the human oesophagus. An impedance planimetric probe with a bag for distension was placed in the distal oesophagus in 14 healthy volunteers. Distension was done at an infusion rate of 25 mL min(-1) with and without the administration of the antimuscarinic drug butylscopolamine. The flow was reversed when moderate pain was experienced by the subject. The total and the passive tension showed an exponential behaviour as function of the change in radius. The active tensions increased until they reached a maximum point. The active tension decreased after the maximum until the distension was stopped shortly after due to the pain. The change in tension during distension-induced contractions (the afterload) was plotted as function of the precontraction radius (the preload). The human oesophagus behaves in a manner known from in vitro studies on muscle strips and exhibits a muscle diagram similar to that in the heart, i.e. the larger the initial muscle length during distension (within limits), the greater the contraction force.

High incidence of skewed X chromosome inactivation in young patients with familial non-BRCA1/BRCA2 breast cancer

BACKGROUND

A higher frequency of skewed X chromosome inactivation has been reported in a consecutive series of young patients with breast cancer compared with controls of a similar age.

OBJECTIVE

To investigate the X inactivation pattern in patients with familial non-BRCA1/BRCA2 breast cancer (n = 272), BRCA1/BRCA2 germline mutations (n = 35), and sporadic breast cancer (n = 292).

METHODS

X inactivation pattern was determined by polymerase chain reaction analysis of the highly polymorphic CAG repeat in the androgen receptor (AR) gene. The X inactivation pattern was classified as skewed when 90% or more of the cells preferentially expressed one X chromosome.

RESULTS

Young patients with familial breast cancer had a significantly higher frequency of skewed X inactivation (11.2%) than young controls (2.7%) (p = 0.001). There was also a strong tendency for middle aged patients with sporadic breast cancer to be more skewed than middle aged controls (13.6% v 4.4%) (p = 0.02). No association between skewed X inactivation and breast cancer was found for the BRCA1/BRCA2 patients .

CONCLUSIONS

Skewed X inactivation may be a risk factor for the development of breast cancer in both sporadic and familial breast cancer and may indicate an effect of X linked genes.

Unintended effects and their detection in genetically modified crops

The commercialisation of GM crops in Europe is practically non-existent at the present time. The European Commission has instigated changes to the regulatory process to address the concerns of consumers and member states and to pave the way for removing the current moratorium. With regard to the safety of GM crops and products, the current risk assessment process pays particular attention to potential adverse effects on human and animal health and the environment. This document deals with the concept of unintended effects in GM crops and products, i.e. effects that go beyond that of the original modification and that might impact primarily on health. The document first deals with the potential for unintended effects caused by the processes of transgene insertion (DNA rearrangements) and makes comparisons with genetic recombination events and DNA rearrangements in traditional breeding. The document then focuses on the potential value of evolving "profiling" or "omics" technologies as non-targeted, unbiased approaches, to detect unintended effects. These technologies include metabolomics (parallel analysis of a range of primary and secondary metabolites), proteomics (analysis of polypeptide complement) and transcriptomics (parallel analysis of gene expression). The technologies are described, together with their current limitations. Importantly, the significance of unintended effects on consumer health are discussed and conclusions and recommendations presented on the various approaches outlined.

Undesired Phenotypic and Genetic Trend for Stillbirth in Danish Holsteins

The primary aim of this study was to evaluate the phenotypic and genetic trends for stillbirth in Danish Holsteins. Trends of calving difficulty and calf size were also evaluated. The second aim was to compare predicted transmitting abilities (PTA) of sires for stillbirth using a linear and a threshold model. Direct and maternal genetic effects were modeled by fitting correlated additive genetic effects of the sire and the maternal grandsire (MGS). For both the calf and the dam, covariates of breed proportions of Holstein-Friesian (HF) and the heterozygosity between HF and the original Danish Black and White (ODBW) were included. Records from 1.8 million first-calving Danish Holstein cows calving from 1985 to 2002 were used. In this period, the overall frequency of stillbirth increased from 0.071 to 0.090. An unfavorable genetic trend of stillbirth was found for both the direct and maternal effect. The background for the genetic trends was an intense use of HF sires as sires of sons, which increased the proportion of HF genes to 94% in the Danish Holstein calves born in 2002. The effect of the imported HF genes was higher direct effects of calf size, calving difficulty, and stillbirth compared with the ODBW genes. The maternal effect of stillbirth was poorer for HF than for ODBW even though HF had a better maternal calving performance than ODBW. The threshold and the linear models showed almost similar predictions of transmitting abilities of sires.

