[Post EVAR rupture of an iliac artery aneurysm complicated with an iliac arteriovenous fistula. Clinical report]

Since the original description by Parodi in 1991, the aim of endovascular treatment of aortic and iliac aneurysms has been the prevention of rupture, with fewer risks than the conventional management. Much has been discussed about its technical feasibility, durability, and follow-up, however little emphasis has been given to the treatment of its emergent complications, namely the aneurysm rupture after endovascular treatment. The authors report the clinical case of a patient that underwent endovascular treatment of a left common iliac artery aneurysm four years before, which presented in the emergency department with symptoms suggestive of aneurysm rupture, together with high output iliac arteriovenous fistula. The patient underwent conventional open surgical procedure, which consisted in partial resection of the aneurysm and repair of the iliac arteriovenous fistula.

[Prosthetic revascularization of the midpopliteal artery through a posterior approach: a clinical experience]

Bypass grafting to the proximal or distal popliteal artery through a lateral approach is the most commum surgical technique used to treat patients with femoro-popliteal obstructive disease. We report all the patients who underwent a bypass graft to the midpopliteal artery through a posterior approach, in whom an autologous vein was not avalaiable, thus avoiding the use of a prosthetic graft implantation in to the infragenicular popliteal artery. Ten bypass grafts to the midpopliteal artery through a posterior approach were performed, for the last 6 years, in patients with critical limb ischaemia. Polytetrafluoroethylene ( PTFE ) grafts were used in all patients. With a mean follow-up of 16,1 months, the 1-year primary patency rate was 85,7 % and the 2-year primary patency rate was 66,7 %. Bypass grafting to the midpopliteal artery through a posterior approach seems to be a safe and sustainable procedure and is an alternative techinique to be considered in patients without autologus vein avalaiable, when an above-knee bypass grafting is not feasible or when a below-knee prothesis should be avoided.

[Large and extensive thoracoabdominal aortic aneurysm in a seropositive young woman, treated with the "simplified technique"]

The clinical case of a 37 years old female with the previous diagnosis of human immunodeficiency virus infection (HIV), under medical control, is reported, in whom an extensive and large thoracoabdominal aortic aneurysm was diagnosed (type II of the Stanley Crawford's classification), completely asymptomatic. The patient underwent surgical management, consisting in the resection of the aneurysm and prosthetic replacement, utilizing the "simplified technique", that was once again extremely well succeeded in this most demanding situation. The clinical and pathological features of this infection and the potential involvement in the pathogenesis of this uncommon aneurysm are discussed, according to the data published in the literature. Furthermore, the main aspects of the surgical management are described and discussed, facing the diverse technical alternatives nowadays used in clinical practice.

[Endovascular femoro-popliteal revascularization in critical limb ischemia: predictive factors for patency]

OBJECTIVES

The objective of this study was to evaluate the results of endovascular treatment of the superficial femoral artery and to identify some possible predictors of poor prognosis.

METHODS

All patients with femoropopliteal artery occlusive disease submitted to endovascular treatment in the internment section of the first author, between July 2007 to September 2010, were reviewed. Intention to treat analysis was performed. Patient's demographics and angiographic anatomic characteristics (results were standardized according to TransAtlantic Inter-Society Consensus II) were analyzed. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. We performed a univariate and bivariate analysis in order to determine factors temporally associated with a poor prognosis of endoluminal therapy. Results were evaluated in view of absence of re-stenosis, absence of re-intervention, patency and overall limb salvage rate.

RESULTS

A total of 34 patients corresponding to 36 lower limbs were treated during this period (mean age 65±12 years; males: 80%). Seventy-five percent of patients presented with chronic lower limb ischemia stage IV according to the Leriche-Fontaine classification, while the remaining 25% presented with chronic lower limb ischemia stage III. The lesions classified according to the TASC II document included 9 lesions TASC II B (25%), 20 lesions TASC II C (55%) and 7 lesions TASC II D (19%). Runoff at the tibial level was 1.8±0.6 patent vessels. The success rate was 94%. Mean follow-up was 13.5 months (varying 1-31 months) from the date of initial intervention. Five lower limbs (14%) presented with re-stenosis. Primary patency rates were 91% at 1 month and 77% at 6 months. Limb salvage rate was 88% at 12 months. Subgroup analysis revealed that primary patency rates were highly dependent on patient gender, lesion type and infra-popliteal runoff patent vessels.

