Endoluminal graft repair of abdominal aortic aneurysms by vascular surgeons at a nonclinical trial center

The purpose of this study was to compare the early results and complication rates of commercially available endoluminal grafts (ELG) for abdominal aortic aneurysm (AAA) by a team of vascular surgeons at a nontrial center with those of published results from trial centers. A retrospective chart review of all patients undergoing endoluminal graft repair of AAA was made at the medical center. From October 1, 1999, to December 31, 2000, a team of vascular surgeons electively repaired AAAs in 100 patients at a regional referral center. Of these patients, 49 underwent repair with a commercially available ELG (35 AneuRx, 14 Ancure) whereas the remaining were repaired with an open operation. In the ELG group, the primary technical success rate was 100% with a 30-day mortality rate of 2.0%. The average hospital length of stay was 3.28 days with ICU stay of 1.20 days. The average operative estimated blood loss was 501 mL (100-2,500) with average transfusions of 0.49 unit packed red blood cells (prbc) (0-6). Eighty-eight percent of ELG patients left the hospital without complication. Seven patients (14%) required 11 follow-up procedures for complications including endoleak, limb or graft thrombosis, graft stenosis, distal embolization, or wound complications. Three of 26 patients (11%) with 6-month computed tomography follow-up had evidence of endoleak (2 have subsequently undergone lumbar embolization). Only 1 6-month follow-up patient had shown increased aneurysm size before endoleak treatment. A team of board-certified vascular surgeons at a nonclinical trial center can safely perform ELG for AAA with results similar to those of published series from trial centers.

The relationship between serum levels of insulin-like growth factor-I and its binding proteins and microvascular function in acromegalic patients

The system of insulin-like growth factor-I (IGF-I) and its binding proteins is thought to be involved in the pathogenesis of vascular damage under different pathological circumstances. The results of various studies are rather controversial. This study considers the relationship between the activity of this system and the function of microcirculation in acromegalic patients. Thirteen patients with hormonally active acromegaly and 15 healthy controls were included in the study. The growth hormone, free IGF-I, IGF-I, IGF binding protein (IGFBP) -1, -2, -3 and -6 serum levels and parameters of lipid metabolism were determined. The function of microcirculation was determined by laser Doppler fluxmetry and the intima media thickness of the common carotid artery was measured by ultrasound. We noted significant reduction in postocclusive reactive hyperaemia (PORH(max)) (P < 0.01), in thermal hyperaemia (TH(max)) (P < 0.05) and in the velocity of reaction in both tests in the group of acromegalic patients. A significant negative correlation between free IGF-I serum levels and maximal perfusion during thermal hyperaemia TH(max) (P < 0.02) was found in the control group. Statistically significant positive correlation between free IGF-I serum levels and the time to maximal perfusion in postocclusive reactive hyperaemia PORH(max) (P < 0.05) was found in the group with hormonally active acromegaly. Moreover, a positive relationship between IGFBP-1 serum levels and serum levels of total (P < 0.01) and low density lipoprotein (LDL) (P < 0.05) cholesterol was found in the group of patients with acromegaly. We conclude that the function of microcirculation is impaired in patients with acromegaly and that free IGF-I serum levels may affect the microvascular function as measured by laser Doppler fluxmetry. In addition, we found a significant relationship between the serum levels of IGFBP-1 and those of total and LDL cholesterol in the group of patients with hormonally active acromegaly.

[The sleep apnea syndrome in hypophyseal disorders with the exception of acromegaly]

The aim of the study was to ascertain the occurrence of the sleep apnoea syndrome (SAS) in patients after pituitary afunctional adenoma operation or in patients with other affection in sella turcica region except acromegaly patients. Eighty-one patients were addressed. Sixteen patients (eight men, eight women) underwent the examination; the rest of them had no interest to be explored. Afunctional pituitary adenoma was diagnosed in twelve patients, afunctional pituitary adenoma and subsequently optic glioma in one patient, craniopharyngioma in one patient, prolactinoma in one patient and undifferentiated cystic pituitary tumour in one patient. Neurological examination was done in all patients (standardized sleep questionnaire was included). SAS was quantified using PolyMESAM. Severity of SAS were set up from the value of M index (M = ODI.delta saturation; ODI--oxygen desaturation index). Mild SAS: 40 < M < 100; middle SAS: 100 < M < 210; severe SAS: M > 210. SAS was diagnosed in 13 patients: mild SAS in three of them (average value of M index: 81.0 +/- 12.7), moderate SAS in seven patients (average value of M index: 129.0 +/- 18.7) and severe SAS in three patients (average value of M index: 790.0 +/- 563.0). Therapy by continuous positive airway pressure (CPAP) was recommended in six patients. Five of them continue in using of CPAP--four patients with good compliance. The occurrence of SAS was 16.05% in measured group, higher than in normal population.

The changes of IGF binding proteins after rhGH administration to patients totally dependent on parenteral nutrition

