Ventricular remodeling in a mouse model of myocardial infarction

We investigated the suitability of studying ventricular remodeling in a mouse model of myocardial infarction (MI). We performed left coronary ligation (n = 22) or a sham procedure (n = 21) on normal C57BL/6J mice. Six weeks later, animals underwent echocardiography and hemodynamic evaluation. Left ventricular (LV) volume at a common distending pressure was calculated from passive pressure-volume curves. The MI group exhibited lower systolic blood pressure (P < 0.05), higher LV end-diastolic pressure (P < 0.05), and lower peak first derivative of LV pressure (dP/dt, P < 0.05) than the sham group. Mice with moderate (< 40%, n = 11) and large (> or = 40%, n = 11) MIs displayed increased LV mass-to-body weight ratio (P < 0.02 and P < 0.01, respectively, vs. sham group), whereas only the large-MI group exhibited increased right ventricular mass-to-body weight ratio (P < 0.01). LV volumes were increased in the moderate-MI group (P = 0.059 vs. sham group) and to a much greater extent in the large-MI group (P < 0.0001 vs. sham group). The moderate- and large-MI groups also exhibited increases in LV end-diastolic diameter (P < 0.03 and P < 0.0001, respectively, vs. sham group) and LV end-systolic diameter (P < 0.01 and P < 0.0001, respectively, vs. sham group) with decreased fractional shortening (P < 0.01 for both). These data demonstrate ventricular remodeling in a mouse model of MI and confirm the feasibility of quantifying indexes of remodeling in vivo and postmortem. This model will be of particular usefulness when applied to transgenic strains.

Warfarin anticoagulation and survival: a cohort analysis from the Studies of Left Ventricular Dysfunction

OBJECTIVES

We sought to evaluate the relation between warfarin anticoagulation and survival and morbidity from cardiac disease in patients with left ventricular (LV) dysfunction.

BACKGROUND

Warfarin anticoagulation plays a major role in the management of patients who have had a large myocardial infarction and in those with atrial fibrillation. However, its use in patients with LV systolic dysfunction has been controversial.

METHODS

We reviewed data on warfarin use in 6,797 patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial and analyzed the relation between warfarin use and all-cause mortality, as well as the combined end point of death or hospital admission for heart failure. We used Cox regression to adjust for differences in baseline characteristics and to test for the interaction between warfarin use and selected patient variables in relation to outcome.

RESULTS

On multivariate analysis, use of warfarin was associated with a significant reduction in all-cause mortality (adjusted hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.65 to 0.89, p = 0.0006) and in the risk of death or hospital admission for heart failure (HR 0.82, 95% CI 0.72 to 0.93, p = 0.0002). Risk reduction was observed when each trial or randomization arm was analyzed separately, as well as in both genders. It was not significantly influenced by the presence of atrial fibrillation, age, ejection fraction, New York Heart Association functional class or etiology.

CONCLUSIONS

In patients with LV systolic dysfunction, warfarin use is associated with improved survival and reduced morbidity. This association is primarily due to a reduction in cardiac events and does not appear to be limited to any particular subgroup.

Endoscopic injection of glutaraldehyde cross-linked collagen for efferent limb incompetence in the Indiana reservoir

PURPOSE

We determined the clinical applicability, safety and efficacy of endoscopically injected glutaraldehyde cross-linked collagen for the treatment of efferent limb incompetence in the incontinent Indiana urinary reservoir.

MATERIALS AND METHODS

Six patients were diagnosed with incompetence of the efferent limb of the Indiana reservoir by video urodynamics. Glutaraldehyde cross-linked collagen was injected through the efferent limb at the level of the ileocecal valve. Outcome was assessed by evaluation of dryness and pouchograms.

RESULTS

With a mean followup time of 26 months (range 6 to 36) after the last injection 5 of the 6 patients were cured. The remaining patient, although improved, had a small capacity and subsequently underwent ileal patch augmentation. No patient failed to improve. The mean volume of collagen was 16 ml. (range, 5 to 26). Reservoir volume increased from 150 to 400 ml.

CONCLUSIONS

The use of glutaraldehyde cross-linked collagen in the treatment of the incontinent Indiana reservoir is safe and effective.