Genetic Parameters for Stillbirth in Danish Holstein Cows Using a Bayesian Threshold Model

The objective of this study was to make an inference about the direct and maternal genetic variation of stillbirth for first-calving Holstein cows and to estimate the effect of breed and heterosis for original Danish black and white and Holstein-Friesian. A Bayesian threshold model, which included correlated genetic effects of sires and maternal grandsires was used. Marginal posterior distributions of effects were obtained using Gibbs sampling. Point estimates were compared with results from a linear model using REML. Data with and without twins were analyzed and models with and without effects of breed and heterosis were fitted, but estimates of genetic parameters were almost identical. In all the analyses with threshold models, the marginal posterior mean (and standard deviation) was 0.10 (0.014) for the direct heritability, 0.13 (0.015) for the maternal heritability, and 0.05 (0.10) for the genetic correlation between direct and maternal effects. The stillbirth rate tended to increase with a higher proportion of Holstein-Friesian in the calf and in the dam, but no effects of breed and heterosis were significant. Joint sampling of all location parameters was found superior to univariate sampling in terms of much better mixing properties of the fixed effects. Based on the results showing genetic variation for stillbirth at first calving, both the direct and the maternal effect could be included in the breeding program.

The influence of consanguineous marriage on infant and child mortality among Palestinians in the West Bank and Gaza, Jordan, Lebanon and Syria

OBJECTIVES

The purpose of this paper is to explore the characteristics of mortality differences associated with consanguineous marriage among Palestinians in the Middle East.

METHODS

The data came from five surveys of Palestinians living in the West Bank and Gaza, Syria, Jordan and Lebanon, conducted during the period 1995-2000. Infant and child mortality was estimated for the offspring of consanguineous and non-consanguineous parents using the synthetic cohort method.

RESULTS

The data showed an increase in infant mortality of 15.0 additional deaths per 1,000 births among the offspring of first cousins, and a corresponding increase of 6.1 deaths per 1,000 for the progeny of parents from the same patrilineal clan.

CONCLUSION

In populations where marriage within kin groups is common, both first cousin marriage and intra-group marriage carries an added risk of infant and child mortality.

Bayesian Estimates of Covariance Components Between Lactation Curve Parameters and Disease Liability in Danish Holstein Cows

In the present work, covariance components for milk yield and disease liability were estimated with bivariate random regression test-day sire models using a Bayesian approach and implemented via the Gibbs sampler. The data consist of 8075 first-parity Danish Holstein (DH) cows, from 1259 sires, performing in 57 herds from 1992 to 1997. Treatments associated with five different type of diseases were pooled into a single general disease liability for each cow. Two models were fitted to the data. First, using a bivariate model, milk yield is modeled via a random regression, and disease liability via a repeatablility model. Second, using a bivariate model, both milk yield and disease liability are modeled using random regressions. A comparison based on a Bayes factor provides very strong support for the bivariate random regression model. Posterior means of heritabilities for each of the traits were estimated for five different points in time throughout lactation. Across models, heritabilities for milk yield are lowest in the beginning of the lactation (0.19) and highest at the end of the lactation (0.35). Posterior means of heritabilities of disease liability range from 0.04 to 0.10 for test days, and is equal to 0.20 for the whole lactation. Heritability of persistency measures estimated from the two models are 0.20 and 0.21. Estimates of posterior means of genetic correlations between single test-day milk yield and single test-day disease liability are in the range of 0.31 to 0.57. The estimates of posterior mean and of the 95% posterior interval of the genetic correlation between persistency and (total) disease liability using the model with the highest posterior probability are -0.12 and (-0.44; 0.20), respectively. Even though the largest proportion of the posterior probability mass is spread along negative values of the correlation (indicating that individuals with a flatter lactation curve tend to have lower disease liability), a value of zero of the genetic correlation falls comfortably within the 95% posterior interval. Thus the prospects of reducing incidence of disease by manipulating persistency as defined in this work remain inconclusive.

