Comprehensive multimodality blood conservation: 100 consecutive CABG operations without transfusion

BACKGROUND

Despite the recent introduction of a number of technical and pharmacologic blood conservation measures, bleeding and allogeneic transfusion remain persistent problems in open heart surgical procedures. We hypothesized that a comprehensive multimodality blood conservation program applied algorithmically on the basis of bleeding and transfusion risk would provide a maximum, cost-effective, and safe reduction in postoperative bleeding and allogeneic blood transfusion.

METHODS

One hundred consecutive patients undergoing coronary artery bypass grafting were prospectively enrolled in a risk factor-based multimodality blood conservation program (MMD group). To evaluate the relative efficacy and safety of this comprehensive approach, comparison was made with a similar group of 90 patients undergoing coronary artery bypass grafting to whom the multimodality blood conservation program was not applied but in whom an identical set of transfusion guidelines was enforced (control group). To evaluate the cost effectiveness of the multimodality program, comparison was also made between patients in the MMD group and a consecutive series of contemporaneous, diagnostic-related group-matched patients.

RESULTS

One hundred consecutive patients in the MMD group underwent coronary artery bypass grafting without allogeneic transfusion. This compared favorably with the control population in whom a mean of 2.2 +/- 6.7 units of allogeneic blood was transfused per patient (34 patients [38%] received transfusion). In addition, the volume of postoperative blood loss at 12 hours in the control group was almost double that of the MMD group (660 +/- 270 mL versus 370 +/- 180 mL [p < 0.001]). Total costs for the MMD group in each of the three major diagnostic-related groups were equivalent to or significantly less than those in the consecutive series of diagnostic-related group-matched patients.

CONCLUSIONS

Comprehensive risk factor-based application of multiple blood conservation measures in an optimized, integrated, and algorithmic manner can significantly decrease bleeding and need of allogeneic transfusion in coronary artery bypass grafting in a safe and cost-effective manner.

Inhibition of endosome function in CHO cells bearing a temperature-sensitive defect in the coatomer (COPI) component epsilon-COP

Recent evidence has suggested that subunits of the coatomer protein (COPI) complexes are functionally associated with endosomes in mammalian cells. We now provide genetic evidence that COPI plays a role in endocytosis in intact cells. The ldlF mutant CHO cell line bears a temperature-sensitive defect in the COPI subunit epsilon-COP. In addition to exhibiting conditional defects in the secretory pathway, we find that the cells are also defective at mediating endosome-associated functions. As found for cells microinjected with anti-COPI antibodies, ldlF cells at the restrictive temperature could not be infected by vesicular stomatitis (VSV) or Semliki Forest virus (SFV) that require delivery to acidic endosomes to penetrate into the cytosol. Although there was no temperature-sensitive defect in the internalization of receptor-bound transferrin (Tfn), Tfn recycling and accumulation of HRP were markedly inhibited at the restrictive temperature. Sorting of receptor-bound markers such as EGF to lysosomes was also reduced, although delivery of fluid-phase markers was only partially inhibited. In addition, lysosomes redistributed from their typical perinuclear location to the tips of the ldlF cells. Mutant phenotypes began to emerge within 2 h of temperature shift, the time required for the loss of detectable epsilon-COP, suggesting that the endocytic defects were not secondary to a block in the secretory pathway. Importantly, the mutant phenotypes were also corrected by transfection of wild-type epsilon-COP cDNA demonstrating that they directly or indirectly reflected the epsilon-COP defect. Taken together, the results suggest that epsilon-COP acts early in the endocytic pathway, most likely inhibiting the normal sorting and recycling functions of early endosomes.