Transcoronary ethanol ablation of the atrioventricular node in a young patient with tricuspid atresia

Catheter ablation of AV conduction with radiofrequency energy can be challenging in the presence of structural abnormalities of the AV junction, either congenitally or after reconstructive surgery. We used transcoronary ethanol to ablate the AV node in a patient with classic tricuspid atresia and refractory intraatrial reentry tachycardia. This approach provides an alternative means of creating complete heart block with catheter-based techniques, when radiofrequency catheter ablation is technically impossible or ineffective.

Subfascial endoscopic perforator vein surgery (SEPS): current practice among British surgeons

Subfascial endoscopic perforator vein surgery (SEPS) has recently caused considerable interest among British surgeons. There are no data indicating which, if any, patients benefit from SEPS. A series of 47 British surgeons, identified as having taken up SEPS, were sent a questionnaire asking about their current practice; 26 were returned completed (55% response rate). Of those surgeons replying, 22 (85%) had performed their first SEPS procedure within the previous 21 months, 18 (69%) within the previous 9 months. Most surgeons had performed five procedures (range 1-52). The most common indication for SEPS was venous ulceration with proven incompetent perforators (eight surgeons), but there was a wide diversity of other indications used to select patients for SEPS. Only nine surgeons had changed their indications for surgery with the advent of SEPS, yet their predicted number of SEPS procedures was far greater than the number of open procedures they currently performed. Out of 26 surgeons, 25 intend to continue performing SEPS. Prospective studies are needed to identify which patients might benefit from this new procedure.

In vivo effects of dexmedetomidine on laser-Doppler flow and pial arteriolar diameter

BACKGROUND

The alpha2-adrenergic agonist dexmedetomidine alters global cerebral blood flow (CBF). However, few studies have investigated the action of dexmedetomidine on the cerebral microcirculation. This investigation examined the effects of dexmedetomidine on (1) regional CBF in the rat cerebral cortex using laser-Doppler flowmetry and (2) on pial arteriolar diameter.

METHODS

Halothane-anesthetized rats were fitted with instruments to measure CBF as determined by laser-Doppler flow (CBFldf) or to measure pial arteriolar diameter by preparing a cranial hollow deepened until a translucent plate of skull remained, thereby maintaining the integrity of the cranial vault. In both groups, 20 microg/kg dexmedetomidine was infused intravenously. Thirty minutes later, the mean arterial pressure was restored to control values with an infusion of phenylephrine (0.5 to 5 microg/kg/min).

RESULTS

Administration of dexmedetomidine was associated with decreases in end-tidal and arterial carbon dioxide. The CBFldf and pial arteriolar diameter were measured during normocapnia (controlled carbon dioxide) and during dexmedetomidine-induced hypocapnia. Intravenous administration of dexmedetomidine significantly decreased systemic arterial pressure concurrent with a decrease in CBFldf (22% in normocapnic animals, 36% in hypocapnic animals). Restoration of mean arterial pressure increased CBFldf in normocapnic but not in hypocapnic animals. Similarly, dexmedetomidine significantly reduced pial vessel diameter in both normocapnic (9%) and hypocapnic animals (17%). However, vessel diameters remained decreased in the normocapnic and hypocapnic animals after the mean arterial pressure was restored.

CONCLUSIONS

These results suggest a modulation of cerebral vascular autoregulation by dexmedetomidine which may be mediated, in part, by alterations in carbon dioxide. Dexmedetomidine may have a direct action on the cerebral vessels to reduce the CBF during normo- or hypocapnia. The differences between CBFldf and pial arteriole responses to restoration of mean arterial pressure may reflect the difference in measurement techniques because laser-Doppler measurements reflect the net effect of several arterial segments on microvascular perfusion, whereas diameter measurements specifically examined individual pial arterioles, suggesting that dexmedetomidine vasoconstriction in the cerebral vasculature may be differentially and regionally mediated.

Antiplatelet agents and survival: a cohort analysis from the Studies of Left Ventricular Dysfunction (SOLVD) trial

OBJECTIVES

This study sought to evaluate the relation between antiplatelet agent (APA) use and survival and morbidity from cardiac disease in patients with left ventricular (LV) systolic dysfunction.

BACKGROUND

APAs play an important role in the prevention and treatment of coronary disease. Their effects in patients with LV systolic dysfunction are unknown.