The objective was to study the effect of recombinant human growth hormone (rhGH) administration to patients with chronic malnutrition maintained on total parenteral nutrition (TPN) on the levels of insulin-like growth factor-I (IGF-I) and IGF binding proteins (IGFBPs) during a double-blind trial. After 1 week of TPN the patients were randomized into group I (placebo) or group II (rhGH). Samples were collected on the first day (start of the TPN) to measure basal values, the seventh day to study the effect of TPN and the 10th, 14th and 21st days to evaluate the rhGH effect. Basal laboratory evaluation, nutritional status and glucose tolerance were assessed using standard laboratory techniques. Radioimmunoassays were used to analyse IGF-I, free IGF-I (fIGF-I) and IGFBP1-3. Electrophoresis with Western ligand blotting and Western immunoblotting was applied to find the pattern of IGFBPs. TPN had no effect on the circulating IGF-I concentration and the pattern of IGFBPs present in the studied groups of patients. The rhGH administration led to significant increases of IGF-I, total IGFBP-3, glycosylated IGFBP-3 (39, 42 kDa) and the 29 kDa fragment of IGFBP-3 and the decrease of IGFBP-2 during the trial (P<0.05). The mean levels of IGFBP-1, fIGF-I and the parameters of nutritional status in group II during the trial were not significantly influenced by rhGH. However, it has been found that IGFBP-1 and fIGF-I levels were correlated with the levels of the weekly nitrogen balance of each patient in group II at the end of the trial. In spite of the significant changes of IGF-I, IGFBP-2, total IGFBP-3 and IGFBP-3 (29 kDa proteolytic fragment) after rhGH administration to patients with malnutrition, maintained on parenteral nutrition, the increase of nitrogen balance was seen only in patients who decreased their IGFBP-1 and increased bioavailable IGF-I as reflected by measurement of fIGF-I. The levels of IGFBP-1 may provide a useful marker of IGF-I bioavailability in monitoring the efficiency of the rhGH therapy in malnourished patients.

[Changes in serum levels of IGF-I and its binding proteins and their relation to microcirculation in obese patients]

The IGF-I system and its binding proteins participate in the pathogenesis of vascular affections under various pathological conditions. The mechanism and mode of its action were however not elucidated in details so far and views on its role are controversial. The objective of the study was to assess the relationship of this system and the blood flow in the microcirculation in obese patients. The authors examined 21 obese patients (BMI 39.7 +/- 7.3 kg/m2) and a group of healthy volunteers. They examined: serum concentrations of total IGF-I, free IGF-I, IGFBP-1,-2,-3, and -6, total cholesterol, HDL-cholesterol, LDL-cholesterol and triglycerides as well as the intimomedial thickness of the common carotid arteries and parameters of blood flow in the microcirculation, evaluated by a laser-Doppler examination. In obese patients there were significantly lower serum concentrations of IGF-I and free-IGF I (p < 0.05) as compared with the control group. Comparison of the function of the microcirculation revealed in obese patients, as compared with the control group, a lower percentage increase of perfusion after occlusion (PORH%, p < 0.05) and after heating (TH%, p < 0.05) and a slower onset of thermal hyperaemia (THmax/t, p < 0.05). In the control group serum concentrations of free-IGF-I correlated inversely with the maximum perfusion after heat induced hyperaemia (THmax (r = -0.54, p < 0.02) and the rate of onset of hyperaemia after heating (THmax/t) (r = 0.51, p < 0.02). In the group of obese patients serum concentrations of free-IGF-I correlated inversely with the maximum perfusion after heat induced hyperaemia (THmax) (r = -0.55, p < 0.02), and IGFBP-3 concentrations correlated inversely with maximum hyperaemia after occlusion (PORGmax) (r = -0.57, p < 0.01). The results suggest that the function of the microcirculation in obese subjects is affected. The activity of the IGF-I system and its binding proteins is related to the affected function of the microcirculation and a negative part is played particularly by serum concentrations of free IGF-I. The negative effect of IGFBP-3 on the function of the microcirculation is surprising.

Insights into the functional architecture of the catalytic center of a maize beta-glucosidase Zm-p60.1

The maize (Zea mays) beta-glucosidase Zm-p60.1 has been implicated in regulation of plant development by the targeted release of free cytokinins from cytokinin-O-glucosides, their inactive storage forms. The crystal structure of the wild-type enzyme was solved at 2.05-A resolution, allowing molecular docking analysis to be conducted. This indicated that the enzyme specificity toward substrates with aryl aglycones is determined by aglycone aromatic system stacking with W373, and interactions with edges of F193, F200, and F461 located opposite W373 in a slot-like aglycone-binding site. These aglycone-active site interactions recently were hypothesized to determine substrate specificity in inactive enzyme substrate complexes of ZM-Glu1, an allozyme of Zm-p60.1. Here, we test this hypothesis by kinetic analysis of F193I/Y/W mutants. The decreased K(m) of all mutants confirmed the involvement of F193 in determining enzyme affinity toward substrates with an aromatic aglycone. It was unexpected that a 30-fold decrease in k(cat) was found in F193I mutant compared with the wild type. Kinetic analysis and computer modeling demonstrated that the F193-aglycone-W373 interaction not only contributes to aglycone recognition as hypothesized previously but also codetermines catalytic rate by fixing the glucosidic bond in an orientation favorable for attack by the catalytic pair, E186 and E401. The catalytic pair, assigned initially by their location in the structure, was confirmed by kinetic analysis of E186D/Q and E401D/Q mutants. It was unexpected that the E401D as well as C205S and C211S mutations dramatically impaired the assembly of a catalysis-competent homodimer, suggesting novel links between the active site structure and dimer formation.

Insights into the functional architecture of the catalytic center of a maize beta-glucosidase Zm-p60.1

The maize (Zea mays) beta-glucosidase Zm-p60.1 has been implicated in regulation of plant development by the targeted release of free cytokinins from cytokinin-O-glucosides, their inactive storage forms. The crystal structure of the wild-type enzyme was solved at 2.05-A resolution, allowing molecular docking analysis to be conducted. This indicated that the enzyme specificity toward substrates with aryl aglycones is determined by aglycone aromatic system stacking with W373, and interactions with edges of F193, F200, and F461 located opposite W373 in a slot-like aglycone-binding site. These aglycone-active site interactions recently were hypothesized to determine substrate specificity in inactive enzyme substrate complexes of ZM-Glu1, an allozyme of Zm-p60.1. Here, we test this hypothesis by kinetic analysis of F193I/Y/W mutants. The decreased K(m) of all mutants confirmed the involvement of F193 in determining enzyme affinity toward substrates with an aromatic aglycone. It was unexpected that a 30-fold decrease in k(cat) was found in F193I mutant compared with the wild type. Kinetic analysis and computer modeling demonstrated that the F193-aglycone-W373 interaction not only contributes to aglycone recognition as hypothesized previously but also codetermines catalytic rate by fixing the glucosidic bond in an orientation favorable for attack by the catalytic pair, E186 and E401. The catalytic pair, assigned initially by their location in the structure, was confirmed by kinetic analysis of E186D/Q and E401D/Q mutants. It was unexpected that the E401D as well as C205S and C211S mutations dramatically impaired the assembly of a catalysis-competent homodimer, suggesting novel links between the active site structure and dimer formation.