CONCLUSIONS

Endovascular treatment of femoropopliteal sector is associated with high technical success rate. The best results were obtained in male patients with segmental, stenotic lesions and with a runoff of at least two vessels.

[High output heart failure due to an iatrogenic arteriovenous fistula after cardiac catheterization]

The occurrence of an arteriovenous fistula is a potential complication of cardiac catheterization. Most of these fistulas cause no harm. We report the clinical case of a 70 years old woman with high-output heart failure caused by an arteriovenous fistula (FAV) in the groin. The fistula was successfully closed by surgical repair and the heart failure was resolved. This case confirms the potential harmfulness for the vascular bed of certain surgical/endovascular interventions and intravascular monitoring techniques. When heart failure of uncertain etiology appears in patients previously submitted to one of the above mentioned procedures, a careful clinical examination can lead to a correct diagnosis of iatrogenic FAV, whose surgical correction is usually followed by the restoration of a normal cardiac function.

Fetal magnetic resonance imaging in the prenatal diagnosis of cerebellar hemorrhage

We report the case of a fetus with a sonographic mid-gestation diagnosis of hyperechogenic cerebellum suspected to be of hemorrhagic origin on fetal brain magnetic resonance imaging (MRI). No etiological factors for fetal hemorrhage were found other than a maternal heterozygocity for factor V Leiden. Following termination of the pregnancy, autopsy confirmed the prenatal diagnosis of massive cerebellar hemorrhage without underlying vascular anomaly. As an additional tool to ultrasonography, fetal brain MRI can affirm the hemorrhagic origin of hyperechogenic cerebellar lesions, especially by showing a high signal on T1-weighted images.

A clinical and molecular study of 26 females with Xp deletions with special emphasis on inherited deletions

We have undertaken a clinical study of 26 females with deletions of Xp including five mother-daughter pairs. Cytogenetic and molecular analyses have mapped the breakpoints of the deletions. We determined the parental origin of each abnormality and studied the X-inactivation patterns. We describe the clinical features and compare them with the amount of Xp material lost. We discuss the putative loci for features of Turner syndrome and describe how our series contributes further to their delineation. We conclude that (1) fertility can be retained even with the loss of two-thirds of Xp, thus, if there are genes on Xp for ovarian development, they must be at Xp11-Xp11.2; (2) in our sample of patients there is no evidence to support the existence of a single lymphogenic gene on Xp; (3) there is no evidence for a second stature locus in proximal Xp; (4) there is no evidence to support the existence of a single gene for naevi; (5) we suggest that the interval in Xp21.1-Xp11.4 between DXS997 and DXS1368 may contain a gene conferring a predisposition to hypothyroidism.

Comparison of Magnetic Resonance Angiography (MRA) and Duplex Ultrasound Arterial Mapping (DUAM) prior to infrainguinal arterial reconstruction

OBJECTIVE

the purpose of this study is to compare Magnetic Resonance Angiography (MRA) to Duplex Ultrasound Arterial Mapping (DUAM) and intraoperative findings to determine the clinical, accuracy of MRA for planning lower extremity revascularization procedures.

METHODS

forty-two patients who underwent lower extremity revascularization procedures had both MRA and DUAM evaluations. These data were analyzed retrospectively and two distinct endpoints were considered. First, we compared the MRA and DUAM findings for aorto-iliac, femoral-popliteal and infra-popliteal segments to intraoperative findings and evaluated the degree to which they agreed. Second, if there was a disagreement between imaging modalities, it was established whether a change in operative procedure would have resulted.