METHODS

We reviewed data on APA use in 6,797 patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial and analyzed the relation between their use and all-cause mortality as well as the combined end point of death or hospital admission for heart failure (HF). We used Cox regression to adjust for differences in baseline characteristics and to test for the interaction between APA use and selected patient variables in relation to outcome.

RESULTS

APA use (46.3% of patients) was associated with significantly reduced mortality from all causes (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.73 to 0.92, p = 0.0005) and reduced risk of death or hospital admission for HF (adjusted HR 0.81, 95% CI 0.74 to 0.89, p < 0.0001) but was not influenced by trial assignment, gender, LV ejection fraction, New York Heart Association class or etiology. A strong interaction was observed among APA use, randomization group and all-cause mortality. The association between APA use and survival was not observed in the enalapril group, nor was an enalapril benefit on survival detectable in patients receiving APAs at baseline. However, randomization to enalapril therapy significantly reduced the combined end point of death or hospital admission for HF in APA users.

CONCLUSIONS

In patients with LV systolic dysfunction, use of APAs is associated with improved survival and reduced morbidity. This association is retained after adjustment for baseline characteristics. APA use is associated with retained but reduced benefit from enalapril.

Reaper-induced apoptosis in a vertebrate system

The reaper protein of Drosophila melanogaster has been shown to be a central regulator of apoptosis in that organism. However, it has not been shown to function in any vertebrate nor have the cellular components required for its action been defined. In this report we show that reaper can induce rapid apoptosis in vitro using an apoptotic reconstitution system derived from Xenopus eggs. Moreover, we show that a subcellular fraction enriched in mitochondria is required for this process and that reaper, acting in conjunction with cytosolic factors, can trigger mitochondrial cytochrome c release. Bcl-2 antagonizes these effects, but high levels of reaper can overcome the Bcl-2 block. These results demonstrate that reaper can function in a vertebrate context, suggesting that reaper-responsive factors are conserved elements of the apoptotic program.

Augmentation cystoplasty

The past 15 years have been witness to an explosion in the number of reconstructive procedures using bowel in the urinary tract. As with many concepts in medicine, one must rely on clinical experience while laboratory models and other advancements develop. This article attempts to address bladder reconstruction by enterocystoplasty, as well as the indications for augmentation, types of procedures available, and the early and late complications.

Conservative surgery for ureteral tumor associated with horseshoe kidney

PURPOSE

We demonstrate the successful conservative management of a ureteral tumor in a horseshoe kidney.

MATERIALS AND METHODS

A patient with low grade transitional cell carcinoma of the left lower ureter had asymptomatic horseshoe kidney. Biopsy specimen revealed low grade tumor in the lower urinary tract that was associated with a congenital abnormality. The patient underwent total ureterectomy with bladder cuff excision and ileal ureteral interposition.

RESULTS

With this technique renal function was preserved without resection through the isthmus of the kidney. The patient has no evidence of recurrent disease after 20-month followup by cytology, computerized tomography, excretory urogram and cystoscopy.

CONCLUSIONS

Organ preserving surgery is an alternative to total nephroureterectomy in lower ureteral tumors in select patients.

Ileal ureter

Ureteral replacement with ileal bowel segments has become common in the armamentarium of the reconstructive urologist. The use of ileal bowel substitution, whether total or segmental, has provided yet another surgical alternative for renal preservation. The indications, surgical technique, and results with the ileal ureter are reviewed.

In vivo forces during remodeling of a two-segment anterior cruciate ligament graft in a goat model

