Clinical and echocardiographic diagnoses disagree in patients with unexplained hemodynamic instability after cardiac surgery

PURPOSE

To investigate 1) if clinical indications match diagnostic findings from urgent transesophageal echocardiography (TEE) in hemodynamically unstable patients after cardiac surgery and 2) the clinical impact of the TEE findings.

METHODS

Retrospective review of all postcardiac surgical intensive care patients who received an urgent TEE over a three- year period from July 1(st) 1997 until June 30(th) 2000. The clinician's presumed diagnosis based on hemodynamic and clinical evaluation was compared to TEE diagnosis. Surgical and medical interventions based on TEE results and the associated mortality were correlated.

RESULTS

A hundred and thirty TEEs were performed for hemodynamic instability or suspected intracardiac vegetation or thrombus, all category I indications according to ASA guidelines. In 41.5% of patients the echocardiographic finding matched the presumed diagnosis. Patient management was significantly changed as a result of TEE findings in 58.5% of patients; 43.3% had changes in pharmacological therapy and 15.3% had a surgical intervention. Mortality was significantly lower in those who received a surgical intervention when compared to those who had changes in drug treatment (P <0.05).

CONCLUSIONS

The results of urgent TEE in hemodynamically unstable patients or patients with thromboembolic phenomena in the postcardiac surgical intensive care unit are unpredictable in over half of cases. Inappropriate management decisions may result without the information obtained from TEE examination. Clinical management is often modified as a result of TEE findings. TEE is essential in the management of hemodynamically unstable postcardiac surgical patients.

Pion Interferometry of square root of (s(NN)) =130 GeV Au + Au collisions at RHIC

Two-pion correlation functions in Au+Au collisions at square root of [s(NN)] = 130 GeV have been measured by the STAR (solenoidal tracker at RHIC) detector. The source size extracted by fitting the correlations grows with event multiplicity and decreases with transverse momentum. Anomalously large sizes or emission durations, which have been suggested as signals of quark-gluon plasma formation and rehadronization, are not observed. The Hanbury Brown-Twiss parameters display a weak energy dependence over a broad range in square root of [s(NN)].

Experience with the ketogenic diet in infants

OBJECTIVE

To evaluate the effectiveness, tolerability, and adverse effects of the ketogenic diet in infants with refractory epilepsy.

METHODS

A retrospective review of 32 infants who had been treated with the ketogenic diet at a large metropolitan institution.

RESULTS

Most infants (71%) were able to maintain strong ketosis. The overall effectiveness of the diet in infants was similar to that reported in the literature for older children; 19.4% became seizure-free, and an additional 35.5% had >50% reduction in seizure frequency. The diet was particularly effective for patients with infantile spasms/myoclonic seizures. There were concomitant reductions in antiepileptic medications. The majority of parents reported improvements in seizure frequency and in their child's behavior and function, particularly with respect to attention/alertness, activity level, and socialization. The diet generally was well-tolerated, and 96.4% maintained appropriate growth parameters. Adverse events, all reversible and occurring in one patient each, included renal stone, gastritis, ulcerative colitis, alteration of mentation, and hyperlipidemia.

CONCLUSION

The ketogenic diet should be considered safe and effective treatment for infants with intractable seizures.

Positive selection of an MHC class-I restricted TCR in the absence of classical MHC class I molecules

The H-2Ld alloreactive 2C T cell receptor (TCR) is commonly considered as being positively selected on the H-2Kb molecule. Surprisingly, 2C TCR+ CD8+ single-positive T cells emerge in massive numbers in fetal thymic organ culture originating from 2C transgenic, H-2KbD(b-/-) (2C+KbD(b-/-)) but not in fetal thymic organ culture from beta2-microglobulin(-/-) 2C transgenic animals. Mature CD8+ T cells are observed in newborn but not in adult 2C+KbD(b-/-) mice. These CD8+ T cells express the alpha4beta7 integrin, which allows them to populate the intestine, a pattern of migration visualized by intrathymic injection of FITC and subsequent accrual of FITC-labeled lymphocytes in the gut. We conclude that the 2C TCR is reactive not only with H-2Ld and H-2Kb, but also with nonclassical MHC class I products to enable positive selection of 2C+ T cells in the fetal and newborn thymus and to support their maintenance in the intestine.

Midrapidity antiproton-to-proton ratio from Au+Au collisions at sqrt [s(NN)]=130 GeV

We report results on the ratio of midrapidity antiproton-to-proton yields in Au+Au collisions at sqrt[s(NN)] = 130 GeV per nucleon pair as measured by the STAR experiment at RHIC. Within the rapidity and transverse momentum range of /y/<0.5 and 0.4<p(t)<1.0 GeV/c, the ratio is essentially independent of either transverse momentum or rapidity, with an average of 0.65+/-0.01((stat))+/-0.07((syst)) for minimum bias collisions. Within errors, no strong centrality dependence is observed. The results indicate that at this RHIC energy, although the p-p pair production becomes important at midrapidity, a significant excess of baryons over antibaryons is still present.