Resynchronization pacing is a useful adjunct to the management of acute heart failure after surgery for congenital heart defects

The acute hemodynamic effect of atrioventricular (AV) and inter/intraventricular (IV) resynchronization accomplished by temporary pacing using multiple epicardial pacing wires was evaluated in 20 children (aged 3.4 months to 14.0 years) after surgery for congenital heart defects fulfilling the following criteria: (1) presence of AV and/or IV conduction delay, and (2) need for inotropic support. AV resynchronization (n = 13) was achieved by AV delay optimization during atrial synchronous right ventricular outflow tract pacing. IV resynchronization (n = 14) was accomplished by atrial synchronous pacing from the right ventricular lateral wall in 7 patients with right bundle branch block and normal AV conduction and by atrial synchronous multisite ventricular pacing in another 7 patients with previously performed AV resynchronization. Compared with baseline values, AV resynchronization resulted in an increase in arterial systolic, mean, and pulse pressures by 7.2 +/- 8.3% (p <0.01), 8.6 +/- 8.1% (p <0.005), and 6.9 +/- 13.5% (p = NS), respectively. IV resynchronization used either alone or added to previously performed AV resynchronization led to a pressure increase of 7.0 +/- 4.7%, 5.9 +/- 4.7%, and 9.4 +/- 7.8%, respectively (p <0.001 for all). The combined effect of AV and IV resynchronization resulted in a systolic, mean, and pulse pressure increase of 10.2 +/- 5.0% (range 4.0 to 19.1), 8.6 +/- 5.4% (range 0.8 to 14.8), and 15.2 +/- 8.5% (range 6.1 to 33.3), respectively (p <0.001 for all). The increase in systolic arterial pressure after IV resynchronization was positively correlated with the initial QRS duration (r = 0.62, p <0.05) and extent of QRS shortening (r = 0.66, p <0.05). In conclusion, resynchronization pacing led to a significant increase in arterial blood pressure and was a useful adjunct to the treatment of acute postoperative heart failure in patients with AV and/or IV conduction delay.

One-Pot Quinazolin-4-yl-thiourea Synthesis via N-(2-Cyanophenyl) benzimidoyl isothiocyanate

1-substituted-3-(2-phenylquinazolin-4-yl) thioureas (7) were produced by an intramolecular cycloaddition reaction of 1-substitued-3-[(2-cyanophenyl- imino)phenylmethyl] thioureas (3). These compounds in turn were prepared by the reaction of N-(2-cyanophenyl)benzimidoyl isothiocyanate (2) with primary amines. The structures of products 7 were confirmed by FTIR, ¹H-NMR, ¹³C-NMR, mass spectroscopy and X-ray crystallography.

[Laparoscopic therapy of symptomatic splenic implants in the minor pelvis]

OBJECTIVE

The radical laparoscopic treatment of the aforementioned pathology has made it possible to eliminate recurrent pelvic pain of the 24 years old patient.

SUBJECT

Case report.

METHODS AND RESULTS

24 year old, nulligravid patient, had primary laparoscopy in 1998 because of chronic pelvic pain. Histology has confirmed both, the infiltrative endometriosis and the pelvic splenosis. While the endometriosis has been radically excised, splenic implants have been, in accordance with the current opinions in the literature, left in situ. Only their biopsy has been done. Due to recurrent pelvic pain after 15 months and the growth of the splenical implants, the second look laparoscopy was performed with the radical excision of these foci.

CONCLUSION

The patient, 4 months after the intervention is asymptomatic. At variance with most of the literature, we assume that the pelvic splenosis in contrast to the abdominal is in many cases symptomatic. It causes especially pelvic pain and dyspareunia in connection with the contingent implant growth. In such cases the radical excision is indicated, where the laparoscopy is the chosen method. Authors are discussing the differentiational diagnosis of this syndrome especially concerning endometriosis, peritoneal carcinomatosis, accessory spleen and the manifestation of the lymphoma.

Craniofacial abnormalities and their relevance for sleep apnoea syndrome aetiopathogenesis in acromegaly

OBJECTIVE

To explain the effect of craniofacial relations on the development of the sleep apnoea syndrome (SAS) in acromegaly, and to elucidate how the activity of acromegaly affects the severity of SAS.

DESIGN

Prospective observational study.

METHODS

Cephalometry and sleep ventilation measurements were performed in 26 acromegalic men and in 96 men with SAS.

RESULTS

SAS was found in 20 acromegalic men. Compared with non-acromegalic men with SAS, patients with acromegaly and SAS were found to have: enlargement of almost all linear dimensions; increased angle indicating mandibular protrusion; increased difference between maxillary and mandibular protrusion; articular angle decrease; soft palate lengthening; and pharyngeal airway space (PAS) enlargement in the palatal and uvular-tip planes. A comparison of acromegalic men with and without SAS revealed no significant difference in the craniofacial skeleton, although there was a narrowing of the minimal PAS (MinPAS) and of PAS in the uvular-tip plane in patients with SAS. SAS was more frequent in the patients with active acromegaly. MinPAS in the patients with active acromegaly was narrower than in those without disease activity.

CONCLUSION

Skeletal abnormalities in acromegalic men with SAS were different from those in SAS patients without acromegaly. Upper airway narrowing due to changes in pharyngeal soft tissues takes a more relevant share in the development of SAS in acromegalic men than skeletal anomalies.