An existing goat model was used to measure in vivo graft forces during walking, to determine if the forces set at surgery change over time under the same external load and if the forces in the graft during in vivo function can be dictated by the forces set at surgery. The anterior cruciate ligament was reconstructed in 12 goats with use of a composite graft consisting of a bone-patellar tendon-bone autograft and a synthetic augmentation segment. The forces in the graft segments were established intraoperatively by a force-setting technique. In five animals, the tendon segment was set to carry 90% of the total graft force, and in the seven other animals, the augmentation segment was set to carry 90% of the total force. The total graft force was the same in all animals. Graft forces due to anterior tibial loads of 67 N were measured before and after fixation and 6 weeks after surgery with the use of buckle transducers mounted extra-articularly over the anterior tibia. They were also measured during straight, level walking at 6 weeks. The forces changed significantly from just after surgery to 6 weeks later, such that the initially set load-sharing was eliminated by 6 weeks. At 6 weeks, a relatively smooth gait had been achieved, and the maximum total graft force in each animal during walking averaged 35 N and was of similar magnitude to forces generated by the anterior tibial loads of 67 N with the animal anesthetized. After fixation, forces in the tendon graft segments were significantly different between the group with high set forces and that with low set forces. At 6 weeks, when functional joint loads were approaching normal levels, the graft segment forces for the two groups were not significantly different. Load-sharing between tendon and augmentation segment and load in the tendon segment at 6 weeks could not be dictated at surgery.

Phospholipase A2 inhibition results in sequestration of plasma membrane into electronlucent vesicles during IgG-mediated phagocytosis

Arachidonic acid is essential for antibody-mediated phagocytosis but its role in this process has not been defined. The phospholipase A2 inhibitor bromoenol lactone decreases arachidonic acid release and arrests phagocytosis; this effect is bypassed by the addition of arachidonic acid to bromoenol lactone-treated cells. In this morphological study, monocytes treated with bromoenol lactone accumulate electronlucent vesicles in the cytoplasm underlying bound targets. The vesicles are not contiguous with the plasma membrane as they are not labeled with cationized ferritin and are not connected to the plasma membrane as determined by high voltage electron microscopy imaging. However, if the plasma membrane is decorated with wheat germ agglutinin-gold prior to vesicle formation, virtually all vesicles contain the gold marker, indicating that they are plasma membrane-derived. The number of vesicles decreases dramatically upon addition of arachidonic acid to phospholipase A2-inhibited monocytes and phagocytosis is restored. Time course studies reveal electronlucent regions surrounding targets at early timepoints and a morphology consistent with fusion of electronlucent vesicles into the developing phagosome. These results are consistent with the following model: during the early stages of antibody-mediated phagocytosis, plasma membrane is sequestered in intracellular vesicles that provide membrane for the forming phagosome via fusion events that require arachidonic acid.

Acute and long-term effects of the angiotensin-converting enzyme inhibitor, enalapril, on adrenergic activity and sensitivity during exercise in patients with left ventricular systolic dysfunction

Patients with heart failure and left ventricular systolic dysfunction exhibit increased adrenergic activity but blunted adrenergic responsiveness. We studied patients enrolled in the Studies of Left Ventricular Dysfunction, examining exercise responses of heart rate (HR) and plasma norepinephrine (PNE). Eighty-seven patients were studied before randomization; 65 of these were examined 1 year after randomization to placebo or enalapril. Compared with prevention trial (asymptomatic) patients, patients in the treatment trial (symptomatic) had higher resting HR and PNE levels and less increase in HR with a greater increase in PNE with exercise. Acute administration of enalapril increased the resting HR in patients in the prevention trial only but had no significant effect on PNE. After 1 year of therapy, patients in the prevention trial exhibited no change. Within the treatment trial, the placebo group displayed both a higher peak PNE and increase in PNE with exercise than did the enalapril group, whose HR response was maintained in spite of a reduction of exercise PNE. We conclude that (1) compared with asymptomatic patients, symptomatic patients with reduced left ventricular ejection fraction manifest greater resting and exercise adrenergic activity, with blunted HR response; and (2) in symptomatic patients, 1 year of enalapril treatment effected an augmented HR response to adrenergic stimulation, supporting an interaction between the renin/angiotensin and adrenergic nervous systems. Normalization of adrenergic tone and response likely contributes to the benefits of long-term angiotensin-converting enzyme inhibitor therapy.

Preparation and properties of N alpha-Bpoc-amino acid pentafluorophenyl esters

The preparation and properties are reported of several N alpha-Bpoc -amino acid pentafluorophenyl esters, including those bearing tert-butyl-, allyl- and trityl-based protecting groups. These derivatives have been used in the solid-phase peptide synthesis of several short peptides.

