Salt-dependent conformational diversity of alternating poly (Glu-Leu)

Alternating poly(Glu-Leu) was synthesized by the condensation of the corresponding dipeptide p-nitrophenyl ester at high concentration. It exhibits a random coil structure in pure water at neutral pH. Addition of monovalent cations, such as NH4+ to a final 0.1 M solution, induces a transition to a water soluble beta-structure. The salt effect is quite selective since no transition was observed with Li+, Na+ or Cs+ ions. Addition of 0.5 equiv of calcium, cobalt or manganese chlorides per glutamyl residue induces similar coil to beta-sheet transitions. No polymer precipitation was observed at these very low salt concentrations. Addition of 0.5 equiv. of Cu2+ or 0.15 equiv. of Fe3- induces a coil to alpha-helix transition. Molecular modeling has been used to understand tentatively the main factors controlling the different conformations observed with the various metal ions.

Evaluation of the effects of mivacurium chloride on hemodynamics and left ventricular function in patients with coronary artery disease undergoing abdominal aortic surgery

OBJECTIVE

To determine the effects of two doses of mivacurium chloride on hemodynamics and left ventricular function in patients with documented coronary artery disease undergoing aortic surgery.

DESIGN

A prospective study with the dose of mivacurium determined by randomization.

SETTING

Induction area at a university hospital.

PARTICIPANTS

Twenty consecutive patients undergoing aortic surgery with clinically and/or angiographically documented coronary artery disease.

INTERVENTIONS

Intravenous administration of mivacurium chloride.

MEASUREMENTS AND MAIN RESULTS

Induction of anesthesia was performed with midazolam and fentanyl. Two different doses of mivacurium chloride, 0.15 mg/kg (n = 10) and 0.2 mg/kg (n = 10; 2 and 2.5 ED95; respectively), were administered as a single bolus injection over a 60-second period in the absence of any surgical stimulation. In addition to standard hemodynamic monitoring, pulmonary artery catheterization and transesophageal echocardiography were used. The occurrence of myocardial ischemia was monitored using both a computerized three-lead ST-segment analysis system and the echocardiographic assessment of regional wall motion. No change in heart rate, mean arterial pressure, pulmonary capillary wedge pressure, cardiac output, and global left ventricular function was noted after administration of mivacurium with the two doses studied. No ST-segment change or new segmental wall motion abnormality was noted in either group.

CONCLUSION

Mivacurium chloride, when injected over a 60-second period, preserves global and regional myocardial function in patients with documented coronary artery disease undergoing noncardiac surgery.

A seroepidemiological study on toxoplasmosis

Using the microparticle capture enzyme-immunoassay (MEIA) based on IMx technology (Abbott), we determined the current prevalence of toxoplasmosis in 784 pregnant women followed up during 1990, and in 1,839 randomly selected blood donors. They all came from the Brabant Wallon area and the South-East of Brussels. Specimens yielding low IgG immunity (6-15 units) [corrected], were further tested with a sensitive direct agglutination assay (Toxo-Screen DA, bioMerieux). Overall, the prevalence was 67% among blood donors and 50% in pregnant women. In blood donors, the prevalence in women was not statistically different from the prevalence in men: X2 = 2.95 NS. In the two populations, a progressive age-related increasing prevalence of up to 60% for pregnant women and 77% for blood donors was observed. In females, the prevalence was higher among female blood donors than among pregnant women: 63% versus 50%, X2 = 16, P < 0.001. However, when the prevalences were compared within three age subgroups of women (< or = 33 yrs, 34 to 41 yrs, > or = 42 yrs), there were no statistically significant differences between pregnant women and blood donors. Thus, the overall observed difference was due to an age effect. Therefore, the distribution of IgG titers was established in each of the six age and sex subgroups. The 25th, 50th and 75th percentiles of those distributions ranged between 14 IU and 20 IU, 24 IU and 35 IU, and 40 IU and 64 IU, respectively. The annual seroconversion rate was 0.8% in pregnant women, against 0.2% amongst non-immune blood donors over 3 months. In conclusion, our findings confirm the general prevalence of 50% of toxoplasmosis and an annual seroconversion rate of 0.8% in these two populations.

ACE polymorphism, a genetic predictor of occlusion after coronary angioplasty

In this study, restenosis after coronary angioplasty is evaluated in a series of 291 consecutive patients according to ACE genotypes. The authors conclude that the ACE 2ID polymorphism has no effect on progressive restenosis after balloon angioplasty, but it is implicated in a distinct mechanism of restenosis (thrombosis and occlusion) that could explain discrepancies among previously published studies.

Effects of pentoxifylline on circulating cytokine concentrations and hemodynamics in patients with septic shock: results from a double-blind, randomized, placebo-controlled study

OBJECTIVE

To determine whether a continuous intravenous infusion of pentoxifylline, a methylxanthine derivative, alters the serum cytokine concentrations and/or hemodynamic measurements in patients with septic shock.

DESIGN

A prospective, randomized, double-blind, placebo-controlled study.

SETTING

Medical intensive care unit in a university hospital.

PATIENTS

Sixteen patients with septic shock.

INTERVENTIONS

Patients were randomly assigned to receive either pentoxifylline (1 mg/kg) followed by an infusion of 1.5 mg/kg/hr for 24 hrs (n = 8), or placebo (n = 8).