Preparation, physicochemical properties and biological activity of copper(II) complexes with 6-(2-chlorobenzylamino)purine (HL1) or 6-(3-chlorobenzylamino)purine (HL2). The single-crystal X-ray structure of

Copper(II) complexes of 6-(2-chlorobenzylamino)purine (HL1) and 6-(3-chlorobenzylamino)purine (HL2), respectively, were prepared. Depending on the pH of the medium and the molar ratio of reactants the following mononuclear (trigonal-bipyramidal) and dinuclear (octahedral, trigonal-bipyramidal or tetrahedral) complexes were isolated: [Cu2(mu-HL1)2(mu-Cl2)2(HL1)2Cl2] (1a,b), [Cu2(mu-Cl)2(mu-L1)2(H2O)2] (2a), [Cu2(mu-Cl)2(mu-L2)2(H2O)2] (2b), [Cu(H+L2)2Cl3]Cl.H2O (3a,b), [Cu2(mu-Cl)2(HL1)2Cl2] (4a), and [Cu2(mu-Cl)2(HL2)2Cl2] (4b). The compounds were characterized by elemental analyses, electronic, infrared and mass (FAB+, ES+) spectral data, magnetic susceptibility temperature dependence measurements and molar conductivity data. An X-ray single-crystal structural analysis of [Cu(H+L2)2Cl3]Cl.2H2O (3b) showed that the Cu2+ ion is penta-coordinated by three chloride ions and by two H+L2 ligands. Thus, the Cu2+ ion adopts a distorted trigonal bipyramidal coordination geometry with the protonated H+L2 ligands coordinated in trans apical positions, while the three chloride ions are situated in an equatorial plane. The cytotoxic activity of the complexes was determined by a calcein AM assay. Mouse melanoma cell line B16-FO, human malignant melanoma cell line G361, human osteogenic sarcoma cell line HOS and human breast adenocarcinoma cell line MCF7 were used. IC50 values, the drug concentrations lethal to 50% of the tumor cells, were estimated. One of the important mechanisms responsible for the cytotoxicity of cytokinin-derived compounds, the inhibition of cyclin-dependent kinases by the studied complexes, was also determined.

[Removal of inital cataract in high degenerative myopia--selection of surgical technique and planned refractive effect]

Visual function deteriorates additionally in high degenerative myopia in consequence of initial cataract causing increase of refractive index and refractive error. This paper presents indications for removal of initial cataract with posterior chamber lens implantation to improve visual acuity, colour perception, contrast sensitivity and to broaden visual field. Particular conditions of cataract surgery in myopic eye, selection criteria of operative technique and anaesthesia, power and diameter of implant and possible postoperative complications are discussed.

Recurrent ACTH-independent Cushing's syndrome in multiple pregnancies and its treatment with metyrapone

A 17-year-old primigravid woman presented with Cushing's syndrome. Typical clinical symptoms and signs developed at the beginning of pregnancy. By week 17 of gestation, plasma cortisol diurnal rhythm was absent and there was a paradoxical increase in plasma cortisol after a 1-mg dexamethasone overnight suppression test. Basal urinary free cortisol was 10 times above the upper limit (in pregnancy) and ACTH levels were suppressed. The diagnosis of ACTH--independent Cushing's syndrome was established. MRI scans revealed normal adrenal and pituitary glands. To control hypercortisolism, the patient was treated with metyrapone. At 34 weeks of gestation, the patient developed preeclampsia and underwent caesarean section. A female infant weighing 1070 g was delivered. No apparent metyrapone-induced teratogenic effects were observed. Cushing's syndrome in the patient resolved within three weeks of delivery. No corticosteroid replacement therapy either for child or mother was needed. Eight months after delivery the patient became pregnant again and rapidly developed Cushing's syndrome with typical clinical symptoms and signs and laboratory results (urinary free cortisol 6464 nmol/24 h). This second pregnancy was unwanted and terminated by artificial abortion that was followed by rapid resolution of hypercortisolism. A third pregnancy, 12 months after delivery was also accompanied by the rapid development of hypercortisolism which recovered after artificial termination. The mechanisms by which pregnancy-induced Cushing's syndrome occurred in this patient are unclear. Aberrant responsiveness or hyperresponsiveness of adrenocortical cells to a non-ACTH and non-CRH substance produced in excess in pregnancy should be considered. Metyrapone suppression of hypercortisolism currently represents the best treatment for these rare cases.

Effect of pH and loading manner on the start-up period of peat biofilter degrading xylene and toluene mixture

Laboratory-scale biofilters packed with a mixture of peat, bark and wood were used for xylene and toluene removal from waste air. Two kinds of peat, which differed in the resulting pH of the leachate, were chosen for degradation of the pollutants by a mixed culture. Using peat with the lower pH value, the feasibility of single and multiple pollutant loading during the start-up period and augmentation with Pseudomonas putida strains were characterized. The lower pH value of the bed resulted in higher efficiency of toluene degradation from the mixture of pollutants. At higher pH values better degradation of both pollutants was achieved. Regarding the manner of loading during the start-up period, the best results were obtained using toluene as a single pollutant in the initial phase of operation. Pseudomonas strains demonstrated a high ability to degrade both pollutants; more efficient degradation for xylene than for toluene was observed at high loading rates.

Purification, crystallization and preliminary X-ray analysis of a maize cytokinin glucoside specific beta-glucosidase

Zm-p60.1, a cytokinin glucoside specific beta-glucosidase from maize, is a key enzyme involved in plant development and growth. It has been overexpressed in soluble form from Escherichia coli with a His tag at its N-terminus. The recombinant protein has been purified and crystallized at room temperature using PEG 4000 as the main precipitant. At least three crystal forms have been observed from very similar growth conditions. A flash-annealed monoclinic crystal diffracted to high resolution (beyond 2 A) with space group P2(1) and unit-cell parameters a = 55.66, b = 110.72, c = 72.94 A, beta = 92.10 degrees. The asymmetric unit is estimated and confirmed by molecular-replacement solution to contain one Zm-p60.1 dimer, giving a crystal volume per protein mass (V(M)) of 1.89 A(3) Da(-1) and a solvent content of 35%.

