Safety of oral nicorandil before coronary artery bypass graft surgery

Nicorandil is a K(ATP) channel opener used to treat angina. It is cardioprotective and a vasodilator. We conducted a prospective, randomized, double-blind, placebo-controlled study to assess oral nicorandil in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Twenty-two patients received nicorandil (10 mg twice a day) and 23 patients received placebo. Haemodynamic data were recorded before induction of anaesthesia (T0), 5 and 20 min after starting mechanical ventilation (T1, T2), before aortic cannulation (T3), after 30 min of CPB (T4), 10 min after CPB (T5) and after 3, 8 and 18 h in the intensive care unit (T6, T7, T8). Serum proteins (creatine kinase metabolite and cardiac troponin I) were measured before and 8 and 18 h after surgery. Haemodynamic values did not differ between the two groups. There was no tachycardia during the study, no significant difference in hypotensive episodes, ST segment changes and no changes in cardiac enzymes. Myocardial infarction after surgery was similar in the two groups. Vasoactive therapy was similar in the two groups. Nicorandil can be continued safely up to premedication without deleterious haemodynamic consequences, but a myocardial protective effect of nicorandil in CABG surgery was not found.

[Bacterial perihepatitis]

The Fitz-Hugh-Curtis syndrome is a peri-hepatitis following a genital infection. It usually occurs in young women. Chlamydia trachomatis is the most frequent causal agent. Clinical signs include acute or recurrent pain in the right hypochondria. Liver tests are not modified and the sonographic examination is normal. Diagnosis can be suspected on the basis of serology, and formally established by laparoscopy showing violin string-like adhesions. Prolonged antibiotic treatment is effective.

Kinetics of hydrazinium nitrate decomposition in nitric acid solutions under the effect of power ultrasound

The effect of ultrasound (f = 20 kHz) on the decomposition of hydrazinium nitrate was investigated in a nitric acid medium. The kinetics of N2H5+ decomposition and initial HN3 formation increase in a linear manner with the HNO3 concentration (from 1 to 6 M) and with the ultrasonic intensity (from 0.5 to 3.1 W cm-2). Both rates were equal to that of HNO2 formation in the absence of N2H5+, indicating that the N2H5+ decomposition mechanism is the same as observed without ultrasound between HNO2 and N2H5+. The variation of the steady-state HN3 concentration with the HNO3 concentration and the ultrasonic intensity suggests the existence of a nonexplosive HN3 thermal decomposition mechanism in the cavitation bubble under the effect of ultrasound. It was also observed at ultrasonic intensities exceeding 3.5 W cm-2 that the decomposition of HN3 led to the accumulation of NH4+ in solution.

[Port-site metastasis after laparoscopic resction of a duodenal stromal tumor]

Gastro-intestinal stromal tumors are rare and their evolution is dubious. This observation of port site metastasis after laparoscopic resection of a small duodenal stromal tumor would be, to our knowledge, the first case reported in the literature. Several direct and indirect mechanisms were supposed to be involved in the appearance of metastases after laparoscopic surgery, but the risk of dissemination remains badly evaluated on its frequency as well as on its mechanisms.

Expression and DNA-binding activity of C/EBPalpha and C/EBPbeta in human liver and differentiated primary hepatocytes

BACKGROUND/AIMS

Limited information is available on the expression and role of C/EBP factors in human liver and hepatocytes. We investigated the expression and DNA-binding activity of C/EBPalpha and C/EBPbeta in human liver needle biopsies, surgical lobectomies and differentiated cultured hepatocytes derived from lobectomies.

METHODS

RNA and protein extracts were analyzed by RNAse protection, immunoblot and gel shift assays.

RESULTS

C/EBP mRNAs, isoforms and DNA-binding activities were low/undetectable in lobectomies. In contrast, several C/EBPalpha (47, 45, 35 and 33 kDa) and C/EBPbeta isoforms (47, 43, 40, 35 and 21 kDa) were observed in needle biopsies. In cultured hepatocytes, the C/EBP expression pattern dramatically changed with time. C/EBPalpha mRNA and the 45 kDa isoform increased in parallel, reaching a maximum after 3-4 weeks coincident with weak DNA-binding activity. C/EBPbeta mRNA and isoform expression increased rapidly reaching a plateau within 1-2 weeks; all C/EBPbeta isoforms were phosphorylated. C/EBPbeta exhibited greater DNA-binding activity than C/EBPalpha, and this activity paralleled C/EBPbeta isoform expression.

CONCLUSIONS

C/EBP isoforms exhibit markedly different expression patterns in lobectomies, needle biopsies and cultured hepatocytes. Stress stimuli during and/or after surgery for lobectomy resections may account for this difference. The pattern of C/EBP isoform expression in long-term highly differentiated cultured hepatocytes is close to that observed in needle biopsies.