MEASUREMENTS AND MAIN RESULTS

Tumor necrosis factor (TNF) and interleukin (IL)-6 concentrations were measured by radioimmunoassays; IL-8 concentrations by an enzyme-linked immunosorbent assay (ELISA) and pentoxifylline concentrations by high-performance liquid chromatography at 0, 3, 6, 12, 18, 24 and 48 hrs after study entry. Pulmonary artery catheter-derived hemodynamics were measured at 0, 0.75, 3, 6, 12, 18, and 24 hrs. In pentoxifylline-treated patients, at 24 hrs, serum concentrations of TNF were significantly lower compared with controls (12 +/- 2 vs. 42 +/- 12 pg/mL, respectively, p = .04). Serum concentrations of IL-6 and IL-8 did not differ between the two treatment groups. There were also no significant differences in any hemodynamic and oxygenation measurements comparing the two treatment groups. Pentoxifylline concentrations were 1,544 +/- 241 ng/mL after the initial dose, and 5,776 +/- 1,781 ng/mL at the end of the 24-hr infusion. Five patients in the pentoxifylline group and four patients in the placebo group died.

CONCLUSIONS

Pentoxifylline is able to decrease serum TNF but not IL-6 or IL-8 serum concentrations during septic shock. Pentoxifylline was well tolerated by all eight patients with no adverse effect. Further studies are needed to determine if pentoxifylline's ability to lower circulating TNF concentration without altering hemodynamics will improve outcome in septic shock.

Fundamental limitations on the contrast-transfer efficiency in elastography: an analytic study

Elastography is a new ultrasonic imaging technique introduced to produce images of the Young's modulus distribution of compliant tissue. This Young's modulus distribution is derived from the ultrasonically estimated longitudinal internal strains induced by an external compression of the tissue. The displayed two-dimensional images are called elastograms. Recently, contrast-transfer efficiency, defined as the ratio of elasticity contrast as measured from elastogram to the true contrast, was used to illustrate by simulation the fundamental limitation of elastography in displaying the elastic modulus contrast of soft inclusion in a hard background and vice versa. In this paper, using a classical analytic solution of the elasticity equations derived for an infinite medium subjected to a uniaxial compression, we confirm such earlier simulations results. For this purpose we derive an analytic expression predicting the observed contrast in elastograms.

Tissue elasticity reconstruction using linear perturbation method

A new method to reconstruct the elastic modulus of soft tissue subjected to an external static compression is presented. In this approach the Newton-Raphson method is used to vary a finite element (FE) model of the elasticity equations to fit, in a least squared sense, a set of axial tissue displacement fields estimated using a correlation technique applied to ultrasound signals. The ill-conditioning of the Hessian matrix is eliminated using the Tikhonov regularization technique. This regularization provides a compromise between fidelity to the observed data and a priori information of the solution. Using an echographic image formation model, it is shown that the method converges within a few iterations (8-10) and that strain images artifacts which are common in elastography are significantly reduced after the resolution of the inverse problem.

Detection of autoantibodies against oxidized low-density lipoproteins and of IgG-bound low density lipoproteins in patients with coronary artery disease

The role of oxidized low-density lipoprotein (ox-LDL) in the pathogenesis of atherosclerosis has been the object of intense investigation. It has been proposed that, due to the antigenic properties of ox-LDL, the anti-ox-LDL antibody titre could represent a useful index of in vivo LDL oxidation. On the other hand, LDL immune complexes (LDL-IC) have been demonstrated in patients with coronary disease and could play an atherogenic role. The goal of our study was to investigate anti-malondialdehyde (MDA)-LDL autoantibodies and LDL-IC in a cohort of patients with coronary artery disease. Seventy control subjects and 70 coronary angiographically documented patients were compared; in addition 32 healthy male non-smokers were compared with 32 healthy male smokers (> 10 cigarettes/day). All patients were matched for age and cholesterolemia. Enzyme-linked immunosorbent assay was used to measure anti-MDA-LDL autoantibodies and LDL-IC. Titres of anti-MDA-LDL autoantibodies were not larger in patients with documented coronary artery stenosis and in smokers than they were in controls and non-smokers. The titre of LDL-IC was not higher in patients with coronary artery stenosis than in controls. The results thus indicate that in populations matched for age and cholesterolemia the titres of anti-MDA-LDL autoantibodies and the titre of LDL-IC are not increased in patients suffering from coronary artery stenosis. Furthermore, cigarette smoking does not induce higher titres of anti-MDA-LDL autoantibodies in healthy patients.

Hemolysis in primary lipoprotein lipase deficiency

A slight to moderate hemolysis is often present in plasma from patients with primary lipoprotein lipase (LPL) deficiency. To determine the nature of this hemolysis, we measured erythrocyte hypo-osmotic fragility, plasma free hemoglobin, and phospholipid composition in 26 patients with primary LPL deficiency and 21 unrelated controls. In some patients, these investigations were completed by erythrocyte cytoskeletal protein determinations and abdominal echography. Osmotic fragility was similar between control subjects and patients. However, there was a significantly increased concentration of plasma free hemoglobin in primary LPL deficiency (0.282 +/- 0.331 v 0.048 +/- 0.038 g/L in controls, P < .005). In LPL-deficient patients, an increase of plasma lysophosphatidylcholine concentration (12.6% +/- 5.8% v 6.4% +/- 1.9% in controls, P < .0001) was also found. The protein composition of the erythrocyte membrane skeleton was abnormal in some LPL-deficient patients and splenomegaly was present in 12, but these abnormalities did not correlate with plasma free hemoglobin levels. Bilirubin and haptoglobin levels were also within physiologic ranges in these patients, suggesting that the observed hemolysis did not result from hypersplenism. It appears likely that the accumulation of lysophosphatidylcholine was due to an impairment in the reverse metabolic pathway converting lysophosphatidylcholine back to phosphatidylcholine. Collectively, these data, along with a positive correlation between plasma free hemoglobin and lysophosphatidylcholine levels (r = .58, P = .0001), suggest that the hemolysis observed in primary LPL deficiency is mediated to some extent by the abnormally elevated concentration of lysophosphatidylcholine.