Genetic parameters of postnatal mortality in Danish Holstein calves

The objective of this study was to estimate genetic parameters of postnatal mortality (PM) in dairy cattle. Data originated from 841,921 Danish Holstein calves. Four binary traits of mortality were considered: D1-14, D15-60, D61-180, and D1-180 with numbers indicating the period of risk in days after birth. The unadjusted frequency of D1-14, D15-60, D61-180, and D1-180 were 0.027, 0.018, 0.020, and 0.066, respectively. A linear sire-model was fitted to the data, and average information-REML was used to estimate (co)variance components. Estimates of direct heritabilities for the four mortality traits ranged from 0.001 to 0.008 but were all significant. D61-180 and D1-180 had the highest direct heritabilities. Maternal heritabilities were very low, ranging from 0.0002 to 0.0015 and significant for D1-14 and D1-180 only. The direct genetic correlation between D1-14 and D15-60, between D15-60 and D61-180, and between D1-14 and D61-180 was 0.73, 0.54, and 0.34, respectively. It indicates that different genes are responsible for early PM (D1-14) and late PM (D61-180). When D61-180 was treated as a different trait for females, males not transferred, and transferred males, the direct heritability was 0.004, 0.008, and 0.034, respectively, but the direct genetic correlations between these three traits were very high. If transfers of calves are getting more common, the importance of including PM in a breeding program will increase, as the genetic variation of PM was considerably higher for transferred calves than for calves that were not transferred.

Time after surgery, symptoms and well-being in survivors of urinary bladder cancer

OBJECTIVE

To evaluate how an increasing burden of symptoms influences well-being, anxiety and depression at different intervals after a radical cystectomy with urostomy for bladder cancer, as this therapy can induce long-term distressful symptoms.

PATIENTS AND METHODS

Patients with bladder cancer undergoing radical cystectomy in Stockholm between 1969 and 1995 were matched with 434 controls from the normal population; all 404 patients operated on between 1985 and 1995 at three other hospitals in Sweden were invited to enter the study. The final analysis included 306 patients and 310 controls, all assessed for symptoms and well-being.

RESULTS

A low or moderate level of well-being was reported by 35% of the patients having none or one of the symptoms studied, by 39% with two symptoms, by 45% with three symptoms and by 66% of those with four or more symptoms. The values, irrespective of symptom burden, were 45% after 2-5 years of follow-up, 58% after 6-10 years and 38% at>10 years after surgery. The total symptom burden also influenced the risk of anxiety and depression. Symptom prevalence remained largely unaffected by the duration of follow-up, except for defecation urgency.

CONCLUSIONS

The number of long-term symptoms after radical surgery with a urostomy for urinary bladder cancer affects the risk of anxiety, depression and low or moderate well-being.

Controlled Mechanical Distension of the Human Oesophagus: Sensory and Biomechanical Findings

BACKGROUND

The relation between mechanical distension of the gut and the sensory response is poorly understood. The current experimental study aimed to examine the sensory response in the human oesophagus during on-line recording of the luminal pressure, cross-sectional area (CSA) and sensory rating using different distension rates before and during relaxation of the smooth muscle.

METHODS

An impedance planimetric probe for bag distension of the oesophagus was used in 13 healthy subjects aged 43 ± 15 years. Ramp distensions were done with an electromechanical pump using infusion rates of 10, 25 and 50 ml/min, with and without relaxation of the smooth muscle with butylscopolamine. The sensory intensity was measured using a 0-10 visual analogue scale (VAS), with 5 as the pain threshold. The pump was reversed at 8 on the scale, corresponding to medium pain intensity, and the pressure, volume, tension and CSA were evaluated. Finally, three isovolumetric experiments where the CSA was held constant for 2 min at initial VAS ratings of 3, 5 and 7 were performed.

RESULTS

A total of 104 distension profiles were investigated. The volume at maximal pain intensity (VAS = 8) increased as a function of the distension rate (P < 0.001), whereas the pressure, tension and CSA were not affected. When the smooth muscle was relaxed, there was a 29% fall in pressure at maximal pain intensity (P = 0.004), a 27% fall in tension (P = 0.003), whereas CSA did not change (P = 0.3). When the pressure was recorded as a function of the sensory intensity, there was an exponential increase after the pain threshold was reached, whereas the stimulus-response functions for tension, volume and CSA were nearly linear. In the isovolumetric experiments the ratings during the three sensory intensities were the same in the individual subjects, but the between-individual pain response was variable, probably reflecting individual differences in adaptation/central integration.