A new PhD training track: a proposal to improve basic science teaching

There has been increasing criticism of medical basic science teaching; much of this has focused on overcrowding of the curriculum, inadequate application to clinical medicine, and the limited commitment of the faculty to teach. We have analyzed some of the factors that may contribute to these complaints, such as the fragmentation of physiology and the conflicting roles of the medical basic scientist. We have also reviewed some previous suggestions for improving basic science teaching. We suggest that a basic scientist with a background of integrative physiology, pharmacology, anatomy, and pathology, with a special emphasis on pathophysiology, would be well qualified to assume an important role in the medical education of the future. Because there is at present no established training program of this type, we have proposed a PhD training track with this objective and have listed some of the advantages and disadvantages of such a program.

Anorexia nervosa and bulimia nervosa: sibling sex ratio and birth rank--a catchment area study

OBJECTIVES

These were to determine (1) whether there is a birth rank effect in eating disorders, and (2) whether all-female sibships are overrepresented in the families of those with eating disorders.

METHOD

The study sample consisted of 293 female patients referred from a defined catchment area, the County of Leicester, United Kingdom, to an eating disorders clinic. Diagnoses were made using DSM-III and DSM-III-R. To discern birth rank effect, this core sample was expanded to one of 673 by adding published data sets to our own.

RESULTS

No evidence for either effect was found.

DISCUSSION

Biases which may have obscured genuine effects are discussed. A comment is made on the implication for family theories of causation of these negative findings.

The peroxin Pex17p of the yeast Yarrowia lipolytica is associated peripherally with the peroxisomal membrane and is required for the import of a subset of matrix proteins

PEX genes encode peroxins, which are required for the biogenesis of peroxisomes. The Yarrowia lipolytica PEX17 gene encodes the peroxin Pex17p, which is 671 amino acids in length and has a predicted molecular mass of 75,588 Da. Pex17p is peripherally associated with the peroxisomal membrane. The carboxyl-terminal tripeptide, Gly-Thr-Leu, of Pex17p is not necessary for its targeting to peroxisomes. Synthesis of Pex17p is low in cells grown in glucose-containing medium and increases after the cells are shifted to oleic acid-containing medium. Cells of the pex17-1 mutant, the original mutant strain, and the pex17-KA mutant, a strain in which most of the PEX17 gene is deleted, fail to form normal peroxisomes but instead contain numerous large, multimembraned structures. The import of peroxisomal matrix proteins in these mutants is selectively impaired. This selective import is not a function of the nature of the peroxisomal targeting signal. We suggest a regulatory role for Pex17p in the import of a subset of matrix proteins into peroxisomes.

Identification and localization of the sod2 gene product in fission yeast

Sod2, the Na+/H+ antiporter of the fission yeast Schizosaccharomyces pombe, was identified by addition of a hemagglutinin tag to the carboxyl terminus of the protein. The tagged protein was expressed in the sod2-deficient strain of S. pombe. Transformants retained tolerance to lithium (1-10 mM) at external pH values from 3.5 to 6.5. Both Na+-dependent proton uptake and active sodium extrusion were also restored in transformed cells, suggesting that a functional antiporter was present. The protein was present in a membrane fraction. In SDS PAGE it migrated as a single 47 kDa band. The protein could be efficiently solubilized with the non-ionic detergent, dodecyl maltoside. Immunofluorescent microscopy revealed an asymmetric distribution with preferable accumulation in polar tip areas. The results are the first identification and localization of the Na+/H+ exchanger in yeast cells.

Identification of an Fe(III)-dihydroxyphenylalanine site in recombinant phosphomannose isomerase from Candida albicans

Candida albicans phosphomannose isomerase (PMI) is a zinc metalloprotein of known crystal structure. When heterologously overexpressed in Escherichia coli, a blue protein that contains up to 0.5 iron atoms/PMI molecule could be isolated, with absorption maxima at 420 nm and 680 nm. These bands are reminiscent of ferric catecholate complexes, an assignment that has been confirmed by resonance Raman spectroscopy, and by reaction with Arnow's reagent, which is specific for the presence of 3,4-dihydroxyphenylalanine (Dopa). After enzymatic digestion of blue PMI, a peptide with the sequence DPHAXISG was isolated corresponding to residues Asp283-Gly290 in the amino acid sequence of C. albicans PMI, where the unidentified residue X287 is encoded by a tyrosine codon. It is proposed that iron and oxygen bring about hydroxylation of Tyr287 in PMI and that Fe(III) subsequently chelates the Dopa residue to give the characteristic absorption spectrum. The EPR spectrum of the blue protein suggests three iron environments in the protein, two in axial environments with E/D values approximately equal to 0.06 and 0.12 and one rhombic species. The nature of the iron co-ordination sites is discussed with the help of model systems and by comparison with other blue non-heme iron proteins.