Long-term regulation of contractility and calcium current in smooth muscle

Longitudinal smooth muscle strips from guinea pig ileum were cultured in vitro for 5 days, and the relationship between extracellular Ca2+ and force in high-K+ medium was evaluated. In strips cultured with 10% fetal calf serum (FCS), this relationship was shifted to the right (50% effective concentration changed by 2-3 mM) compared with strips cultured without FCS. The shift was prevented by inclusion of verapamil (1 microM) during culture and mimicked by ionomycin in the absence of FCS. The intracellular Ca2+ concentration ([Ca2+]i) during stimulation with high-K+ solution or carbachol was reduced after culture with FCS, whereas the [Ca2+]i-force relationship was unaffected. Cells were isolated from cultured strips, and whole cell voltage-clamp experiments were performed. Maximum inward Ca2+ current (10 mM Ba2+), normalized to cell capacitance, was almost three times smaller in cells isolated from strips cultured with FCS. Culture with 1 microM verapamil prevented this reduction. These results suggest that increased [Ca2+]i during culture downregulates Ca2+ current density, with associated effects on contractility.

Intracerebroventricular transplantation of embryonic neuronal tissue from inflammatory resistant into inflammatory susceptible rats suppresses specific components of inflammation

To more directly define the role of central nervous system factors in susceptibility to peripheral inflammatory disease, we examined the effect of intracerebroventricular transplantation of neuronal tissue from inflammatory resistant into inflammatory susceptible rats on subcutaneous carrageenan-induced inflammation (a measure of innate immunity), and on the relative percentage of naive and memory T helper cells in peripheral blood (a measure of the anamnestic immune response). Female inflammatory disease susceptible Lewis (LEW/N) rats transplanted with hypothalamic tissue from inflammatory resistant Fischer (F344/N) rats exhibited > 85% decrease in carrageenan inflammation compared to naive LEW/N rats, LEW/N rats transplanted with F344/N spinal cord, or sham-operated animals. LEW/N rats transplanted with LEW/N hypothalamic tissue exhibited > 50% decrease in carrageenan inflammation. In contrast, intracerebroventricular transplantation of neuronal tissue did not affect the characteristically twofold higher percentage of naive versus memory T helper cells in LEW/N rats, suggesting that the central nervous system (CNS) and hypothalamus play a greater role in the innate inflammatory response than in the acquired immune processes. Grafted tissue survived well and did not show extensive gliosis or inflammation. Compared to naive LEW/N rats, LEW/N rats transplanted with F344/N or LEW/N hypothalamic tissue expressed significantly greater hypothalamic corticotropin releasing hormone mRNA. LEW/N rats transplanted with F344/N hypothalamic tissue also showed significant increases in plasma corticosterone responses to lipopolysaccharide. These data indicate that intracerebroventricular transplantation of fetal hypothalamic tissue from inflammatory resistant into inflammatory susceptible rats suppresses peripheral inflammation partially through hypothalamic factors. These findings have implications for understanding the contribution of specific neuronal tissue in regulation of components of the immune/inflammatory response and in susceptibility to inflammatory disease. Furthermore, this model could be used in the development of potential new treatments for inflammatory/autoimmune diseases aimed specifically at sites within the CNS.

Ectopic pituitary adenoma in the sphenoid causing Nelson's syndrome

An ectopic functioning pituitary in the sphenoid is an extremely rare occurrence, and even rarer is pituitary adenoma causing symptoms of Nelson's syndrome. A case is presented of a young female diagnosed and treated in our clinic. The only functioning hypophyseal tissue was detected inside the sphenoid, as the pituitary gland had been radiated because of Cushing's syndrome 10 years before and imaging studies revealed an empty sella.