RESULTS

MRA and DUAM findings agreed in 26 of 31 cases (83%) of aorto-iliac segments, in 25 of 31 cases (81%) of femoral-popliteal segments, and in 16 of 21 cases (76%) of infra-popliteal segments. In total, DUAM agreed with intraoperative findings in 98% of cases while MRA agreed in 82% (p<.001). Disagreement between intraoperative findings and DUAM lead to an alternate surgical procedure in only one case (2%) while disagreement with MRA lead to a different procedure in 38% of cases (p<.001).

CONCLUSIONS

these data show that MRA is not yet adequate to replace conventional angiography and is less accurate that DUAM. Further improvements are necessary before MRA can be used as the sole modality for formulation of a pre-operative plan for lower extremity revascularization.

A 1.5 million-base pair inversion polymorphism in families with Williams-Beuren syndrome

Williams-Beuren syndrome (WBS) is most often caused by hemizygous deletion of a 1.5-Mb interval encompassing at least 17 genes at 7q11.23 (refs. 1,2). As with many other haploinsufficiency diseases, the mechanism underlying the WBS deletion is thought to be unequal meiotic recombination, probably mediated by the highly homologous DNA that flanks the commonly deleted region. Here, we report the use of interphase fluorescence in situ hybridization (FISH) and pulsed-field gel electrophoresis (PFGE) to identify a genomic polymorphism in families with WBS, consisting of an inversion of the WBS region. We have observed that the inversion is hemizygous in 3 of 11 (27%) atypical affected individuals who show a subset of the WBS phenotypic spectrum but do not carry the typical WBS microdeletion. Two of these individuals also have a parent who carries the inversion. In addition, in 4 of 12 (33%) families with a proband carrying the WBS deletion, we observed the inversion exclusively in the parent transmitting the disease-related chromosome. These results suggest the presence of a newly identified genomic variant within the population that may be associated with the disease. It may result in predisposition to primarily WBS-causing microdeletions, but may also cause translocations and inversions.

A new syndrome with craniofacial and skeletal dysmorphisms and developmental delay

We report a 16-year-old boy with multiple craniofacial and skeletal dysmorphic features including brachycephaly, acrocephaly, hypertelorism, wide palpebral fissures, broad nose, anteverted nares, broad columella, long and smooth philtrum, thin upper lip, macrostomia, carp-like mouth, micrognathia, low-set and posteriorly angulated ears with small and abnormal pinnae, a low posterior hairline, a short neck, hypoplastic and widely-spaced nipples, multiple severe pterygia, an umbilical hernia, metatarsus varus, low implantation of the halluces, and delayed motor and language development. An MRI of the head showed bilateral frontal pachygyria but no sign of heterotopia. The unique features of our patient suggest that he represents a new syndrome.

Successful prevention of hiv transmission from mother to infant in Brazil using a multidisciplinary team approach

OBJECTIVES

To determine the HIV vertical transmission rate (VTR) and associated risk factors by use of zidovudine and infant care education in Brazil.

METHODS

Since 1995, a prospective cohort of HIV infected pregnant women has been followed at the Federal University of Rio de Janeiro. A multidisciplinary team was established to implement the best available strategy to prevent maternal-infant HIV transmission. Patients with AIDS or low CD(4) and high viral load received anti-retroviral drugs in addition to zidovudine. Children were considered infected if they had 2 positive PCR-RNA tests between 1 and 4 months of age, or were HIV antibody positive after 18 months. Education regarding infant treatment and use of formula instead of breast feeding was provided.

RESULTS

Between 1995 and August, 2000, HIV status was determined for 145 infants. Compliance with intra-partum treatment, infant treatment and use of formula was 88.2%. Intra-partum zidovudine treatment was completed in 134/145 (92.6%) of patients; 88.1% had rupture of membranes < 4 hours; 85.4% of mothers were asymptomatic. The mean CD(4) count was 428.4 cells and mean viral load 39,050 copies. HIV vertical transmission rate was 4/145 (2.75%; CI: 0.1%-5.4%). The only risk factor significantly associated with transmission was a failure to use zidovudine intra-partum in 2 of the 4 mothers (50% versus 6.4% in non-transmitting mothers). A trend toward low CD(4) and high viral load at entry, and rupture of membranes > 4 hours were associated with increased HIV transmission.