CONCLUSIONS

The study allowed us to assess the strain-rate dependency of both perception and biomechanical properties in the oesophagus. It was demonstrated that the pain response was related to the CSA (and hence strain), independently of the contractile state of the muscle and biomechanical behaviour of the tissue. The findings support the fact that the pain-sensitive mechanoreceptors in the human oesophagus depend on circumferential wall stretch rather than on pressure, tension and volume. The model should be used in future studies to investigate whether changes in strain are responsible for the oesophageal sensation in health and disease.

Controlled mechanical distension of the human oesophagus: sensory and biomechanical findings

BACKGROUND

The relation between mechanical distension of the gut and the sensory response is poorly understood. The current experimental study aimed to examine the sensory response in the human oesophagus during on-line recording of the luminal pressure, cross-sectional area (CSA) and sensory rating using different distension rates before and during relaxation of the smooth muscle.

METHODS

An impedance planimetric probe for bag distension of the oesophagus was used in 13 healthy subjects aged 43 +/- 15 years. Ramp distensions were done with an electromechanical pump using infusion rates of 10, 25 and 50 ml/min, with and without relaxation of the smooth muscle with butylscopolamine. The sensory intensity was measured using a 0-10 visual analogue scale (VAS), with 5 as the pain threshold. The pump was reversed at 8 on the scale, corresponding to medium pain intensity, and the pressure, volume, tension and CSA were evaluated. Finally, three isovolumetric experiments where the CSA was held constant for 2 min at initial VAS ratings of 3, 5 and 7 were performed.

RESULTS

A total of 104 distension profiles were investigated. The volume at maximal pain intensity (VAS = 8) increased as a function of the distension rate (P < 0.001), whereas the pressure, tension and CSA were not affected. When the smooth muscle was relaxed, there was a 29% fall in pressure at maximal pain intensity (P = 0.004), a 27% fall in tension (P = 0.003), whereas CSA did not change (P = 0.3). When the pressure was recorded as a function of the sensory intensity, there was an exponential increase after the pain threshold was reached, whereas the stimulus-response functions for tension, volume and CSA were nearly linear. In the isovolumetric experiments the ratings during the three sensory intensities were the same in the individual subjects, but the between-individual pain response was variable, probably reflecting individual differences in adaptation/central integration.

CONCLUSIONS

The study allowed us to assess the strain-rate dependency of both perception and biomechanical properties in the oesophagus. It was demonstrated that the pain response was related to the CSA (and hence strain), independently of the contractile state of the muscle and biomechanical behaviour of the tissue. The findings support the fact that the pain-sensitive mechanoreceptors in the human oesophagus depend on circumferential wall stretch rather than on pressure, tension and volume. The model should be used in future studies to investigate whether changes in strain are responsible for the oesophageal sensation in health and disease.

Genetic parameters for milk production and persistency for Danish Holsteins estimated in random regression models using REML

(Co)variance components for milk, fat, and protein yield of 8075 first-parity Danish Holsteins (DH) were estimated in random regression models by REML. For all analyses, the fixed part of the model was held constant, whereas four different functions were applied to model the additive genetic effect and the permanent environment effect. Homogeneous residual variance was assumed throughout lactation. Univariate models were compared using a minimum of -2 ln(restricted likelihood) as the criterion for best fit. Heritabilities as a function of time were calculated from the estimated curve parameters from univariate analyses. Independent of the function applied and the trait in question, heritabilities were lowest in the beginning of the lactation. Heritabilities for persistency of fat yield were slightly higher than heritabilities for persistency of milk and protein yield. Genetic correlations between persistency and 305-d production were higher for protein and milk yield than for fat yield. Bivariate analyses between the production traits were carried out in sire models using the models with the best 3-parameter curve fit in the univariate analyses. Correlations between traits were calculated from covariance components for curve parameters estimated in bivariate analyses. Genetic correlations between milk and protein yield were higher than between milk and fat yield.