[Radiosurgical treatment of hypophyseal adenomas with the gamma knife: results in a group of 163 patients during a 5-year period]

BACKGROUND

Gamma knife radiosurgery of pituitary adenomas is considered to be very perspective. It can be a very useful complement of traditional microsurgery, pharmacotherapy or fractionated radiotherapy which are seldom a sufficient treatment on their own. The modern radiosurgery does not offer the experience representative enough in this indication. We can offer results of medium long follow-up for tumor growth and hormonal hypersecretion of pituitary adenomas in a relatively large series of patients.

METHODS AND RESULTS

We have analyzed a group of 163 patients with pituitary adenoma treated with gamma knife during 5 years and followed 12-60 months, median 24 months after irradiation. An antiproliferative effect has been achieved in 1-2 years using the minimal dose to the margin 16-35 Gy, median 20 Gy in all our patients who were controlled by MRI (n = 126 patients). One half of these adenomas evidently decreased their size. Our effective antiproliferative dose was safe for the surrounding structures. The hormonal normalization has been achieved at 50.4% from 133 hypersecreting adenomas (39/91 = 43% of acromegalics, 11/13 = 85% of patients with Cushing's disease, 2/9 = 22% of patients with Nelson's syndrome, 11/18 = 61% of prolactinomas). The median latency was 12 months. The minimal dose to the margin was 10-45 Gy, median 35 Gy. Rare side effects were provoked only by increasing the dose to influence the hypersecretion-the development of partial hypopituitarism in 3.1% of patients, the panhypopituitarism in 0.6% of patient and there was 1 hemianopic visual field defect (0.6%).

CONCLUSIONS

Radiosurgery by gamma knife has a similar value for pituitary adenomas as microsurgery has with different distribution of advantages and drawbacks. This makes it suitable for the combined treatment where pharmacotherapy has its place under special conditions. Fractionated radiotherapy has now a marginal importance.

Cluster buckling as a result of compression-bending balance in lipid bilayer

A new approach supporting the possibility of cluster buckling during the main phase transition in the lipid bilayer is presented. The elastic energy is calculated via harmonic approximation which yields the potential minimum in the case of buckling cluster, if critical cluster size is achieved. The significance of this event for interbilayer interaction in multilamellar vesicles is discussed.

Crystal structure of the haloalkane dehalogenase from Sphingomonas paucimobilis UT26

The haloalkane dehalogenase from Sphingomonas paucimobilis UT26 (LinB) is the enzyme involved in the degradation of the important environmental pollutant gamma-hexachlorocyclohexane. The enzyme hydrolyzes a broad range of halogenated cyclic and aliphatic compounds. Here, we present the 1.58 A crystal structure of LinB and the 2.0 A structure of LinB with 1,3-propanediol, a product of debromination of 1,3-dibromopropane, in the active site of the enzyme. The enzyme belongs to the alpha/beta hydrolase family and contains a catalytic triad (Asp108, His272, and Glu132) in the lipase-like topological arrangement previously proposed from mutagenesis experiments. The LinB structure was compared with the structures of haloalkane dehalogenase from Xanthobacter autotrophicus GJ10 and from Rhodococcus sp. and the structural features involved in the adaptation toward xenobiotic substrates were identified. The arrangement and composition of the alpha-helices in the cap domain results in the differences in the size and shape of the active-site cavity and the entrance tunnel. This is the major determinant of the substrate specificity of this haloalkane dehalogenase.

[Combined therapy of acromegaly with a combination of lanreotide and terguride]

BACKGROUND

The aim of the treatment of acromegaly is to normalise the hormonal activity. Besides the surgical and radiation treatment, medical therapy can be used. The project was set to determine the value of combined therapy with lanreotide and terguride in patients with active acromegaly.

METHODS AND RESULTS

Nine patients previously treated with lanreotide for at least one year without normalisation of hormonal activity were included in the study. Terguride was added to lanreotide for one month. The combined treatment brought about reduction of growth hormone (GH) levels, however, with marginal significance only. GH-BP, IGF-I and IGFBP-3 serum levels were not changed significantly. Considering the individual cases, the combined treatment resulted in normalisation of GH levels in one patient and that of IGF-I in another one. Substantial decrease of GH levels (> 50%) was found in three patients and that of IGF-I (> 20%) in another one patient.

CONCLUSIONS

The combined treatment of acromegaly appears to be more effective than monotherapy with lanreotide only in a subset of acromegalic patients.

Prevalence of the sleep apnea syndrome in acromegaly population

The prevalence of sleep apnea syndrome (SAS) in acromegaly is high. Consequences of SAS are serious and are associated with increased morbidity and mortality. The aim of this study was to assess the relative frequency and predictive factors for SAS in a group of patients with acromegaly (n=55). The presence of SAS was evaluated using the Polymesam device. Hormonal and clinical examination consisted of assessment of growth hormone, insulin-like growth factor I plasma levels, body mass index (BMI), neck circumference, age, sex, treatment modes of acromegaly and ear, nose and throat (ENT) examination. The relative frequency of SAS in our group of patients with acromegaly was 75%. Independent predictors of SAS were: increased activity of acromegaly, higher age and neck circumference. No association between SAS and BMI and ENT findings was observed. The role of gender was controversial.