Echographic image mean gray level changes with tissue dynamics: a system-based model study

In echography, several groups have reported a systematic decrease in the total backscattering intensity or image mean gray level during myocardial contraction with a minimum at end-systole and maximum at end-diastole. In order to investigate this phenomenon, we use a three-dimensional inhomogeneous continuum model to mimic the tissue as a collection of cells that scatter the acoustic wave due to their individual impedance. The mathematical analysis clearly shows the relationship between the mean gray level changes and the size, orientation, and deformation of the cells that compose the tissue, as well as the frequency of the transducer. Using a myocardial model example, the mean gray level changes reported in the literature during contraction are described in terms of changes in orientation and deformation of cardiac fibers. The model is simple and should set the ground for further study and analysis of speckle pattern changes during tissue motion.

Ultrasonic texture motion analysis: theory and simulation

A theoretical model was previously developed to evaluate the relationship between the dynamics of ultrasonic speckle and its underlying tissue. The model is divided into an instrumental part represented by the point spread function (in the far field) of the ultrasonic apparatus and a moving tissue component described by a collection of scatterers. By computing the convolution of these terms and then the envelope, one obtains a simulated ultrasonic speckle pattern sequence which shows speckle motions closely linked to the tissue dynamics when small motion amplitudes are involved. Here, a theoretical study of the correlation between various linear transformations of the tissue and the corresponding ultrasonic speckle motions is performed, based on a 2D extension of the envelope cross-correlation analysis of a narrow-band Gaussian noise. In the linear scan case, obviously, tissue translation generates an identical speckle translation. However, tissue/speckle motion correlation decreases with increasing rotation and/or biaxial deformation, lateral deformation (perpendicular to the beam propagation axis) being much less sensitive. With respect to the transducer frequency, the rotation and the axial deformation of the tissue show a better relationship with their respective speckle motion at lower frequencies while lateral deformation correlation is independent of the pulse frequency. With respect to beam (pulse) size parameters, tissue/speckle correlation decreases with rotation when a wide ultrasonic beam is used while the axial deformation correlation decreases with the axial duration of the pulse. This study sets the ground for the development of an ultrasonic strain gauge particularly useful for the assessment of biomechanical soft tissue and fluid flow properties based on speckle tracking.

Aprotinin to decrease bleeding and intraoperative blood transfusion requirements during descending thoracic and thoracoabdominal aortic aneurysmectomy using cardiopulmonary bypass

The purpose of this retrospective study was to assess the efficacy of aprotinin, an antifibrinolytic agent, in reducing bleeding and blood transfusion requirements in patients undergoing descending thoracic or thoracoabdominal aortic aneurysmectomy using cardiopulmonary bypass (CPB). Sixty-nine consecutive patients underwent thoracic or thoracoabdominal aneurysmectomy using CPB in a 2-year period. None of the 29 patients operated on in 1990 (group 1) received aprotinin, whereas all 40 patients operated on in 1991 (group 2) were placed on a high-dose regimen of aprotinin. There were no significant differences between the two groups. Administration of aprotinin was associated with a decrease in CPB time (p = 0.02), surgical duration (p = 0.05) and intraoperative blood loss (p = 0.008) as well as a reduction in intraoperative packed red cells (p = 0.01), Cell-Saver units (p = 0.05), fresh-frozen plasma units (p = 0.002), and platelet concentrate (p = 0.01) requirements. These data suggest that aprotinin is effective in reducing bleeding and blood transfusion requirements during descending thoracic or thoracoabdominal aortic aneurysmectomy using CPB.

Comparison of the photoreduction of protochlorophyllide to chlorophyllide in leaves and cotyledons from dark-grown bean as a function of age

77 K fluorescence spectra of bean (Phaseolus vulgaris cv Commodore) leaves and cotyledons show the presence of active and inactive protochlorophyllides. The first detected product of the protochlorophyllide photoreduction is the chlorophyllide emitting fluorescence at 690 nm (C690) which is observed one day (leaves) and three days (cotyledons) after sowing. In cotyledons, C690 undergoes the 'rapid' and 'Shibata' shifts; in leaves, these spectral changes are age-dependent. In order to characterize the formation of C690, we have recorded 298 K fluorescence kinetics at 690 nm and the corresponding absorbance kinetics at 440 nm. The amplitude of the variations of both kinetics increases with the sample age. The absorbance and fluorescence kinetics can be modelized as a monoexponential law. The rate constant of the absorbance and fluorescence kinetics does not significantly change during the studied period (except for old cotyledons). The results presented in this paper give evidences for a low energy transfer between pigments during the photoreduction of protochlorophyllide at room temperature.