Preliminary results on the effect of power ultrasound on nitrogen oxide and dioxide atmosphere in nitric acid solutions

The effect of ultrasound (20 kHz, 3 W cm-2) on the kinetics of HNO2 and H2O2 formation was investigated in a 1 M HNO3 medium for NO2-Ar and NO-Ar gas mixtures in various volume fractions (f(NO2) < 1.7 vol% and f(NO) < 1.1 vol%, respectively). The H2O2 formation rate measured in 1 M HNO3 in the presence of N2H5NO3 was observed to be much lower than that of HNO2 without N2H5NO3, and was relatively independent of the NO2 or NO gas volume fractions in the argon atmosphere. The HNO2 formation rate increased under ultrasound, and was higher with NO than with NO2. The induction period observed without ultrasound disappeared when ultrasound was applied. The first step in the sonochemical mechanism of HNO2 formation in the presence of NO2 involves thermal decomposition of NO2 into NO within the cavitation bubble. In the second step of HNO2 formation, NO reacts either with HNO3 in the cavitation bubble, or with NO2 in the cavitation bubble or at the bubble/solution interface.

Determination of C4-C14 carboxylic acids by capillary zone electrophoresis. Application to the identification of diamide degradation products and partitioning studies

Capillary zone electrophoresis (CZE) was investigated for the determination of linear saturated carboxylic acid homologues ranging from C4 to C14. Separation conditions were optimised to overcome the problems of decreasing solubility and decreasing selectivity between successive homologues with increasing chain length. Separations were performed at 20 degrees C, using a 20 kV separation voltage and a pH 8 electrolyte containing 30% methanol. A suitable chromophore (4-aminobenzoate) was added to ensure indirect UV detection of the analytes. Calibration curves and repeatability were established. Minimum detectable concentrations of 3 x 10(-6) mol l(-1) were achieved. Resolution between successive homologues was better than 2. The electrophoretic mobility of each homologue (n=7-14) was assessed and a quasi-linear relationship between the mobility value and 1/n was observed. The quantitative analysis of a diamide degradation solution was performed and compared to potentiometric results. The CZE method was also applied to the determination of C7-C14 partitioning between an organic medium containing tributylphosphate in n-dodecane and different basic solutions. Their behaviour was established according to the chain length and the pH of the aqueous phase. For C10-C14 compounds, results were validated by comparison with gas chromatographic analysis of the organic phases.

Variable phenotypic presentation of iron overload in H63D homozygotes: are genetic modifiers the cause?

BACKGROUND

First considered as a polymorphism of the HFE gene, the H63D mutation is now widely recognised as a haemochromatosis associated allele. But few H63D homozygotes with clinical manifestations of hereditary haemochromatosis (HH) have been reported. Concurrently, an increasing number of genes have been shown to interact with HFE in iron metabolism.

AIMS

To describe the clinical expression of iron overload (IO) associated with H63D homozygosity, and search for potential genetic modifiers (within the HFE or other genes) that could explain the variability of the phenotypes.

PATIENTS AND METHODS

We retrospectively analysed the clinical phenotype of 56 H63D homozygotes referred for a personal or family history of IO. For each subject we examined intragenic HFE haplotypes and transferrin receptor (TfR) gene polymorphisms and searched for the Y250X mutation on the TFR2 gene. Additionally, we sequenced the HFE gene of H63D homozygotes with HH.

RESULTS

Fifty of 56 subjects had biological and/or clinical abnormalities of iron metabolism. Up to two thirds of patients (n=34) had no acquired cause of IO. Among these, 12 had a phenotypic diagnosis of HH. In the iron loaded group there was a strong prevalence of male patients. No correlation was found between the potential genetic modifiers and phenotypes. No additional mutation of HFE was identified.

CONCLUSION

The variable phenotypes associated with H63D homozygosity do not appear to be linked to other HFE mutations, to the TFR2 Y250X mutation, or to HFE or TfR gene intragenic polymorphisms. The exact role of H63D homozygosity in IO and HH needs to be further investigated in unselected populations.

[Is thiamine supplementation necessary in patient with cardiac insufficiency?]

Interest has recently risen regarding thiamine deficiency in patients with cardiac deficiency who are receiving long-term diuretic therapy. Thiamine deficiency can lead biventricular myocardial failure (cardiac beriberi), and treatment consists of thiamine administration. Studies have shown that long-term furosemide use may be associated with thiamine deficiency through urinary loss, contributing to cardiac insufficiency in patients with congestive heart failure. Thiamine supplementation could improved left ventricular function. However, the results of those studies are controversial, and none study have till proved the clinical impact of a systematic administration of thiamine in a cohort of patients with cardiac insufficiency. To date, and waiting for available literature, thiamine administration should be consider in patients at risk for thiamine deficiency (elderly, malnourished, alcoholic), and in patients receiving very large doses of diuretics.