PCR identification of dermatophyte fungi Trichophyton rubrum, T. soudanense and T. gourvilii

Diagnosis of dermatophytosis employing conventional laboratory procedures has been complicated by the slow growth and varied morphological features shown by dermatophytes. After analysis of the nucleotide base sequences of a 1.2-kb fragment amplified from a dermatophyte fungus Trichophyton rubrum by arbitrarily primed PCR with random primer OPD18, a pair of primers (TRIF and TR1R) was designed and evaluated for specific identification of T. rubrum. The sensitivity of the primers TR1F and TR1R was high, as a specific PCR band of c. 600 bp was detected from as little as 7 pg of T. rubrum DNA. By examining 92 dermatophyte strains and clinical isolates, it was found that this pair of primers reacted in PCR with T. rubrum, T. soudanense and T. gourvilii through formation of the specific fragment of 600 bp, but not with any other of the dermatophyte species or varieties, fungi, yeasts or bacteria tested. As T rubrum is one of the most frequently isolated dermatophyte fungi, and T. soudanense and T. gourvilii are relatively uncommon in many parts of the world, these primers can be used for rapid, sensitive and specific identification and differentiation of T. rubrum from other fungi and micro-organisms.

Transoesophageal echocardiographic monitoring during paediatric cardiac surgery: obtainable information and feasibility in 532 children

BACKGROUND

We hypothesized that transoesophageal echocardiography (TOE) performed by the anaesthesiologists would be beneficial for monitoring purposes during paediatric cardiac surgery. We present the results for the first 5 years in 532 consecutive children.

METHODS

The probe was successfully inserted in 99% of cases and remained in the oesophagus for 211 min on average (range 10-555 min).

RESULTS

Insignificant valve leak, single- or biventricular failure and volume depletion were the most common new findings due to TOE. Changes in inotropic strategy and volume replacement were the most frequent interventions. In 45% of the cases, new information was disclosed and, in a total of 8% of cases, decisive information was provided. Except for tracheal extubation in one child who was uneventfully reintubated, no severe complications were identified.

CONCLUSIONS

These data stress the safety and ease of performing TOE in children undergoing cardiac surgery. There is evidence for benefit from TOE findings to potentially enhance the therapeutic basis.

Tetrameric dipeptidyl peptidase I directs substrate specificity by use of the residual pro-part domain

The crystal structure of mature dipeptidyl peptidase I reveals insight into the unique tetrameric structure, substrate binding and activation of this atypical papain family peptidase. Each subunit is composed of three peptides. The heavy and light chains form the catalytic domain, which adopts the papain fold. The residual pro-part forms a beta-barrel with the carboxylate group of Asp1 pointing towards the substrate amino-terminus. The tetrameric structure appears to stabilize the association of the two domains and encloses a 12700 A3 spherical cavity. The tetramer contains six chloride ions, one buried in each S2 pocket and two at subunit interfaces.

Combustion of gasolines in premixed laminar flames European certified and California phase 2 reformulated gasoline

Two gasoline qualities, European unleaded certified gasoline (EUCG) and California phase 2 reformulated gasoline (P2 RFG), were analysed. EUCG contained about twice the amount of alkyl benzenes compared to P2 RFG and a large amount of cyclohexane. As a balance, P2 RFG contained higher amounts of isooctane and MTBE. The gasolines were burned in a premixed laminar flame burner at 1 atm and at about stoichiometric fuel/air ratio. The species profiles were measured using on-line GC/MS. About 40 compounds were be detected in the gasoline flames. The EUCG resulted in formation of more reactive and toxic compounds. The combustion profiles of the fuel components showed a similar slope, which suggests that the fuel components burn quite independently of each other. Ethene and propene were the dominating species produced from the two gasolines. Commonly, substantial amounts of higher alkenes were found. Combustion of P2 RFG produced higher amounts of isobutene, propene, propyne, propadiene and methanol compared to combustion of EUCG. The high amount of isobutene is reasonably a result of high concentration of isooctane and MTBE in the fuel. The high amount of methanol formed is probably due to the MTBE present in the gasoline. EUCG produced significantly higher amounts of 1,3-butadiene, which quite likely is formed from the cyclohexane in the fuel. The benzene profiles from both gasolines shows an almost constant level up to 800 microm from the burner surface; this is probably due to formation of benzene from alkyl benzenes.

Elevated androgens and prolactin in aromatase-deficient mice cause enlargement, but not malignancy, of the prostate gland

Although androgens are the main steroids controlling the growth of the mammalian prostate, increasing evidence demonstrates that estrogens also regulate prostate development and growth. This study describes the effects of estrogen deficiency using aromatase knockout mice (ArKO) with targeted disruption of the cyp19 gene. Serum and tissue testosterone and 5alpha-dihydrotestosterone as well as serum PRL levels are significantly (P < 0.05) elevated in mature male ArKO mice. Histological, stereological, and immunohistochemical studies demonstrated enlargement of the ventral, anterior, and dorsolateral lobes of the prostate in young and older ArKO mice. Hyperplasia of the epithelial, interstitial, and luminal compartments was identified and associated with up-regulation of androgen receptors. There was no evidence of malignancy as the animals aged (up to 56 weeks). The changes observed in the prostates of ArKO mice were unaffected by maintaining mice on regular or soy-free diets. It is concluded in ArKO mice that, despite the long-term elevation of androgens and PRL, the absence of estrogen in these animals does not result in induction of malignancy in the prostate gland.