High-frequency jet ventilation vs continuous positive airway pressure for differential lung ventilation in patients undergoing resection of thoracoabdominal aortic aneurysm

Twenty patients, scheduled for surgical resection of thoracoabdominal aortic aneurysm were divided into two groups according to the type of differential lung ventilation used during graft replacement of the descending thoracic aorta. In the high-frequency jet ventilation (HFJV) group of ten patients, HFJV was applied to the left lung once collapsed and retracted by the surgeon, the patient lying in the right lateral decubitus and being intubated by a Carlens' tube. In the continuous positive airway pressure (CPAP) group of ten patients, CPAP was applied to the left lung at the same mean airway pressure as HFJV (1 kPa). Before anaesthetic induction, an arterial and a Swan-Ganz catheter were inserted for cardiovascular monitoring. The same anaesthetic technique using fentanyl 6 micrograms.kg-1, flunitrazepam 0.02 mg.kg-1 and pancuronium 0.1 mg.kg-1 was used for each patient. Haemodynamic and respiratory measurements were made; 15 min after positioning the patients in the right lateral decubitus using two-lung ventilation; 15 min after collapse and retraction of the left lung using one-lung ventilation and 15 min after using differential lung ventilation with CPAP or HFJV. Left lung collapse with conventional one-lung ventilation induced a dramatic decrease in arterial oxygenation: PaO2/FIO2 ratio decreased from 43 +/- 6 kPa to 20 +/- 8 kPa, alveolo-arterial oxygen difference increased from 24 +/- 7 kPa to 72 +/- 11 kPa and pulmonary shunt increased from 17 +/- 2% to 37 +/- 3%. Whereas differential lung ventilation with CPAP did not improve any of the respiratory parameters measured, differential lung ventilation with HFJV, significantly increased PaO2/FIO2 ratio to 41 +/- 14 kPa.(ABSTRACT TRUNCATED AT 250 WORDS)

A pilot study of intra-arterial carboplatin in patients with recurrent carcinoma of the cervix, postradiation

Twelve patients with recurrent squamous cell carcinoma of the cervix restricted to the pelvis were treated with intra-arterial infusion of carboplatin. The initial carboplatin dose was 300 mg/m2, every 4 weeks, and the dose was escalated to 450 mg/m2. Myelosuppression was the dose-limiting toxicity at the 450 mg/m2 dose. One patient died of treatment-related febrile neutropenia at that dose level. Two patients having received one cycle at 300 mg/m2 suffered grade 3 peripheral paresthesia. There were no objective responses but five patients had a subjective improvement of pain and performance status.

Recoil following Wiktor stent implantation for restenotic lesions of coronary arteries

The purpose of this study was to determine acute recoil of the vessel wall immediately after Wiktor stent implantation in native coronary arteries of 77 consecutive patients and to assess whether there was compression or "late recoil" of the stent itself at long-term follow-up. Furthermore, the relationship between recoil and a number of clinical, angiographic, and procedural variables was studied in addition to the relation between acute recoil renarrowing or restenosis was assessed. All angiograms were analyzed with the Cardiovascular Angiography Analysis System using automated edge detection. Acute recoil was defined by the difference between the mean diameter of the fully expanded balloon on which the stent was mounted and the mean diameter of the stented segment. Late recoil was calculated by comparing the mean diameter of the stent itself immediately after implantation and at follow-up without opacification of the vessel. Acute recoil amounted to 0.25 +/- 0.32 mm or 8.2%. Multivariate analysis identified sex (coefficient = -0.20, p = 0.04) and stent/artery ratio (coefficient = 0.99, p = 0.0001) as the only independent predictors of acute recoil. "Late recoil" of the stent itself was not observed. The overall difference between the mean diameter of the stent itself immediately after implantation and at follow-up was -0.15 +/- 0.33 mm, suggesting an overall increase in diameter of 5.0%. There was no relation between acute recoil and late restenosis. On the contrary, there was a trend towards a greater degree of recoil in patients without restenosis. Moreover, linear regression analysis disclosed a weak but negative correlation between acute recoil and a loss in minimal luminal diameter (coefficient: -0.55, p = 0.04). The Wiktor stent effectively scaffolds the instrumented vessel. Only a minimal amount of acute recoil was noted, which did not contribute to late luminal renarrowing or restenosis. In addition, no late compression of the stent itself was observed. These data suggest that tissue ingrowth into the lumen of the stented segment is the main cause of late luminal renarrowing after stent implantation.

The application of electrospray and neutral-loss mass spectrometry to the identification of the metabolites of S12813 in rat liver slices

The metabolism of S12813, (3-(2-[4-phenyl piperazin-1-yl] ethyl)-2-oxo-2,3-dihydro oxazolo [4,5-b] pyridine chlorohydrate), in rat liver slice incubates was examined by high performance liquid chromatography combined with mass spectrometry. Electrospray ionization was used together with tandem mass spectrometric techniques of analysis (MS/MS). Polar phase I and phase II metabolites were identified as C-oxidation products, which were then conjugated to form either sulphate or glucuronide metabolites. On the basis of the identifications made, a metabolic pathway of S12813 in rat liver slices has been proposed.