[Assessment of left ventricular diastolic pressure with Doppler echocardiography]

Transthoracic echocardiography is able to provide immediate and relevant information in case of respiratory failure. The authors report a case of congestive heart failure with normal systolic function. Transmitral and pulmonary venous flow velocities have been used to assess left ventricular filling pressure and diastolic function.

Cardiac surgery with cardiopulmonary bypass in patients with type II heparin-induced thrombocytopenia

BACKGROUND

The use of cardiopulmonary bypass (CPB) in patients with a history of type II heparin-induced thrombocytopenia (HIT) may be associated with complications related to their anticoagulation management.

METHODS

Between January 1997 and December 1999, among 4,850 adults patients who underwent cardiac surgery in our institution, 10 patients presented with preoperative type II HIT. In 4 patients, anticoagulation during CPB was achieved with danaparoid sodium. In 6 other patients, heparin sodium was used after pretreatment with epoprostenol sodium.

RESULTS

No significant change in platelet count occurred in any patient. No intraoperative thrombotic complication was encountered. Total postoperative chest drainage ranged from 250 to 1,100 ml in patients pretreated with epoprostenol and 1,700 to 2,470 ml in patients who received danaparoid sodium during CPB (p < 0.05, Mann-Whitney U test).

CONCLUSIONS

During CPB, inhibition of platelet aggregation by prostacyclin may be a safe anticoagulation approach in patients with type II HIT.

[Jargon of the neonatal intensive care unit]

Jargon, the specialized vocabulary and idioms, is frequently used by people of the same work or profession. The neonatal intensive care unit (NICU) makes no exception to this. As a matter of fact, NICU is one place where jargon is constantly developing in parallel with the evolution of techniques and treatments. The use of jargon within the NICU is very practical for those who work in these units. However, this jargon is frequently used by neonatologists in medical reports or other kinds of communication with unspecialized physicians. Even if part of the specialized vocabulary can be decoded by physicians not working in the NICU, they do not always know the exact place that these techniques or treatments have in the management of their patients. The aim of this article is to describe the most frequent jargon terms used in the French NICU and to give up-to-date information on the importance of the techniques or treatments that they describe.

Physician reports of work-related asthma in California, 1993-1996

BACKGROUND

Work-related asthma is a leading cause of occupational respiratory illness.

METHODS

Work-related asthma was studied in California over a 36-month period, from March 1, 1993 to February 29, 1996. The surveillance system identified cases from Doctor's First Reports (DFRs), a mandated physician reporting system. Structured follow-up telephone interviews of DFR asthma cases were conducted to collect work history, exposure, and medical information. Statewide employment data was used to calculate disease rates among industry groups.

RESULTS

Based on 945 cases of work-related asthma, the average annual reporting rate for work-related asthma in California was 25/million workers. We estimate that the actual rate is 78/million, adjusted for likely underreporting. Janitors and cleaners (625/million) and firefighters (300/million) had the highest reporting rates of work-related asthma. Half of all work-related asthma cases were associated with agents not known to be allergens.

CONCLUSIONS

A greater proportion of work-related asthma associated with irritant exposures was identified than has previously been reported. The surveillance data provide a very conservative estimate of the incidence of work-related asthma.

Kinetic analysis of red pigment and citrinin production by Monascus ruber as a function of organic acid accumulation

In submerged cultures performed in synthetic medium containing glucose and glutamate, the filamentous fungus Monascus ruber produced a red pigment and a mycotoxin, citrinin. In oxygen-limiting conditions, the production of these two metabolites was growth-associated, as was the production of primary metabolites. In oxygen-excess conditions, the profile of citrinin production was typical of a secondary metabolite, since it was produced mostly during the stationary phase. In contrast, the production of the pigment decreased rapidly throughout the culture, showing a profile characteristic of an inhibitory mechanism. The organic acids produced during the culture, L-malate and succinate, were shown to be slightly inhibitory against pigment production, while citrinin production was unaffected. However, this inhibition could not account for the observed profile of pigment production in batch cultures. Other dicarboxylic acids such as fumarate or tartrate showed a similar effect to that provoked by malate and succinate as regards pigment production. It was concluded that the decrease in red pigment production during the culture was due to the inhibitory effect of an unknown product whose accumulation was favored in aerobic conditions.