CONCLUSION

HIV vertical transmission in Brazil was reduced to a level similar to other countries with the most effective prevention programs using a multidisciplinary team approach. A high level of compliance for use of anti-retroviral drugs, the provision of health education to mothers, and use of formula for all exposed infants.

Alternative translation initiation produces a short form of a spore coat protein in Bacillus subtilis

During endospore formation in Bacillus subtilis, over two dozen polypeptides are localized to the developing spore and coordinately assembled into a thick multilayered structure called the spore coat. Assembly of the coat is initiated by the expression of morphogenetic proteins SpoIVA, CotE, and SpoVID. These morphogenetic proteins appear to guide the assembly of other proteins into the spore coat. For example, SpoVID forms a complex with the SafA protein, which is incorporated into the coat during the early stages of development. At least two forms of SafA are found in the mature spore coat: a full-length form and a shorter form (SafA-C(30)) that begins with a methionine encoded by codon 164 of safA. In this study, we present evidence that the expression of SafA-C(30) arises from translation initiation at codon 164. We found only a single transcript driving expression of SafA. A stop codon engineered just upstream of a predicted ribosome-binding site near codon M164 abolished formation of full-length SafA, but not SafA-C(30). The same effect was observed with an alanine substitution at codon 1 of SafA. Accumulation of SafA-C(30) was blocked by substitution of an alanine codon at codon 164, but not by a substitution at a nearby methionine at codon 161. We found that overproduction of SafA-C(30) interfered with the activation of late mother cell-specific transcription and caused a strong sporulation block.

Expression and characterization of recombinant human alpha-3/4-fucosyltransferase III from Spodoptera frugiperda (Sf9) and Trichoplusia ni (Tn) cells using the baculovirus expression system

The human alpha-3/4-fucosyltransferase III (Fuc-TIII) participates in the synthesis of Lewis determinants. The enzyme from human sources is scarce and heterogeneous. In this paper we describe the expression of a secreted form of Fuc-TIII (SFT3) in two insect cell lines, Spodoptera frugiperda (Sf9) and Trichoplusia ni (Tn), using the baculovirus expression system. The Sf9 cells secreted approx. 0.4 unit/l (1 mg/l) of the enzyme. The Tn cells secreted approx. 3-fold this amount. A large proportion of active protein was accumulated in the two cell lines (50 and 75% respectively for Sf9 and Tn cells, on the fourth day after infection) indicating a possible limitation not only of the folding machinery, but also a saturation of the secretory pathway. SFT3 was purified by cation-exchange chromatography followed by affinity chromatography. The enzyme from the Tn cell line had a lower global charge, possibly due to post-translational modifications, such as phosphorylation or sulphation. The two glycosylation sites from SFT3 were occupied. SFT3 secreted by Sf9 cells was completely deglycosylated by peptide-N-glycanase F, whereas 50% of SFT3 secreted by Tn cells was resistant to deglycosylation by this enzyme. The apparent kinetic parameters determined with the type I acceptor were k(cat)=0.4 s(-1) and K(m)=0.87 mM for the SFT3 secreted by Tn cells, and k(cat)=0.09 s(-1) and K(m)=0.76 mM for the SFT3 secreted by Sf9 cells, indicating that the enzymes had substrate affinities within the same order of magnitude as their mammalian counterpart. Furthermore, SFT3 secreted by either cell type showed a clear preference for type 1 carbohydrate acceptors, similarly to human Fuc-TIII.