Fluorescence polarization assay for the diagnosis of bovine brucellosis: adaptation to field use

A fluorescence polarization assay (FPA) was used to test whole blood samples prepared by mixing blood cells from cattle without exposure to Brucella abortus (B. abortus) with sera from animals with confirmed (bacteriologically) infection. A cut-off value between negative and positive values was initially established to be 87.2mP. This value was changed to 95mP to increase assay specificity without loss of sensitivity when testing blood samples from negative animals. The FPA technology was applied to whole blood samples in the field and to stored whole blood samples using two diluent buffers. Relative sensitivity and specificity values for the FPA performed in the field, based on buffered antigen plate agglutination test and competitive enzyme immunoassay results were 95.3 and 97.3%, respectively. However, to obtain maximum sensitivity and specificity, a cut-off value of 105mP was determined for fresh whole blood samples. The relative sensitivity and specificity values of the FPA when testing stored whole blood samples were 100% each using a 95mP cut-off.The usefulness of the FPA for testing whole blood samples in the field was demonstrated.

Ultra-fast-track anesthetic technique facilitates operating room extubation in patients undergoing off-pump coronary revascularization surgery

OBJECTIVE

To determine if implementation of ultra-fast-track anesthetic (UFTA) technique facilitates operating room extubation in patients undergoing off-pump coronary artery bypass graft (CABG) surgery.

DESIGN

Retrospective review.

SETTING

Referral center for cardiovascular surgery at a university hospital.

PARTICIPANTS

Thirty-seven patients undergoing off-pump CABG surgery.

INTERVENTIONS

Two groups represented UFTA (n = 10) and standard anesthetic (controls, n = 27) techniques. Anesthesia was conducted with propofol, remifentanil, vecuronium, and thoracic epidural analgesia in the UFTA group and thiopental, fentanyl, pancuronium, and isoflurane in the control group. Active temperature control was an integral part of the UFTA technique but not the standard technique. The active temperature control included intravenous fluid warmer, prewarmed skin preparation, humidified inspired gases, a circulating water warming blanket, and a forced-air warmer, along with the maintenance of the operating room temperature at 24 degrees C. The control group was managed with an intravenous fluid warmer, and the ambient temperature remained constant (20 degrees C). Patients who did not satisfy extubation criteria within 30 minutes from the end of surgery were sedated and transferred to the intensive care unit (ICU).

MEASUREMENTS AND MAIN RESULTS

All patients in the UFTA group and 2 in the control group were extubated in the operating room immediately after surgery. None of the patients required reintubation. There was no significant difference in postextubation PaO(2) and PaCO(2) between the groups. Nasopharyngeal temperature decreased from 36.7 +/- 0.4 degrees C to 36.4 +/- 0.3 degrees C in the UFTA group and from 36.6 +/- 0.5 degrees C to 35.6 +/- 0.4 degrees C in the control group (p < 0.0001). Bradycardia occurred significantly more often in the UFTA group but there was no difference in episodes of hypotension. There were no perioperative deaths. Patients who were extubated in the operating room required lower nurse-to-patient acuity ratio (1:2) in the ICU. No difference was found in ICU and hospital length of stay.

CONCLUSIONS

Implementation of UFTA technique provided adequate hemodynamic control and facilitated operating room extubation in all patients. The impact of UFTA on earlier patient discharge and actual cost savings within a fully integrated post-cardiac surgery unit requires further evaluation.

Increased expression of type 2 cytokines in chronic proliferative dermatitis (cpdm) mutant mice and resolution of inflammation following treatment with IL-12

Chronic proliferative dermatitis (cpdm) is a spontaneous mutation that results in eosinophilic inflammation in multiple tissues, including the skin. To determine the mechanisms underlying the eosinophilic inflammation, the expression of cytokines in the skin was determined. There was increased expression of IL-4, IL-5, IL-13, and granulocyte-macrophage colony-stimulating factor in the skin of cpdm/cpdm mice, and no change in IL-10 and TNF expression. Supernatants of cultured spleen cells of cpdm/cpdm mice contained an increased amount of IL-5 and IL-13, and a decreased amount of IFN-gamma. The ability of the cpdm/cpdm mice to mount a delayed-type hypersensitivity response was greatly reduced. These data are consistent with impaired type 1 and excessive type 2 cytokine production in cpdm/cpdm mice. The significance of this imbalanced cytokine production was evident in the efficacy of systemic treatment of cpdm/cpdm mice with IL-12. Mutant mice treated for 3 weeks with IL-12 had minimal changes in the skin as opposed to the severe dermatitis in mice treated with the vehicle. Treatment with IL-11, which opposes the effect of IL-12, had no effect.