[Sleep apnea syndrome in acromegaly. Treatment and development-- retrospective analysis]

In total 56 subjects with acromegaly (37 men and 19 females) were examined in attempt to find sleep apnoea syndrome (SAS). The examination consisted of clinical examination and of all-night monitoring MESAM4 or polyMESAM. The diagnosis of SAS was established in 76.4% of subjects: 31 men and 11 females, average age 51.8 (SD +/- 9.6) years. The average ODI (oxygen desaturation index--number of oxygen saturation drops per 1 hour of sleep) of SAS patients was 29.2 (+/- 20.7). The therapy of SAS was recommended to 27 patients: sleeping position on the side (3 patients), reduction of the weight (8 patients), change of hypnotic drug (1 patient) and CPAP--continuous positive airway pressure (24 patients). CPAP titration was performed in 18 patients (in one subject the titration was repeated 4 years later). CPAP was titrated within all-night polysomnography in 10 subjects and in 9 subjects using self adjusting CPAP. Primary acceptance of CPAP was 94.4%. The average CPAP pressure was 7.8 (+/- 2.1) mbar. The theoretical duration of CPAP use was 546.6 (+/- 533.7) days. Long term compliance was considered as sufficient (weekly 25 hours or more) in 66.7% of patients. Ten patients underwent important acromegaly therapy or its change during the follow up and the improvement or the disappearance of SAS symptoms occurred in 6 of them.

[Multihormonal and multifunctional hypophyseal adenoma and the acromegaly syndrome]

Woman 75-year-old treated 30 years for syndrome of acromegaly refused pituitary surgery and irradiation. Five years and nine months before death she had a colon carcinoma successfully removed. Multinodular hyperfunctional goitre was treated with carbimazole. For six last years of life corticosteroids were given as a replacement therapy. Her cause of death was the heart failure due to acromegalic heart disease. In autopsy a large intrasellar and extrasellar pituitary adenoma without rests of nonneoplastic tissue was found. Nevertheless the target peripheral endocrine glands except ovaries, were not atrophic. A multinodular goitre and diffuse adrenocortical hyperplasia were revealed. Histology, and immunohistochemistry demonstrated that mot neoplastic cells were producing GH and ACTH, dispersly Prl, scattered cells were positive for beta-subunit of FSH, LH, TSH. Electron microscopy proved most of the cells to be densely granulated. We classify the adenoma according to the newly proposed WHO pituitary tumours classification (1) as plurihormonal, hyperfunctional, extrasellar, typical adenoma from densely granulated cells. We conclude that in plurihormonal adenomas with dominant (in the case referred acromegalic) symptomatology the additional hormonal production should be monitored as a possible source of important complications.

Stereospecific formation of alpha-hydroxycarboxylato oxo peroxo complexes of vanadium(V). Crystal structure of (NBu4)2[V2O2(O2)2(L-lact)2] x 2H2O and (NBu4)2[V2O2(O2)2(D-lact)(L-lact)] x 2H2O

An overview of structurally characterized alpha-hydroxycarboxylatodioxo- and alpha-hydroxycarboxylatooxoperoxovanadates(V) is presented and the geometric parameters of the V2O2 bridging core are discussed. The first case of a stereospecific formation of oxoperoxovanadates(V) is reported: The crystal structures of the isomeric compounds (NBu4)2[V2O2(O2)2(L-lact)2] x 2H2O and (NBu4)2[V2O2(O2)2(D-lact)(L-lact)] x 2H2O (lact = C3H4O3(2-), the anion of the lactic acid) differ mainly in the arrangement of the V2O2 core and in mutual orientation of the V=O bonds. The complexes with achiral ligands adopt the same structural type as the complexes formed from a racemic mixture of a chiral ligand, while the structure obtained using an enantiopure L,L-hydroxycarboxylate is different.

Increase of adhesion molecules, fibrinogen, type-1 plasminogen activator inhibitor and orosomucoid in growth hormone (GH) deficient adults and their modulation by recombinant human GH replacement

OBJECTIVE

GH deficiency (GHD) is usually associated with a higher incidence of cardiovascular disease (CVD). The aim of this study was to establish whether patients with GHD, like those with CVD, show an increase in fibrinogen (FBG), type-1 plasminogen activator inhibitor (PAI-1), acute phase response proteins (APR), and soluble adhesion molecules. The effect of recombinant human GH (rhGH) replacement, on these parameters was also investigated.

PATIENTS AND DESIGN

Concentrations of PAI-1 antigen (Ag), adhesion molecules sE-selectin, sP-selectin, and intercellular adhesion molecule-1 (sICAM-1), FBG and levels of APR orosomucoid (ORM), and 'negative APR' transferrin (TRF) were established in 11 panhypopituitary (PHP) patients (eight men and three women, age median 39.0 years, body mass index (BMI) 27. 49 +/- 3.89 kg/m2) before and after 12-month replacement with rhGH. Control values were obtained by examination of 33 healthy age and sex matched subjects (24 men and nine women with BMI 24.16 +/- 1.99 kg/m2).

RESULTS

PHP patients had higher concentrations of ORM (0.80 +/- 0.25, vs. 0.61 +/- 0.20 g/l; P = 0.05), FBG (3.22 +/- 0.48, vs. 2.57 +/- 0.47 g/l; P = 0.001), PAI-1 Ag (97.12 +/- 33.23, vs. 44.11 +/- 21.40 microgram/l; P = 0.001), sE-selectin (72.42 +/- 28.35, vs. 42. 80 +/- 12.60 microgram/l; P = 0.004), sP-selectin (221.26 +/- 75.12, vs. 104.79 +/- 26.01 microgram/l; P = 0.001) sICAM-1 (409.75 +/- 137.78, vs. 228.10 +/- 37.54 microgram/l; P = 0.001), and lower levels of TRF (2.14 +/- 0.40, vs. 2.76 +/- 0.39 g/l; P = 0.001) than controls. After 12-month rhGH replacement the patients showed an increase of TRF (2.64 +/- 0.84 g/l, P = 0.037) and decrease of soluble adhesion molecules (sE-selectin 57.98 +/- 27.04 microgram/l, P = 0.01, sP-selectin 121.74 +/- 50.42 microgram/l, P = 0.007; and sICAM-1 279.95 +/- 88.32 microgram/l, P = 0.005), which then, similarly to the ORM (0. 67 +/- 0.12 g/l) and FBG level (2.82 +/- 0.51 g/l), did not statistically differ from the values in the control group.