Tissue injury and the inflammatory response to pediatric cardiac surgery with cardiopulmonary bypass: a descriptive study

BACKGROUND

There are few detailed descriptions of the inflammatory response to cardiac surgery with cardiopulmonary bypass (CPB) in children beyond 24 h postoperatively. This is especially true for the antiinflammatory cytokines and the extent of tissue injury. The aim of the current study was to describe the inflammatory and injury responses in uncomplicated pediatric cardiac surgery with CPB, where methylprednisolone and modified ultrafiltration (MUF) were used.

METHODS

Blood samples were collected up to 48 h postoperatively. Cytokines (tumor necrosis factor-alpha and interleukin-6, -1beta, -10, and -1ra), complement (C3d and C4d) and coagulation system (prothrombin activation fragments 1 and 2 and antithrombin III) activation, neutrophil elastase, and the resulting tissue injury (creatine kinase, lactate dehydrogenase, alanine transaminase, amylase, and gamma-glutamyl transferase) were measured.

RESULTS

The proinflammatory cytokine release varied widely, in contrast to a clear-cut antiinflammatory response. Cytokine concentrations did not decrease immediately after MUF, and no rebound increases later in the postoperative period were observed. The coagulation system, but not complement, was activated. There was a late release of C-reactive protein. Tissue injury could be quantified biochemically without evidence of hepatic or pancreatic dysfunction.

CONCLUSION

In this group of uncomplicated subjects, the antiinflammatory cytokine and tissue injury responses were well defined, in contrast to a variable proinflammatory cytokine release. This was accompanied by activation of the coagulation system but not of complement. Concentrations of inflammatory mediators did not decrease immediately after MUF, and there was no evidence for rebound release later in the postoperative period.

A specific PCR assay for the dermatophyte fungus Microsporum canis

A DNA fragment of approximately 1.2 kb, generated from the common dermatophyte Microsporum canis by arbitrarily primed polymerase chain reaction (PCR) using random primer OPU13, was cloned and sequenced. Based on the resulting sequencing data, a forward primer (MC1F) and a reverse primer (MC1R) have been designed and assessed by PCR for their usefulness in the improved identification of M. canis. The results obtained suggest that these primers are specific for M. canis, as a band of 900 bp was amplified in PCR with genomic DNA from M. canis only, and not from any of the other dermatophyte species or varieties, other fungi or common bacteria examined. Combining this PCR technique with a rapid mini-preparation method for fungal DNA, a definitive diagnosis of M. canis can be achieved within a day from the primary cultures. Future refinement of a DNA purification protocol from clinical specimens would further enhance the potential of the PCR based test for improved detection and identification of M. canis.

Fast track as a routine for open heart surgery

OBJECTIVE

Evaluation of thoracic epidural analgesia (TEA), normothermic cardiopulmonary bypass (CPB) and normothermic blood cardioplegia as a routine procedure for fast track open heart surgery.

METHODS

Consecutive patients (n=250, age 36--81 years, mean 63, M/F, ratio=4) were subjected to the combination of general anaesthesia using ultra-short acting opiates, TEA, normothermic CBP, normothermic whole blood cardioplegia. Operative procedures included coronary artery bypass grafting (CABG), valve replacement, combined CABG and valves, aortic aneurysm and Maze III. LVEF ranged 20--76%. Eighty percent were in Tuman score 0--5 and 20% in score >5.

RESULTS

All patients were extubated within 10 min after skin closure. There was one myocardial infarction. Four percent were shortly treated with cathecholamines. Postoperative atrial fibrillation was noticed in 9.6%. Four transient cerebral ischemic events were encountered. No neurological disturbance related to the use of TEA was seen. Seven patients were reoperated because of bleeding. Blood transfusion was given to 6.4% of the patients. Mortality was 0.8%.

CONCLUSIONS

The combined methods provides a way for routine immediate postoperative extubation, with low morbidity and short hospital stay.