Intravenous oxytocin in patients undergoing elective cesarean section

The objective of this study was to compare four different doses of oxytocin to determine its minimal effective dose during elective cesarean section. A prospective, double-blind, randomized study was undertaken in 40 healthy term parturients presenting for elective cesarean section under regional anesthesia. Subjects were assigned to one of four groups. Group I received 5 IU, Group II 10 IU, Group III 15 IU, and Group IV 20 IU of oxytocin after clamping of the umbilical cord. Uterine tone was assessed by palpation on a linear analog scale (LAS) of 0 to 10 (0 = completely atonic, 10 = fully contracted) at 5, 10, 15 and 20 min after the start of oxytocin infusion. Estimated blood loss (EBL) and the difference in pre- and postoperative hematocrit (delta Hct) were also recorded. At alpha = 0.05, the study design had a power of 95% to detect a 25% difference in the LAS between the four groups. There were no differences in the uterine tone in the four groups at any of the four intervals. EBL and delta Hct were similar in all four groups. There appears to be no benefit in terms of degree of uterine contraction and amount of blood loss to administering more than 5 IU of intravenous oxytocin to term parturients undergoing elective cesarean section with a neuraxial block.

Identification of a new sigmaB-controlled gene, csbX, in Bacillus subtilis

We have identified a new member, csbX, of the general stress regulon controlled by sigmaB in Bacillus subtilis. As with other members of the sigmaB regulon csbX is expressed during the stationary phase of cell growth and inactivation of this gene produces no obvious phenotype during cell growth or early development. csbX lies uspstream from the sporulation gene bofC which is co-transcribed during stationary phase.

Expression of the Bacillus subtilis spoIVB gene is under dual sigma F/sigma G control

The expression of the Bacillus subtilis spoIVB gene, which encodes a developmental cell-cell signalling molecule, has been characterized. In some conditions, this gene can be transcribed by RNA polymerase associated with either sigma F or sigma G, in contrast to previous studies implying exclusive control by sigma G. However, during sporulation, only sigma G directs significant levels of spoIVB expression.

A comparison of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Trauma-Injury Severity Score (TRISS) for outcome assessment in intensive care unit trauma patients

OBJECTIVE

To assess the ability of the Acute Physiology and Chronic Health Evaluation (APACHE II) system and Trauma-Injury Severity Scoring (TRISS) system in predicting group mortality in intensive care unit (ICU) trauma patients.

DESIGN

Prospective study.

SETTING

A Canadian adult trauma tertiary referral hospital.

PATIENTS

Consecutive trauma patients admitted to the medical-surgical ICU or the neurosurgical ICU.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

For each patient, demographic data, mechanism of injury, and surgical status were collected. Revised Trauma Scores and Injury Severity Scores were calculated from emergency room and operative data. The APACHE II score was calculated based on the data from the first 24 hrs of ICU admission. The probability of death was calculated for each patient based on the APACHE II and TRISS equations. The ability to predict group mortality for APACHE II and TRISS was assessed by receiver operating characteristic curve analysis, two by two decision matrices, and calibration curve analysis. Four hundred seventy trauma patients were admitted to the ICU. Sixty-three (13%) patients died and 407 (87%) survived. There were significant differences between survivors and nonsurvivors in age, Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score, and APACHE II score. By receiver operating characteristic curve analysis, the areas under the curves (+/- SEM) of APACHE II and TRISS were 0.92 +/- 0.02 and 0.89 +/- 0.02, respectively. Using two by two decision matrices with a decision criterion of 0.5, the sensitivities, specificities, and percentages correctly classified were 50.8%, 97.3%, and 91.1%, respectively, for APACHE II, and 50.8%, 97.1%, and 90.9%, respectively, for TRISS. From the calibration curves, the r2 value was .93 (p = .0001) for APACHE II and .67 (p = .004) for TRISS.

CONCLUSIONS

Both APACHE II and TRISS scores were shown to accurately predict group mortality in ICU trauma patients. APACHE II and TRISS may be utilized for quality assurance in ICU trauma patients. However, neither APACHE II nor TRISS provides sufficient confidence for prediction of outcome of individual patients.

Triiodothyronine therapy lowers the incidence of atrial fibrillation after cardiac operations

BACKGROUND

Cardiopulmonary bypass results in a euthyroid sick state, and recent evidence suggests that perioperative triiodothyronine (T3) supplementation may have hemodynamic benefits. In light of the known effects of thyroid hormone on atrial electrophysiology, we investigated the effects of perioperative T3 supplementation on the incidence of postoperative arrhythmias.