CONCLUSION

rhGH replacement led to modulation of the 'inflammatory response' in panhypopituitary patients. This modulation occurred locally at vascular endothelium level where after rhGH replacement, sE-selectin, sP-selectin and sICAM-1 concentrations decreased, a similar effect as in the systemic inflammatory response, as was also apparent from the changes in acute phase response protein levels.

Late complications and quality of life after atrial correction of transposition of the great arteries in 12 to 18 year follow-up

BACKGROUND

Most adolescents and young adults born with transposition of the great arteries and survivors of Mustard operation are alive today and are leading ordinary lives. How far is the quality of their life influenced by residual findings?

METHODS

We have analysed the oldest group of 177 children operated on with the Mustard procedure during 1979-1984 from our total experience of 609 corrections of transposition of the great arteries until 1996. In the long-term follow-up 12 to 18 years after Mustard operation the clinical investigation, 24 hours ECG Holter monitoring, 2D and colour flow Doppler echocardiography, radionuclide angiocardiography and exercise testing were performed.

RESULTS

Basic sinus rhythm had 61% of 137 survivors, sinus node dysfunction had 51%. All but 4 patients needed no antiarrhythmic therapy. There were 10 sudden deaths. Severe tricuspid valve regurgitation developed in 15.9% of children, and decreased to 6% after intensive medical treatment. The right ventricular systolic dysfunction was found on radionuclide ventriculography in 8% of children after surgery. The left ventricular ejection fraction was subnormal in 10% and left ventricular diastolic function expressed by rapid filling fraction was subnormal in 80% of patients and may cause inability to increase cardiac output at exercise The obstruction of caval veins was found in 9%. There were neurological complications in 13.3% (10% already preoperatively) but severe brain damage was found in 4.4% only.

CONCLUSIONS

Exercise tolerance with the maximum oxygen consumption over 30 ml/kg/min in 96% of investigated children suggests the good ability and full efficiency for recreation sports. Most survivors (84%) are reported to lead ordinary lives and function in NYHA class I.

MRI--diagnostic and follow-up tool for microprolactinomas

Magnetic resonance imaging is a method of choice for the diagnosis of microprolactinomas. Using a Phillips Gyroscan NT 15 (1.5 T), 42 patients whose clinical history and serum prolactin levels were compatible with the diagnosis of prolactinomas were examined. Four patients (3 male and 1 female) with macroadenoma were investigated and excluded, while microprolactinoma was found in the other 38 (32 female and 6 male) patients. Imaging features were similar in all microprolactinomas--hypointensity up to 10 mm in size in T1 weighted images, only sometimes, in the case of a cystic or a hemorrhagic component, also registered in T2 weighted images. Deviation of the pituitary stalk was present in 19 of the 38 patients (16 with microprolactinoma, 3 without any detectable lesion). Convex upper limit of the gland was demonstrated in 17 subjects (16 microprolactinomas, 1 without detectable lesion). Pituitary adenoma is not the only cause of raised serum prolactin level. This can be a consequence of medication, spinal cord tumor, compression of the pituitary stalk, hypothyroidism or a lesion in dermatomes T3 to T5 (mammary gland level). Results from imaging must always be assessed in the light of the patient's clinical history and biochemical parameters.

Retinal oligodendroglioma

PURPOSE

To report a case of oligodendroglioma originating from the accessory glia of retina.

METHOD

Case report of a 72-year-old woman with a tumor in the temporal fundus of the right eye that was suspected to be choroidal melanoma. Enucleation was declined, but 5 years later, because of tumor growth, pain, and loss of light perception, the globe was enucleated.

RESULTS

Histopathologic examination disclosed a neuroepithelial tumor with a structure of oligodendroglioma. Melanoma and metastatic tumor were excluded.

CONCLUSIONS

Oligodendrogliomas are rare in the retina but may originate from retinal oligodendrocytes. This case suggests that the differential diagnosis of choroidal melanoma should include the possibility of oligodendroglioma.

Crystallization and preliminary X-ray diffraction analysis of haloalkane dehalogenase LinB from Sphingomonas paucimobilis UT26

Haloalkane hydrolytic dehalogenase LinB from Sphingomonas paucimobilis UT26, an enzyme which releases chloride or bromide anion from n-halogenated alkanes and has a broad range of substrate specificity, was crystallized using the hanging-drop vapour-diffusion method at 278 K. The best crystals were obtained by microseeding with a precipitant containing 18-20%(w/v) PEG 6000, 0.2 M calcium acetate and 0.1 M Tris-HCl pH 8.9. The crystals diffract to at least 1.60 A using synchrotron X-ray under cryogenic (100 K) conditions. They belong to the orthorhombic space group P21212 with unit-cell parameters a = 50.29, b = 71.70, c = 72.73 A. The asymmetric unit contains one molecule of the enzyme.

Regression of acromegalic left ventricular hypertrophy after lanreotide (a slow-release somatostatin analog)

A group of 13 acromegalic patients was treated with lanreotide for 18 months and followed-up echocardiographically; these patients showed significant correlations between the decrease of both growth hormone (GH) and insulin-like growth factor-1 and the decrease of left ventricular mass index. This documents a regression of left ventricular hypertrophy in acromegaly after lanreotide treatment, the degree of which is dependent on the magnitude of the decrease of GH and insulin-like growth factor-1 serum levels.