Three-dimensional echocardiography of left atrial appendage thrombus

Transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE) in evaluating the left atrial appendage (LAA) as a potential cardiac source of embolus in patients with stroke. We describe two such patients in whom a TEE and subsequently a three-dimensional (3-D) reconstruction of the LAA were performed. These case reports show that 3-D echocardiography provides better visualization of LAA anatomy, and that a 3-D description of LAA morphology may be the basis of describing normal and abnormal LAA.

The initiation and regulation of Ca2+ signalling at fertilization in mammals

The transition from oocyte to embryo in mammals is triggered by a series of calcium transients. There are two distinguishing features of this signal transduction pathway. First, it appears to be triggered by a cell fusion event between egg and sperm that allows the direct introduction of a factor that leads to the release of intracellular Ca2+. Second, it features a slow-frequency calcium oscillator (one transient every 10-20 min) that persists for 3-4 h. In this review I report on recent developments in our understanding of how the Ca2+ oscillations are started and on the regulation of the overall temporal organization. The review focuses on mammalian fertilization and (inevitably) it is fertilization in the mouse that will be predominantly discussed. Relevant and topical contributions from the excellent body of literature available on other species will be utilized where appropriate but extensive reviews can be found elsewhere [Stricker S A (1999) Comparative biology of calcium signaling during fertilization and egg activation in animals Dev Biol 211: 57-76; Jaffe et al., this issue].

Elliptic flow in Au+Au collisions at square root(S)NN = 130 GeV

Elliptic flow from nuclear collisions is a hadronic observable sensitive to the early stages of system evolution. We report first results on elliptic flow of charged particles at midrapidity in Au+Au collisions at square root(S)NN = 130 GeV using the STAR Time Projection Chamber at the Relativistic Heavy Ion Collider. The elliptic flow signal, v2, averaged over transverse momentum, reaches values of about 6% for relatively peripheral collisions and decreases for the more central collisions. This can be interpreted as the observation of a higher degree of thermalization than at lower collision energies. Pseudorapidity and transverse momentum dependence of elliptic flow are also presented.

Derivation and initial characterization of a mouse mammary tumor cell line carrying the polyomavirus middle T antigen: utility in the development of novel cancer therapeutics

Here we describe the derivation of novel cell lines from spontaneous mammary tumors that arose in mouse mammary tumor virus-polyomavirus (MMTV-PyV) Middle T (MidT) transgenic mice. Clonal cell lines from four mixed cell populations were tested for adenovirus transducibility and sensitivity to p53 tumor suppressor gene therapy mediated by SCH58500, a replication-deficient adenovirus that expresses human p53. The MidT2-1 cell line was selected for further characterization in vitro and in vivo. This cell line carried the PyV MidT antigen, had wild-type p53 DNA, and was sensitive to suppression of proliferation by MMAC/PTEN tumor suppressor gene therapy. MidT2-1 cells gave rise to highly aggressive tumors in syngeneic FVB mice in both the mammary fat pad and the peritoneal cavity. The histopathology of MidT2-1 tumors closely resembled the histopathology of the primary transgenic tumors. Tumor growth in vivo was inhibited by p53 gene therapy or by MMAC gene therapy. In addition, combination therapy with a number of anticancer agents had synergistic or additive efficacy in vitro. In particular, MMAC gene therapy synergized with SCH58500 or paclitaxel. In the i.p. MidT2-1 tumor model p53 gene therapy enhanced the survival benefits of paclitaxel/cisplatin chemotherapy. Combination therapy has become a mainstay in cancer treatment. In this report, we use a novel transgenic mouse tumor cell line to suggest new combinations that might be explored in clinical cancer care. These include gene therapy using the tumor suppressors MMAC and p53, chemotherapy using farnesyl transferase inhibitors, the microtubule stabilizing taxanes, and the DNA synthesis disruptors gemcitabine and cisplatin. The precise biological mechanisms by which these therapies induce their antitumor effects are not fully elucidated. However, the work presented here suggests that many of these therapeutic approaches have synergistic antitumor activity when used in combination.

Non-steroidal anti-inflammatory drugs in treatment of postoperative pain after cardiac surgery

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) are used as analgesic in postoperative pain to reduce opioid side effects, such as drowsiness and nausea. However, NSAIDs have not been used extensively in cardiac surgical patients due to the fear of untoward effects on gastric, renal, and coagulation parameters. This study will evaluate the efficacy and safety of three NSAIDs for pain control in CABG patients.