Autologous blood donation before myocardial revascularization: a Holter-electrocardiographic analysis

The influence of preoperative autologous blood donation on myocardial ischemia and arrhythmias was evaluated in 24 patients scheduled for coronary artery bypass grafting (CABG). All had a Holter recorder placed 24 hours before predonation (day 1), the cassette was changed prior to donation, and the recording continued for 24 hours thereafter (day 2). Each patient served as his or her own control, and observations made on day 2 were compared with those of day 1. Ischemia was quantitated by calculating the duration (C.Dur.) and the area (C. Area) of ischemic ST segment depressions, and ventricular premature beats (VPB) were classified according to the Lown grading system. Twenty-one men and 3 women were monitored. On day 1, 9 patients had 20 ischemic events, 3 being symptomatic. Nine patients demonstrated ischemia on day 2, representing a total of 3 symptomatic and 26 silent events. When comparing the two monitoring periods, 7 patients had longer or more severe ST segment depression whereas 6 other patients presented with more severe VPBs on day 2. Three patients had less ischemia on day 2, one remained stable, and 13 had no ischemia throughout the study. Silent ischemia was significantly more prolonged (C.Dur.Sil 316 v 152 sec, P < 0.05) and more intense (C. Area Sil 8 v 3.8 mm.min, P < 0.05) on day 2. Moreover, on top of a normal circadian distribution of ischemic events in the morning and in the evening, 40% of events were related to the donation or to a trip to the hospital. No preoperative characteristic helped to detect patients at risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Dipyridamole-thallium scintigraphy and gated radionuclide angiography to assess cardiac risk before abdominal aortic surgery

BACKGROUND

Because many patients with atherosclerotic disease of the abdominal aorta also have coronary artery disease, assessment of cardiac risk before abdominal aortic surgery has received much attention. Our prospective study was designed to identify predictors of cardiac risk in consecutive patients evaluated preoperatively with dipyridamole-thallium single-photon-emission computed tomography (SPECT) to assess myocardial perfusion and radionuclide angiography to measure left ventricular ejection fraction.

METHODS

Clinical and scintigraphic data were collected prospectively during hospitalization in 457 consecutive patients undergoing elective abdominal aortic surgery. Adverse cardiac outcomes were predicted with multivariate analyses.

RESULTS

Eighty-six patients (19 percent) had one or more of the following postoperative complications: prolonged myocardial ischemia (61 patients), myocardial infarction (22), congestive heart failure (20), and severe ventricular tachyarrhythmia (2). Twenty patients died postoperatively (4.4 percent), half of them from cardiac causes. Information about myocardial perfusion obtained from dipyridamole-thallium SPECT did not accurately predict adverse cardiac outcomes. The best correlates of cardiac complications were definite clinical evidence of coronary artery disease (odds ratio, 2.6; 95 percent confidence interval, 1.6 to 4.3) and age greater than 65 years (odds ratio, 2.3; 95 percent confidence interval, 1.4 to 3.6). Measurement of the ejection fraction was useful only in the prediction of left ventricular failure. Age greater than 65 years was the only predictor of death (odds ratio, 26.4; 95 percent confidence interval, 3.5 to 200.0).

CONCLUSIONS

The presence of definite clinical evidence of coronary artery disease and older age were the most important preoperative predictors of an adverse cardiac outcome after abdominal aortic surgery. These results suggest that the routine use of dipyridamole-thallium SPECT and radionuclide angiography for screening before abdominal aortic surgery may not be justified.

Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoracotomy

PURPOSE

In an attempt to clarify the role of hypothermic circulatory arrest (HCA) in the management of complex aortic aneurysms operated on through the left thoracotomy, our technique of HCA and outcome were reviewed.

METHODS

During a 21-month period, 15 (17%) of 87 aneurysms of the descending thoracic or thoracoabdominal aorta were operated on by HCA. Eleven patients had chronic aortic dissections (four type A and seven type B), two patients had atherosclerotic aneurysms, and one each had congenital or infected postoperative aneurysms. The use of HCA was planned before surgery in 14 patients. Indications included proximal aortic disease in 12 patients, making either clamping of the transverse aortic arch unsafe (eight patients) or necessitating replacement of the arch with a graft (four patients). Preoperative decision to use HCA was made in two additional patients, one with a ruptured aneurysm and another patient for spinal cord and visceral protection because of anticipated prolonged ischemia as a result of reoperation. Intraoperative technical difficulties prompted the use of HCA in only one patient. Deep hypothermia (15 degrees to 24 degrees C) was induced through partial cardiopulmonary bypass. Left-sided heart venting was necessary in five patients. Aortic replacement was limited to the descending thoracic aorta in five patients, whereas it involved the thoracoabdominal aorta in 10 patients. Four patients had associated replacement of the aortic arch.

RESULTS

Three patients died (one of a ruptured aneurysm) during surgery or early after surgery (two of bleeding and one of left ventricular failure). All other patients awoke neurologically intact, but one patient had delayed onset of paraplegia. Another patient died 4 days after surgery of rupture of the ascending aorta. Eleven patients were perioperative survivors without significant morbidity.

CONCLUSIONS

Hypothermic circulatory arrest is a valuable adjunct in the management of complex aortic aneurysms through left-sided thoracotomy. Its results warrant consideration of its selective use for spinal cord/visceral protection.