Mammary growth in Holstein cows during the dry period: quantification of nucleic acids and histology

Influence of the dry period on mammary growth was studied using multiparous Holstein cows. Sixty days before expected parturition, 13 cows were dried off, and another 13 cows were milked throughout the prepartum period. Lactating cows and dry cows were slaughtered at 53, 35, 20, and 7 d prepartum. Total mammary parenchymal DNA increased twofold from 53 to 7 d prepartum without influence of lactation status. However, overall rate of [3H]thymidine incorporation by mammary tissue was 80% greater in dry cows than in lactating cows, indicating that replacement of mammary cells was greater in dry cows. Of the mammary cells labeled with [3H]thymidine, the percentage of epithelial cells in dry cows was greater than that in lactating cows (96% vs. 86%). By 7 d prepartum, epithelial calls accounted for a greater percentage of total mammary cells in dry cows than in lactating cows (83% vs. 74%). Tissue area occupied by alveolar or ductular lumina decreased by 25 d into the dry period (35 d prepartum) and then increased to a maximum by 7 d prepartum. None of the mammary epithelial cells in dry cows were classified as secretory at 35 d prepartum, but 98% of the epithelial cells of dry cows were classified as secretory at 7 d prepartum. Results indicated that mammary involution did not occur during a typical dry period of dairy cows. Data suggest that a dry period is important for replacing senescent mammary epithelial cells and increasing the epithelial component of the gland prior to the next lactation.

The role of nitric oxide in the cerebrovascular response to hypercapnia

Laser Doppler flowmetry was used to further investigate the role of nitric oxide (NO) in CO2-induced cerebrocortical hyperemia in rats. A second objective was to elucidate the source(s) of the NO involved in the response to hypercapnia. We used the L-arginine analogue N omega-nitro-L-arginine methyl ester (L-NAME) to inhibit NO synthase (NOS) and 7-nitroindazole (7-NI) to selectively inhibit brain or nonendothelial NOS. Rats were anesthetized with a single dose of intraperitoneal (IP) pentobarbital (65 mg/kg) for surgery; 60-90 min later they were ventilated with 1.0% halothane in 30% O2 for 1 h to achieve a steady state. The animals were assigned to one of five groups. A control group (n = 9) was infused with 1 mL of saline. The second group (n = 10) received 20 mg/kg of L-NAME intravenously (IV). A third group (n = 9) also received L-NAME; in addition, cerebrocortical laser Doppler flow (LDF) and mean arterial pressure (MAP) were restored to baseline using the NO donor sodium nitroprusside (SNP). In a fourth group (n = 9), MAP was increased to the level usually seen after L-NAME with an infusion of phenylephrine (0.5-5 micrograms.kg-1.min-1). A fifth group (n = 11) received 7-NI at 40 mg/kg IP. The hypercapnic response of LDF was tested in all groups by adding 5% CO2 to the inspired gas at 30-45 min posttreatment; all changes in LDF were significant. In the control group, hypercapnia induced a 70% +/- 24% increase in LDF. In the L-NAME-treated group, the response was decreased to 36% +/- 22% at a posttreatment LDF that was 25% +/- 13% lower than the pre-L-NAME level. In the group where baseline LDF and MAP were restored with SNP, the CO2 response was 56% +/- 15% (not significant versus control). In the group in which MAP was increased with phenylephrine, the response to hypercapnia was 48% +/- 22% at a posttreatment LDF unchanged from pretreatment. These data suggest that increased vascular tone or the absence of basal NO after NOS inhibition influenced the vasodilator response to hypercapnia. In the 7-NI-treated group the response to hypercapnia was 38% +/- 3%, significantly attenuated at a posttreatment flow only 14% +/- 7% lower than pre-7-NI. We conclude that 1) endothelial NO does not mediate the response to hypercapnia but may have a permissive role in the response and 2) that brain NO may have an important role in response to hypercapnia.