Highly potent nociceptin analog containing the Arg-Lys triple repeat

One of the structural characteristics of a neuropeptide nociceptin is the existence of Arg-Lys (RK) residues at positions 8-9 and 12-13; both RKs have been suggested to bind to the acidic amino acid cluster in the second extracellular loop of the seven transmembrane domain receptor ORL1. With a design strategy of attempting to obtain an analog that binds more strongly to the receptor's acidic cluster, we synthesized a series of nociceptin analogs in which the RK dipeptide unit was placed at positions 6-7, 10-11, or 14-15 adjacent to the parent RKs. Among these nociceptin analogs containing the RK triple repeat, [Arg-Lys(6-7)]- and [Arg-Lys(10-11)]nociceptins exhibited weak activities (6-9 and 60-90% of nociceptin, respectively) both in the receptor binding assay and in the [(35)S]GTPgammaS binding functional assay. In contrast, [Arg-Lys(14-15)]nociceptin was found to be very potent in both assays (3-fold in binding and 17-fold in GTPgammaS functional assay). [Arg-Lys(14-15)]nociceptin was the first peptide analog found to be stronger than the parent nociceptin, and structure-activity studies have suggested that the incorporated Arg-Lys(14-15) interacts with either the receptor acidic amino acid cluster or the receptor aromatic amino acid residues.

Mutational analysis of the highly conserved arginine within the Glu/Asp-Arg-Tyr motif of the alpha(1b)-adrenergic receptor: effects on receptor isomerization and activation

We have suggested previously that both the negatively and positively charged residues of the highly conserved Glu/Asp-Arg-Tyr (E/DRY) motif play an important role in the activation process of the alpha(1b)-adreneric receptor (AR). In this study, R143 of the E/DRY sequence in the alpha(1b)-AR was mutated into several amino acids (Lys, His, Glu, Asp, Ala, Asn, and Ile). The charge-conserving mutation of R143 into lysine not only preserved the maximal agonist-induced response of the alpha(1b)-AR, but it also conferred high degree of constitutive activity to the receptor. Both basal and agonist-induced phosphorylation levels were significantly increased for the R143K mutant compared with those of the wild-type receptor. Other substitutions of R143 resulted in receptor mutants with either a small increase in constitutive activity (R143H and R143D), impairment (R143H, R143D), or complete loss of receptor-mediated response (R143E, R143A, R143N, R143I). The R413E mutant displayed a small, but significant increase in basal phosphorylation despite being severely impaired in receptor-mediated response. Interestingly, all the arginine mutants displayed increased affinity for agonist binding compared with the wild-type alpha(1b)-AR. A correlation was found between the extent of the affinity shift and the intrinsic activity of the agonists. The analysis of the receptor mutants using the allosteric ternary complex model in conjunction with the results of molecular dynamics simulations on the receptor models support the hypothesis that mutations of R143 can drive the isomerization of the alpha(1b)-AR into different states, highlighting the crucial role of this residue in the activation process of the receptor.

Catechol-binding serines of beta(2)-adrenergic receptors control the equilibrium between active and inactive receptor states

The binding free energy for the interaction between serines 204 and 207 of the fifth transmembrane helix of the beta(2)-adrenergic receptor (beta(2)-AR) and catecholic hydroxyl (OH) groups of adrenergic agonists was analyzed using double mutant cycles. Binding affinities for catecholic and noncatecholic agonists were measured in wild-type and mutant receptors, carrying alanine replacement of the two serines (S204A, S207A beta(2)-AR), a constitutive activating mutation, or both. The free energy coupling between the losses of binding energy attributable to OH deletion from the ligand and from the receptor indicates a strong interaction (nonadditivity) as expected for a direct binding between the two sets of groups. However, we also measured a significant interaction between the deletion of OH groups from the receptor and the constitutive activating mutation. This suggests that a fraction of the decrease in agonist affinity caused by serine mutagenesis may involve a shift in the conformational equilibrium of the receptor toward the inactive state. Direct measurements using a transient transfection assay confirm this prediction. The constitutive activity of the (S204A, S207A) beta(2)-AR mutant is 50 to 60% lower than that of the wild-type beta(2)-AR. We conclude that S204 and S207 do not only provide a docking site for the agonist, but also control the equilibrium of the receptor between active (R*) and inactive (R) forms.