METHODS

One hundred and twenty patients scheduled for elective CABG surgery were enrolled in randomized, double blind, controlled study. Standardized fast track cardiac anesthesia was used. One dose of drug (75 mg diclofenac, 100 mg ketoprofen, 100 mg indomethacin, or placebo) was given pr one hour before tracheal extubation and a second dose 12 hr later. Pain was treated with morphine iv and acetaminophen po. Visual analogue pain scores were recorded at baseline, 3, 6, 12 and 24 hr after the first dose of drug.

RESULTS

There were no differences among the groups in pain scores. Only patients who received diclofenac required less morphine than patients in the control group (P < 0.05). When the total amounts of pain medications were computed to morphine equivalents, only patients in the diclofenac group received less pain medications than the placebo group (P < 0.05). Proportion of patients with postoperative increase of creatinine level (20% and over) did not differ between placebo and drug groups.

CONCLUSION

Non-steroidal anti-inflammatory drugs may be used for analgesia management post CABG surgery in selected patients. Diclofenac appears to have the best analgesic effects by reducing the morphine and other analgesic requirement postoperatively.

A profile of early versus late onset of obesity in postmenopausal women

Obesity is a serious health problem among women across the life span. Although people can become obese at any age, there is a large proportion of older women who have been obese since childhood. The purpose of this study was to determine whether postmenopausal women with an early versus late onset of obesity manifested differences in body habitus, eating behaviors, and mood. One hundred thirty-five postmenopausal women with obesity responded to self-report questionnaires on weight history, weight loss and maintenance expectancy, eating behaviors, and mood. Women with an early onset of obesity had a significantly higher body mass index (BMI), waist circumference, and highest attained adult body weight than women with a late onset of obesity. They had attempted a significantly larger number of diets and had lost more weight on any single diet. The groups also differed significantly on binge eating and overeating in response to negative affect. There was a tendency for women with an early onset to have more depressive and anxious symptoms. Postmenopausal women with an early onset of obesity differed physiologically and psychologically from those with a late onset. Tailoring dietary and behavioral interventions to profiles of postmenopausal women based on onset of obesity may improve the overall efficacy of weight loss programs.

The EGF receptor provides an essential survival signal for SOS-dependent skin tumor development

The EGF receptor (EGFR) is required for skin development and is implicated in epithelial tumor formation. Transgenic mice expressing a dominant form of Son of Sevenless (SOS-F) in basal keratinocytes develop skin papillomas with 100% penetrance. However, tumor formation is inhibited in a hypomorphic (wa2) and null EGFR background. Similarly, EGFR-deficient fibroblasts are resistant to transformation by SOS-F and rasV12, however, tumorigenicity is restored by expression of the anti-apoptotic bcl-2 gene. The K5-SOS-F papillomas and primary keratinocytesfrom wa2 mice display increased apoptosis, reduced Akt phosphorylation and grafting experiments imply a cell-autonomous requirement for EGFR in keratinocytes. Therefore, EGFR functions as a survival factor in oncogenic transformation and provides a valuable target for therapeutic intervention in a broader range of tumors than anticipated.

Inositol 1,4,5-trisphosphate receptors are downregulated in mouse oocytes in response to sperm or adenophostin A but not to increases in intracellular Ca(2+) or egg activation

Fertilization in mammals stimulates a series of Ca(2+) oscillations that continue for 3-4 h. Cell-cycle-dependent changes in the ability to release Ca(2+) are one mechanism that leads to the inhibition of Ca(2+) transients after fertilization. The downregulation of InsP(3)Rs at fertilization may be an additional mechanism for inhibiting Ca(2+) transients. In the present study we examine the mechanism of this InsP(3)R downregulation. We find that neither egg activation nor Ca(2+) transients are necessary or sufficient for the stimulation of InsP(3)R downregulation. First, parthenogenetic activation fails to stimulate downregulation. Second, downregulation persists when fertilization-induced Ca(2+) transients and egg activation are inhibited using BAPTA. Third, downregulation can be induced in immature oocytes that do not undergo egg activation. Other than fertilization, the only stimulus that downregulated InsP(3)Rs was microinjection of the potent InsP(3)R agonist adenophostin A. InsP(3)R downregulation was inhibited by the cysteine protease inhibitor ALLN but MG132 and lactacystin were not effective. Finally, we have injected maturing oocytes with adenophostin A and produced MII eggs depleted of InsP(3)Rs. We show that sperm-induced Ca(2+) signaling is inhibited in such InsP(3)R-depleted eggs. These data show that InsP(3)R binding is sufficient for downregulation and that Ca(2+) signaling at fertilization is mediated via the InsP(3)R.