METHODS

One hundred forty-two patients with depressed left ventricular function (ejection fraction < 0.40) undergoing coronary artery bypass grafting were randomized to either T3 or placebo treatment groups in a prospective, double-blind fashion. Triiodothyronine was administered as a 0.8 micrograms/kg intravenous bolus at the time of aortic cross-clamp removal followed by an infusion of 0.113 micrograms.kg-1.h-1 for 6 hours. Patients were monitored for the development of arrhythmias during the first 5 postoperative days.

RESULTS

The incidence of sinus tachycardia and ventricular arrhythmias were similar between groups. Triiodothyronine-treated patients had a lower incidence of atrial fibrillation (24% versus 46%; p = 0.009), and fewer required cardioversion (0 versus 6; p = 0.012) or anticoagulation (2 versus 10; p = 0.013) during hospitalization. Six patients in the T3 group versus 16 in the placebo group required antiarrhythmic therapy at discharge (p = 0.019).

CONCLUSIONS

Perioperative T3 administration decreased the incidence and need for treatment of postoperative atrial fibrillation.

Intracerebroventricularly transplanted embryonic neuronal tissue from inflammatory-resistant F344/N rats decreases acoustic startle responses in inflammatory-susceptible LEW/N rats

Recently, we have shown that intracerebral transplantation of fetal F344/N hypothalamic tissue into LEW/N rats converts the LEW/N inflammatory-susceptible phenotype into an inflammatory-resistant phenotype in LEW/N hosts. Because LEW/N rats also exhibit relatively high acoustic startle responses (ASRs) compared to F344/N rats, in the present study we examined the effects on ASR of transplantation of F344/N hypothalamic tissue into the third ventricle of LEW/N rats. Dissected neuronal tissue from F344/N rats (Day E15-16) was implanted into the third ventricle of LEW/N rats. After 4 wk of postoperative survival, the animals' responses to acoustic startle stimuli were tested. Compared to naive and sham-operated animals, LEW/N rats transplanted with hypothalamic tissue exhibited significant decreases in ASR amplitudes. A similar decrease in ASR amplitude was observed in the group of LEW/N rats transplanted with embryonic striatal tissue. Our results indicate that the third ventricular neuronal grafts may modulate behavioral responses in the LEW/N rats. Although the mechanism of this effect is unknown, these studies suggest that intracerebral neuronal transplantation is a viable method with which to explore mechanisms of behavioral, neuroendocrine, and inflammatory response associations.

Age-related effects of aluminum ingestion on brain aluminum accumulation and behavior in rats

Both aluminum and aging have been associated with neurobehavioral changes in mammals. This study assessed in young (21 day old), adult (8 months), and old rats (16 months) the effects of prolonged aluminum ingestion on open-field activity and passive-avoidance conditioning. Aluminum was administered in drinking water as aluminum nitrate at doses of 0, 50, and 100 mg Al/kg/day over a 6.5 month period. There were no aluminum effects on the horizontal and vertical activity in an open-field, or in passive-avoidance learning in any group. On the other hand, measurement of aluminum concentrations in a number of brain regions indicated that the olfactory bulb and the rhachidical bulb were the regions with the highest aluminum levels, while the cortex and the thalamus were the cerebral regions showing the lowest aluminum content. For most brain regions analyzed the highest aluminum concentrations were found in young rats, which would indicate that early stages of the life cycle must be considered for enhanced brain aluminum accumulation.