[Electron microscopic comparison of the antithrombotic potential of 2 low osmolality iodine contrast media in percutaneous transluminal coronary angioplasty]

The antithrombogenic potentials of two low osmolality iodine contrast media, ioxaglate (Iox), an ionic product, and iopamidol (Iop), a non-ionic product, were compared in a multicentre, randomised, double-blind study in 64 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) by scanning electron microscopy for the presence of thrombotic material on the guiding catheter (GC) and guide wires (GW). The procedure was strictly standardised: stable angina, type A coronary lesions; aspirin administration (at least 300 mg the day before and on the day of angioplasty); heparinisation (10000 IU at the beginning of the procedure); same GCs (Marathon Baxter 8F), same GWs (Veriflex USCI 0.014). The tips of the catheters and guide wires were scanned by an electronic microscope in a double-blind protocol. The scores for the number of erythrocytes (RBCs), platelets (PLs) and constituted thrombi (THi) were; thickness scored from 0 to 3, the % surface covered and an index of volume combining these two parameters. The clinical and angiographic characteristics of the 2 groups were strictly comparable. The time that the GCs and GWs were in the circulation were 30.0 +/- 2.3 vs 32.6 +/- 3.0 minutes for the former, and 18.6 +/- 1.8 vs 17.1 +/- 1.4 minutes for the later in the Iox and Iop groups, respectively (NS). An angiographic filling defect was not observed in any of the patients in the Iox group and in 4 patients (13%) in the Iop group (NS). The number of thrombotic elements observed on the GCs (RBCs, PLs, THi) was negligible in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Posttraumatic intracerebral pneumatocele after ventilation with a mask: case report

We report an unusual case of posttraumatic tension pneumatocele following manually operated ventilation with a face mask. This is a rare cause of such injury. Diagnosis is confirmed by skull films and CT scans. Early surgical treatment may be required.

Recombinant protein expression in a Drosophila cell line: comparison with the baculovirus system

In this report, we compare two different expression systems: baculovirus/Sf9 and stable recombinant Drosophila Schneider 2 (S2) cell lines. The construction of a recombinant S2 cell line is simple and quick, and in batch fermentations the cells have a doubling time of 20 hours until reaching a plateau density of 20 million cells/ml. Protein expression is driven by the Drosophila Metallothionein promoter which is tightly regulated. When expressed in S2 cells, the extracellular domain of human VCAM, an adhesion molecule, is indistinguishable from the same protein produced by baculovirus-infected Sf9 cells. Additionally, we present data on the expression of a seven trans-membrane protein, the dopamine D4 receptor, which has been successfully expressed in both systems. The receptor integrates correctly in the S2 membrane, binds [3H]spiperone with high affinity and exhibits pharmacological characteristics identical to that of the receptor expressed in Sf9 and mammalian cells. The general implications for large scale production of recombinant proteins are discussed.

[Silent ischemia]

Silent myocardial ischaemia is a very common phenomenon in patients with coronary artery disease. It may occur in patients with clinical manifestations of angina, be detected during the post-myocardial infarction period or in patients totally asymptomatic. Whatsoever, it is well demonstrated that silent myocardial ischaemia has a very potent prognostic value. Therapeutic implications are similar to those in symptomatic ischaemia. Indications for myocardial revascularization by mean of angioplasty or bypass grafting may be discussed and depend on ventricular function and extension of coronary lesions.

[Traumatic rupture of the aorta diagnosed by transesophageal echocardiography. Apropos of a case and review of the literature]

The authors report the case of subadventitial rupture of the isthmus of the aorta due to trauma, diagnosed by transoesophageal echocardiography. The role of transoesophageal echocardiography compared with conventional diagnostic techniques is discussed. This method of investigation is a very good diagnostic tool in cases of closed trauma of the thorax.

[Hemangiopericytoma: a case report]

We describe one case of hemangiopericytoma touching a 44-year-old man. It is a rare vascular tumor originating from pericytes surrounding capillaries. The main typical features of it are the difficulty in doing an histologic diagnosis and the impossibility to make out a reliable prognosis. The therapy of choice is a surgical procedure sometimes in combination with radio- and/or chemotherapy.

Angiographic predictors of recurrence of restenosis after Wiktor stent implantation in native coronary arteries

Intracoronary stenting has been proposed as an adjunct to balloon angioplasty to improve the immediate and long-term results. However, late luminal narrowing has been reported following the implantation of a variety of stents. One of the studies conducted with the Wiktor stent is a prospective registry designed to evaluate the feasibility, safety and efficacy of elective stent implantation in patients with documented restenosis of a native coronary artery. To identify angiographic variables predicting recurrence of restenosis, the angiograms of the first 91 patients with successful stent implantation and without clinical evidence of (sub)acute thrombotic stent occlusion were analyzed with the Computer Assisted Angiographic Analysis System using automated edge detection. The incidence of restenosis was 44% by patient and 45% by stent according to the 0.72 mm criterion, and 30% by patient and 29% by stent according to the 50% diameter stenosis criterion. The risk for restenosis for several angiographic variables was determined using an univariate analysis and is expressed as odds ratio with corresponding confidence interval. The only statistically significant predictor of restenosis was the relative gain when it exceeded 0.48 using the 0.72 mm criterion (odds ratio 2.7, 95% confidence interval 1.1-6.4). Furthermore, the relation between the relative gain (increase in minimal luminal diameter normalized to vessel size) as angiographic index of vessel wall injury and relative loss (decrease in minimal luminal diameter normalized to vessel size) as index of neointimal thickening was analyzed using a linear regression analysis. When using the categorical approach to address restenosis, there is an increased risk for recurrent restenosis when the relative gain exceeds 0.48. The continuous approach underscores this concept by indicating a weak but positive relation between the relative gain and relative loss.