[Congenital thrombosis of the aortic arch simulating aortic coarctation in a neonate]

The authors present the case-history of a two-day-old neonate with clinical signs of critical coarctation of the aorta where echocardiography revealed thrombosis of the aortic arch and isthmus. By surgery it was impossible to remove the organized thrombus from the aorta, therefore the portion of the aorta with the thrombus was resected and the aorta was reconstructed by an end-to-end anastomosis. After surgery long-term anticoagulation treatment with Warfarin was started. Examination of haemocoagulation factors, incl. proteins C and S and antithrombin III revealed normal findings. The test for lupus erythematosus was also negative. From the case-history of the mother's pregnancy the cause of the serious congenital aortic thrombosis could not be traced. The child is all right after surgery and thrives.

Evaluating institutional variability of duplex scanning in the detection of carotid artery stenosis

PURPOSE

Duplex scanning is widely used to measure carotid artery stenosis, but the issue of variability between institutions must be raised. To examine for this potential variability, we evaluated two ATL Ultramark 9 duplex machines at two hospitals within our institution.

METHODS

Stenosis was calculated angiographically as in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Internal carotid artery (ICA) to common carotid artery (CCA) peak systolic velocity (PSV) ratios were determined using the two ATL machines. Receiver operating characteristic (ROC) curves were generated for each hospital.

RESULTS

ROC curves varied significantly. The area under the curve from hospital 1 was 0.95 (SE = 0.021); the area under the curve from hospital 2 was 0.87 (SE = 0.034). The curves were essentially statistically different (P = 0.0516).

COMMENTS

We showed a difference in predicting diameter stenosis utilizing ICA PSV/CCA PSV ratios at two hospitals within our institution. Variability is likely due to technologists, since equipment and physician interpreters were the same. Criteria must be developed for each different machine in each laboratory. Quality assurance is critical to minimize variability.

[Can normalization of vascular cytoadhesive activity be explained by the anti-atherosclerosis effect of growth hormone?]

BACKGROUND

The increased mortality caused by premature atherosclerosis has been shown among patients with hypopituitarism receiving conventional hormone treatment but with unsubstituted growth hormone deficiency. This experience belongs among the most important arguments in favour of replacement with growth hormone. The mechanisms of the antiatherogenic effect of growth hormone are poorly understood. The protective effect of growth hormone on the vascular endothel and its intervention in the clotting process, which have not been yet elucidated, may be the causative factors.

METHODS AND RESULTS

The endothelial damage as given by measuring of circulating soluble cytoadhesive molecules sE-selectin, sP-selectin and intercellular adhesive molecule 1 (ICAM 1) was measured in 15 adult panhypopituitaric patients before and after 1 year treatment with recombinant human growth hormone. The blood levels of all of these cytoadhesive molecules decreased significantly (p < 0.01) during the treatment. None of the concomitantly followed coagulation tests (prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin III, von Willebrand's factor and D-dimer) was significantly changed during the treatment. The tendency to decrease (p = 0.054) was observed with antithrombin III.

CONCLUSIONS

The decrease of circulating cytoadhesive molecules in blood during the treatment of growth hormone gives evidence for its protective effect, either direct or mediated, on the vascular endothel. These findings could bring an explantation for the premature atherosclerotic changes in hypopituitarism and antiatherogenic effect of growth hormone.

Dexfenfluramine in psychotic patients

Dexfenfluramine (DF) is contraindicated in severe psychiatric disorders and in depression. We used DF in 3 patients with chronic psychosis and severe overeating without changes in psychiatric pharmacotherapy. Two patients had paranoid schizophrenic psychosis with hallucinations, one patient mixed psychosis, beginning with lactation psychosis, and several attacks of hallucinations and depression later. Overeating was removed in all 3 patients without any negative effect on the psychotic state. All patients were able to maintain their body weight. Two patients with poorly controlled diabetes improved markedly their metabolic status. Doses up to 75 mg per day of DF were necessary during binge eating episodes in one patient. We conclude that DF can be used with care under close psychiatric supervision in psychotic patients with severe overeating.

Results of primary and two-stage repair of interrupted aortic arch

OBJECTIVE

Early results of primary and two-stage repair of interrupted aortic arch have improved. Experience with different surgical approaches should be analysed and compared.

METHODS

Forty neonates and infants with interrupted aortic arch underwent primary repair (19 patients) or palliative operation (21 patients). Twenty (50%) patients were followed-up for 5.1+/-4.3 years. All patients were regularly examined with the aim of determining clinical development, presence of residual lesions or complications and need for re-intervention. Aortic arch and the left ventricular outflow tract growth were assessed by echocardiographic examination. Data from hospital and outpatient department records were analysed.

RESULTS

The early mortality was 61.9% after palliative operations and 36.8% after the primary repair. Presence of complications (P < 0.001), earlier year of surgery (P < 0.01), bad clinical condition and acidosis (P < 0.05) represented statistically significant risk factors for death in the whole series. In seven (87.5%) out of eight early survivors, after the initial palliative operation, closure of ventricular septal defect and debanding were done, and in three (37.5%) patients, re-operation for aortic arch obstruction was also required. Out of 12 patients, after the primary repair, one required early re-operation for persistent left ventricular outflow tract obstruction and two needed late re-intervention for left bronchus obstruction. In three (25%) patients, after the primary repair, left ventricular outflow tract obstruction with a maximal systolic pressure gradient higher than 30 mmHg developed. At present, all 20 early survivors are alive. Five patients, after palliative operation, are in NYHA class 1, but in three patients, who are in class III or IV, the outcome is influenced by severe complications. All patients after the primary repair are in class I or II.

CONCLUSIONS

Our experience confirmed better results after the primary repair of interrupted aortic arch, which was associated with lower mortality, prevalence of severe complications and need for re-intervention. Higher prevalence of subaortic stenosis after primary repair could be explained by patient selection early in our experience. We recommend the primary repair of interrupted aortic arch and associated heart lesions in neonates, however, in unfavourable conditions an individualised surgical approach with initial palliative surgery should be considered.