The estrogen antagonist tamoxifen inhibits carrageenan induced inflammation in LEW/N female rats

Carrageenan induces a measurable inflammatory response in susceptible animals, and mature females are more responsive to carrageenan, than males. In the present study, we tested whether the estrogen antagonist tamoxifen influences carrageenan-induced inflammatory responses. Female LEW/N rats were treated with tamoxifen and compared to a control group of animals injected with vehicle. Tamoxifen significantly reduced estrous phase of estrous cycle during treatment, consistent with its functional anti-estrogen effects. Moreover, tamoxifen significantly decreased exudate volume but did not significantly influence relative white blood cell counts in the exudate. Interestingly, tamoxifen induced differential dose-dependent alterations in peripheral blood lymphocyte subpopulations. Low dose of tamoxifen increased CD25 cells. The high tamoxifen dose significantly increased CD8 blood lymphocytes counts. Our data indicate that tamoxifen treatment decreases carrageenan-induced inflammatory response in female LEW/N rats and suggest therefore that this inflammatory response is, at least in part, estrogen related. Moreover, our results suggest a possible role for tamoxifen in treatment of inflammatory disorders.

Intracerebroventricularly Transplanted Embryonic Neuronal Tissue from Inflammatory-Resistant F344/N Rats Decreases Acoustic Startle Responses in Inflammatory-Susceptible Lew/N Rats

Recently, we have shown that intracerebral transplantation of fetal F344/N hypothalamic tissue into LEW/N rats converts the LEW/N inflammatory-susceptible phenotype into an inflammatory-resistant phenotype in LEW/N hosts. Because LEW/N rats also exhibit relatively high acoustic startle responses (ASRs) compared to F344/N rats, in the present study we examined the effects on ASR of transplantation of F344/N hypothalamic tissue into the third ventricle of LEW/N rats. Dissected neuronal tissue from F344/N rats (Day E15-16) was implanted into the third ventricle of LEW/N rats. After 4 wk of postoperative survival, the animals' responses to acoustic startle stimuli were tested. Compared to naive and sham-operated animals, LEW/N rats transplanted with hypothalamic tissue exhibited significant decreases in ASR amplitudes. A similar decrease in ASR amplitude was observed in the group of LEW/N rats transplanted with embryonic striatal tissue. Our results indicate that the third ventricular neuronal grafts may modulate behavioral responses in the LEW/N rats. Although the mechanism of this effect is unknown, these studies suggest that intracerebral neuronal transplantation is a viable method with which to explore mechanisms of behavioral, neuroendocrine, and inflammatory response associations.

Stereoselective metabolic pathways of ketoprofen in the rat: incorporation into triacylglycerols and enantiomeric inversion

The enantiomeric bioinversion of ketoprofen (KP) enantiomers and their incorporation into triacylglycerols were investigated in the rat (1) in vitro, using liver homogenates, subcellular fractions, and hepatocytes, and (2) in vivo, in different tissue samples after oral administration of the radiolabelled compounds. In liver homogenates or subcellular fractions, the enantiomer (S)-ketoprofen (S-KP) was recovered unchanged, whereas (R)-ketoprofen (R-KP) was partially converted into its Coenzyme A (CoA) thioester and inverted to S-KP. Both processes occurred mainly in the mitochondrial fraction. This supports the mechanism of inversion via stereoselective formation of CoA thioester of R-KP, already described for other non-steroidal anti-inflammatory drugs. Incorporation into triacylglycerols was detected after incubation with intact hepatocytes in the presence of added glycerol. The process was stereoselective for R-KP vs. S-KP (covalently bound radioactivity 26,742 +/- 4,665 dpm/10(6) cells vs. 6,644 +/- 3,179 dpm/10(6) cells, respectively). However, no incorporation was found in liver samples after oral administration of either R-KP or S-KP. On the contrary, in adipose tissue samples a significant and stereoselective formation of hybrid triacylglycerols was observed: 11,076 +/- 2,790 dpm.g-1 for R-KP vs. 660 +/- 268 dpm.g-1 for S-KP. The incorporated R/S ratio, higher in adipose tissue (R/S = 17) than in hepatocytes (R/S = 4), indicates that fat may be the main tissue store for the xenobiotic R-KP in rats.