Volatile metal beta-diketonates--new precursors for the sonochemical synthesis of nanosized materials--sonolysis of thorium(IV) beta-diketonates

Ultrasonic irradiation (22 kHz, Ar atmosphere) of Th(IV) beta-diketonates Th(HFAA)4 and Th(DBM)4, where HFAA and DBM are hexafluoroacetylacetone and dibenzoylmethane respectively, causes them to decompose in hexadecane solutions, forming solid thorium compounds. The first-order rate constants for Th(IV) beta-diketonate degradation were found to be (9.3 +/- 0.8) x 10(-3) for Th(HFAA)4 and (3.8 +/- 0.4) x 10(-3) min-1 for Th(DBM)4, (T = 92 degrees C, I = 3 W cm-2). The rate of the sonochemical reaction increased with the rising beta-diketonate volatility and decreased with the rising hydrocarbon solvent vapor pressure. Solid sonication products consisted of a mixture of thorium carbide ThC2 and Th(IV) beta-diketonate partial degradation products. The average ThC2 particle size was estimated to be about 2 nm. ThC2 formation was attributed to the high-temperature reaction occurring within the cavitating bubble. The thorium beta-diketonate partial degradation products formed in the liquid reaction zones surrounding the cavitating bubbles.

Usefulness of procalcitonin for diagnosis of infection in cardiac surgical patients

OBJECTIVE

To determine the value of procalcitonin (PCT) as a marker of postoperative infection after cardiac surgery.

DESIGN

A prospective single institution three phase study.

SETTING

University cardiac surgical intensive care unit (31 beds).

PATIENTS

Phase 1: To determine the normal perioperative kinetics of PCT, 20 consecutive patients undergoing elective cardiac surgery with cardiopulmonary bypass were included. Phase 2: To determine whether PCT may be useful for diagnosis of postoperative infection, 97 consecutive patients with suspected infection were included. Phase 3: To determine the ability of PCT to differentiate patients with septic shock from those with cardiogenic shock, 26 patients with postoperative circulatory failure were compared.

MEASUREMENTS AND MAIN RESULTS

Phase 1: Serum samples were drawn for PCT determination after induction of anesthesia (baseline), at the end of surgery, and daily until postoperative day (POD) 8. Baseline serum PCT concentration was 0.17 +/- 0.08 ng/mL (mean +/- SD). Serum PCT increased after cardiac surgery with a peak on POD 1 (1.08 +/- 1.36). Serum PCT returned to normal range on POD 3 and remained stable thereafter. Phase 2: In patients with suspected infection, serum PCT was measured at the same time of C-reactive protein (CRP) and bacteriologic samples. Among the 97 included patients, 54 were infected with pneumonia (n = 17), bacteremia (n = 16), mediastinitis (n = 9), or septic shock (n = 12). In the 43 remaining patients, infection was excluded by microbiological examinations. In noninfected patients, serum PCT concentration was 0.41 +/- 0.36 ng/mL (range, 0.08-1.67 ng/mL). Serum PCT concentration was markedly higher in patients with septic shock (96.98 +/- 119.61 ng/mL). Moderate increase in serum PCT concentration occurred during pneumonia (4.85 +/-3.31 ng/mL) and bacteremia (3.57 +/- 2.98 ng/mL). Serum PCT concentration remained low during mediastinitis (0.80 +/- 0.58 ng/mL). Five patients with mediastinitis, two patients with bacteremia, and one patient with pneumonia had serum PCT concentrations of <1 ng/mL. These eight patients were administered antibiotics previously and serum PCT was measured during a therapeutic antibiotic window. For prediction of infection by PCT, the best cutoff value was 1 ng/mL, with sensitivity 85%, specificity 95%, positive predictive value 96%, and negative predictive value 84%. Serum CRP was high in all patients without intergroup difference. For prediction of infection by CRP, a value of 50 mg/L was sensitive (84%) but poorly specific (40%). Comparing the area under the receiver operating characteristic curves, PCT was better than CRP for diagnosis of postoperative sepsis (0.82 for PCT vs. 0.68 for CRP). Phase 3: Serum PCT concentration was significantly higher in patients with septic shock than in those with cardiogenic shock (96.98 +/- 119.61 ng/mL vs. 11.30 +/- 12.3 ng/mL). For discrimination between septic and cardiogenic shock, the best cutoff value was 10 ng/mL, with sensitivity of 100% and specificity of 62%.

CONCLUSION

Cardiac surgery with cardiopulmonary bypass influences serum PCT concentration with a peak on POD 1. In the presence of fever, PCT is a reliable marker for diagnosis of infection after cardiac surgery, except in patients who previously received antibiotics. PCT was more relevant than CRP for diagnosis of postoperative infection. During a postoperative circulatory failure, a serum PCT concentration >10 ng/mL is highly indicative of a septic shock.