[Angiography of the left ventricle]

Left ventricular angiography in the 30 degree right anterior oblique projection is the reference method of calculating volumes and assessing segmental wall motion. The calculation of volumes is based on the surface-length or Simpson's methods which assume that the ventricle has an ellipsoid shape. The use of both the right and left anterior oblique projections only slightly improves the accuracy of the method and is not necessary in routine procedures. The global parameters of left ventricular function are the end-systolic and end-diastolic volumes and the ejection fraction. Segmental wall motion assessment provides a more precise analysis of left ventricular function. Many methods have been described but only two have been validated clinically: the Stanford method proposed by Ingels in which fractional shortening is calculated with respect to a point situated at 69% of the length of the axis between the apex and the anterior aortic border, and the more complex Rotterdam method reported by Slager. The introduction of digitisation of the image has enabled calculation of these different parameters in routine investigations.

Effects of thoracic extradural block on diaphragmatic electrical activity and contractility after upper abdominal surgery

BACKGROUND

Upper abdominal surgery (UAS) induces diaphragmatic dysfunction. Thoracic extradural block (TEB) using 0.5% bupivacaine improves some pressure and motion indices of diaphragmatic function. However, no direct information on diaphragmatic activity is available after UAS. The aim of this study was to assess diaphragmatic electrical activity (Edi) after UAS before and after TEB.

METHODS

A postoperative electromyogram was obtained, using intramuscular electrodes inserted by the surgeon in the costal and crural parts of the diaphragm, in 14 patients undergoing abdominal aortic surgery. Tidal changes in abdominal (VAB) and rib-cage (VRC) volumes, and gastric (delta Pgas), esophageal (delta Pes), and transdiaphragmatic (delta Pdi) pressures were used to measure tidal volume (VT) and respiratory rate and to provide indirect indices of diaphragmatic activity from the two ratios VAB/VT and delta Pgas/delta Pdi. These respiratory variables were obtained preoperatively. Postoperatively, measurements including Edi were obtained before and after a segmental epidural block, reaching a T4 level was achieved with 0.5% plain bupivacaine.

RESULTS

Upper abdominal surgery induced an increase in respiratory rate (+28 +/- 15%; P < .01), associated with a decrease in VAB/VT (from 0.75 +/- 0.11 to 0.07 +/- 0.08; P < .01), delta Pgas/delta Pdi (from 0.3 +/- 0.08 to 0.01 +/- 0.19; P < .05), and VT (-30 +/- 14%; P < .01). After surgery, all patients exhibited electrical diaphragmatic activity that increased with TEB by 48 +/- 28% (P < .01) and 60 +/- 22% (P < .001) for the cural and costal segments, respectively. The ratio delta Pdi/Edi, used to evaluate diaphragmatic contractility, was not modified by TEB. Tidal volume, respiratory rate, and delta Pgas/delta Pdi returned to preoperative levels, whereas VAB/VT increased but remained different from preoperative values.

CONCLUSIONS

This study demonstrates that TEB produces an increase in diaphragmatic activity, identical for the two segments of the muscle. Interruption of afferents that produce an inhibitory effect on diaphragmatic activity appears the most attractive hypothesis to explain the consequences of TEB after UAS.

The relation between triglyceride synthesis in peripheral tissues and postprandial plasma triglyceride levels: preliminary evidence of a role for acylation stimulating protein

The present study examines the hypothesis that the rate at which peripheral tissues synthesize triglycerides is a key determinant of the rate at which they are removed from plasma. The cells of greatest interest in this regard would, of course, be the adipocytes. However, serial sampling of this tissue is not possible in man. We have approached the question indirectly, by studying triglyceride synthesis in human mononuclear cells before and after an oral fat load. In addition, plasma levels of Acylation Stimulating Protein (ASP) were measured after an overnight fast and 4 h after ingestion of the oral fat load. Similar measurements were made in the same subjects after fasting overnight and with the fast extended for 4 additional hours. With the extended fast, no parameter measured changed significantly. However, after the oral fat load, the following changes were found to be significant: plasma triglycerides increased (63.6 +/- 31.1 vs 101.5 +/- 43 mg/dl, p less than 0.005) as did d less than 1.006 g/ml triglycerides (42.3 +/- 22.8 vs 78.0 +/- 39.7 mg/dl, p less than 0.005) and plasma ASP (10.4 +/- 2.2 vs 14.7 +/- 2.3 mg/dl, p less than 0.005). In addition, the rate of triglyceride synthesis in the mononuclear cells increased significantly (1.22 +/- 0.3 vs 1.52 +/- 0.3 nmol oleate/mg cell protein per h, p less than 0.005). There was also a significant inverse relation between the increase in the d less than 1.006 triglycerides between 0 and 4 h and the increase in triglyceride synthesis in the mononuclear cells (r = 0.91, p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Wiktor stent implantation in patients with restenosis following balloon angioplasty of a native coronary artery