Thyroid hormone treatment after coronary-artery bypass surgery

BACKGROUND

Thyroid hormone has many effects on the cardiovascular system. During and after cardiopulmonary bypass, serum triiodothyronine concentrations decline transiently, which may contribute to postoperative hemodynamic dysfunction. We investigated whether the perioperative administration of triiodothyronine (liothyronine sodium) enhances cardiovascular performance in high-risk patients undergoing coronary-artery bypass surgery.

METHODS

We administered triiodothyronine or placebo to 142 patients with coronary artery disease and depressed left ventricular function. The hormone was administered as an intravenous bolus of 0.8 microgram per kilogram of body weight when the aortic cross-clamp was removed after the completion of bypass surgery and then as an infusion of 0.113 microgram per kilogram per hour for six hours. Clinical and hemodynamic responses were serially recorded, as was any need for inotropic or vasodilator drugs.

RESULTS

The patients' preoperative serum triiodothyronine concentrations were normal (mean [+/- SD] value, 81 +/- 22 ng per deciliter [1.2 +/- 0.3 nmol per liter]), and they decreased by 40 percent (P < 0.001) 30 minutes after the onset of cardiopulmonary bypass. The concentrations in patients given intravenous triiodothyronine became supranormal and were significantly higher than those in patients given placebo (P < 0.001). However, the concentrations were once again similar in the two groups 24 hours after surgery. The mean postoperative cardiac index was higher in the triiodothyronine group (2.97 +/- 0.72 vs. 2.67 +/- 0.61 liters per minute per square meter of body-surface area, P = 0.007), and systemic vascular resistance was lower (1073 +/- 314 vs. 1235 +/- 387 dyn.sec.cm-5, P = 0.003). The two groups did not differ significantly in the incidence of arrhythmia or the need for therapy with inotropic and vasodilator drugs during the 24 hours after surgery, or in perioperative mortality and morbidity.

CONCLUSIONS

Raising serum triiodothyronine concentrations in patients undergoing coronary-artery bypass surgery increases cardiac output and lowers systemic vascular resistance, but does not change outcome or alter the need for standard postoperative therapy.

Toxicology of vanadium compounds in diabetic rats: the action of chelating agents on vanadium accumulation

The possible use of vanadium compounds in the treatment of diabetic patients is now being evaluated. However, previously to establish the optimal maximum dose for diabetes therapy, it should be taken into account that vanadium is a highly toxic element to man and animals. The toxic effects of vanadium are here reviewed. The tissue vanadium accumulation, which would mean an additional risk of toxicity following prolonged vanadium administration is also discussed. Recently, it has been shown that coadministration of vanadate and TIRON, an effective chelator in the treatment of vanadium intoxication, reduced the tissue accumulation of this element, decreasing the possibility of toxic side effects derived from chronic vanadium administration without diminishing the hypoglycemic effect of vanadium. However, previously to assess the effectiveness of this treatment in diabetic patients, a critical reevaluation of the antidiabetic action of vanadium and its potential toxicity is clearly needed.

Cytoplasmic coat proteins involved in endosome function

Endosomes are intermediates for a complex series of sorting and transport events that occur during receptor-mediated endocytosis. These involve the recognition of targeting determinants on the cytoplasmic domains of many membrane proteins as well as the formations of specific transport vesicles. Accordingly, endosome function is likely to be governed by the regulated assembly of cytoplasmic coat complexes. We have found that, in vitro, endosomes recruit a characteristic set of cytoplasmic proteins in a GTP gamma S-stimulated and brefeldin A-sensitive fashion. Among these are members of the COP-I and ARF families of coat proteins. In addition, endosomes were also found to assemble distinct, clathrin-like coats. Since microinjection of antibodies to beta-COP inhibits the entry of enveloped viruses via the endocytic pathway, it is apparent that the recruitment of COP-I or COP-I-related proteins plays an important role in the function of endosomes in intact cells.