Intracoronary stenting has been introduced as an adjunct to balloon angioplasty aimed at overcoming its limitations, namely acute vessel closure and late restenosis. This study reports the first experience with the Wiktor stent implanted in the first 50 consecutive patients. All patients had restenosis of a native coronary artery lesion after prior balloon angioplasty. The target coronary artery was the left anterior descending artery in 26 patients, the circumflex artery in 7 patients and the right coronary artery in 17 patients. The implantation success rate was 98% (49 of 50 patients). There were no procedural deaths. Acute or subacute thrombotic stent occlusion occurred in 5 patients (10%). All 5 patients sustained a nonfatal acute myocardial infarction. Four of these patients underwent recanalization by means of balloon angioplasty; the remaining patient was referred for bypass surgery. A major bleeding complication occurred in 11 patients (22%): groin bleeding necessitating blood transfusion in 6, gastrointestinal bleeding in 3 and hematuria in 2. Repeat angiography was performed at a mean of 5.6 +/- 1.1 months in all but 1 patient undergoing implantation. Restenosis, defined by a reduction of greater than or equal to 0.72 mm in the minimal luminal diameter or a change in diameter stenosis from less than to greater than or equal to 50%, occurred in 20 (45%) and 13 (29%) patients, respectively. In this first experience, the easiness and high technical success rate of Wiktor stent implantation are overshadowed by a high incidence of subacute stent occlusion and bleeding complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphologic change in coronary artery stenosis with the Medtronic Wiktor stent: initial results from the core laboratory for quantitative angiography

The purpose of this study was to assess the early changes in stenosis geometry after implantation of the Medtronic Wiktor stent in human coronary arteries. Morphologic changes were evaluated by quantitative coronary angiography using automated edge detection. The hemodynamic significance of the morphologic changes were assessed by the calculation of the theoretical pressure drop across the dilated and stented stenosis derived from the Poiseuile and turbulent resistances assuming a coronary blood flow of either 0.5, 1, or 3 ml/sec. Fifty patients were studied before and immediately after stent implantation. The stented coronary artery was the left anterior descending artery in 26 patients, the circumflex artery in eight patients, and the right coronary artery in 16 patients. Stent implantation resulted in an additional increase in the minimal luminal cross-sectional area and minimal luminal diameter of the dilated vessel without changing the curvature of the stenosis. Furthermore, there was a significant reduction of the "plaque area." This was associated with a normalization of the calculated resistances to flow and pressure drop across the stenosis. To a minimal extent, recoil (0.1 +/- 0.36 mm) was observed after stent implantation.

[Torsades de pointes and prolongation of the duration of QT interval after injection of droperidol]

Following a case of torsades de pointe (TDP) after the injection of droperidol (D), the authors studied the electrocardiographic variations caused by the drug. Fifty five unselected patients under the same conditions (general anesthesia) were given D (0.25 mg/kg IV). Significant prolongation of the QT interval was seen in 70% of cases by the end of the first minute. QT interval and the ratio of QTm (measured) over QTt increased from 387 +/- 34 ms to 423 +/- 37 ms (p less than 0.0001) and from 1.06 +/- 0.08 to 1.28 +/- 0.1 (p less than 0.001) respectively. These changes could favourise the onset of TDP. Although exceptional in terms of the extensive use of the neuroleptic in question, this possibility indicates the need for monitoring of the duration of QT before and during treatment with droperidol and for prescription of the drug to be avoided in circumstances known to be propitious to this arrhythmia (bradycardia, hypokalemia, anti-arrhythmic drugs).

Combined epidural and general anesthesia versus general anesthesia for abdominal aortic surgery

The goal of this randomized study of high-risk surgical patients was to determine whether intraoperative thoracic epidural anesthesia in combination with light general anesthesia alters postoperative morbidity when compared to a standard technique of "balanced" general anesthesia. A total of 173 patients scheduled for abdominal aortic reconstruction were admitted to the study; 86 were to receive "balanced" general anesthesia (group 1) and 87 thoracic epidural anesthesia in combination with light general anesthesia (group 2). Preoperative evaluation included standard clinical tools, dipyridamole thallium gammatomography, and radionuclide angiography. In these patients, all of whom had peripheral artery disease, there were no significant differences in associated coronary artery disease, hypertension, and cardiovascular treatment. The distribution of left ventricular ejection fraction and the number of patients with thallium redistribution were not statistically different between the two groups. During the postoperative period, group 1 received analgesia of subcutaneous morphine (n = 35), epidural fentanyl (n = 30), or epidural bupivacaine (n = 21). In group 2, 6 patients with a nonfunctioning epidural catheter due to technical failure received a balanced general anesthesia and were eliminated from the study. During the postoperative period, group 2 received analgesia of subcutaneous morphine (n = 26), epidural fentanyl (n = 25), or epidural bupivacaine (n = 30). Cardiovascular morbidity did not differ between the two groups: 22 patients in group 1 and 19 patients in group 2 had a major postoperative cardiac event.(ABSTRACT TRUNCATED AT 250 WORDS)

An experimental study in electrical impedance tomography using backprojection reconstruction

This paper reports on experiments designed to evaluate the performance of the equipotentials backprojection method under conditions modeling those of proposed applications of electrical impedance tomography. Small spherical targets were placed inside a saline-filled tank with dimensions similar to a human torso. Data were acquired with a computer-based instrument that applies current to pairs of electrodes located on two horizontal planes and records potential differences between electrodes of a third plane. The relative contrast produced by nonconducting spheres in a uniform saline background was measured on the reconstructed images and used to determine system sensitivity to target volume and to the radial and vertical positions of single spheres. Results show that for radial positions within a critical radius sensitivity is always maximum when the spheres center is on the recording plane and decreases gradually when the target is moved outside this plane. Localization of simple targets in 3-D, with data acquired from multiple recording planes, appears feasible. The results provide guidelines for the interpretation of images with complex 3-D conductivity distributions.