Mediastinal lymph node staging with transesophageal echography in cancer of the lung

Transesophageal echography (TEE) was used prospectively to study mediastinal lymph node enlargement in 23 patients with cancer of the lung. The findings were validated blindly by comparison with computed tomography (CT, n = 23) and pathological N classification after curative surgery (n = 9). Lymph nodes larger than 1 cm were defined as pathologically enlarged. In the upper mediastinum, 22% (8 vs 36), in the lower mediastinum including the subaortic region 112% (37 vs 33) and in the hilar region 67% (6 vs 9) of enlarged lymph nodes diagnosed by CT were detected by TEE. A pathological study in 9 patients demonstrated true positive findings in 2 vs 1, true negatives in 4 vs 5, false positives in 3 vs 2 and false negatives in 0 vs 1 comparing TEE with CT. From these preliminary data, we conclude that TEE, although still experimental, is equal or superior to CT in detecting enlarged nodes in the lower mediastinum, specifically in the aortopulmonary window but clearly inferior in the upper mediastinum and the hilar region. Additional information on central tumors and infiltration of the heart or great vessels can be clarified. In addition, data on hemodynamics and cardiac status can be obtained. TEE seems to be a promising tool in the preoperative staging of lung cancer.

Surgical correction of a severely obstructed pulmonary artery bifurcation in Takayasu's arteritis

A young male patient (NYHA III) presented with a severe pulmonary artery bifurcation stenosis of unknown origin. He underwent successful radical resection and endarterectomy of abundant endoluminal and perivascular inflammatory tissue. Surgery was performed with extracorporeal circulation (ECC) without transection of the aorta and the pulmonary artery bifurcation was enlarged with a patch. Right ventricular to peripheral pulmonary artery pressure gradient fell from 80 mmHg preoperatively to 25 mmHg 18 months postoperatively. The patient is fully rehabilitated and working (NYHA I). Histological examination confirmed Takayasu's arteritis as the underlying disease and medium-term follow-up angiography showed an almost normal pulmonary artery bifurcation. We conclude that the radical surgical approach is a valuable palliation in this disease.

Gross and Histological Criteria for Developmental Disorders in Brains of Schizophrenics

Autopsy findings and examination of histological sections from 12 schizophrenic patients and from age-matched, non-schizophrenic controls were enlarged and confirmed our previous study. Four subgroups were differentiated with gross abnormalities, in most cases with asymmetry of the temporal sulcal gyral pattern. Two types of macroscopical deviations are described. Different periods of developmental termination, concerning the sulcal gyral pattern of the temporal lobe, suggest a period in which the disturbance of the development originated which coincides with a probably genetically-induced disturbed migration in the entorhinal region toward the end of the fifth month. It is thought that the parahippocampal or entorhinal area develops differently, space- and time-wise. This may explain why migratory disturbances particularly occur in this precisely limited area. The findings in the ventral insular area are discussed, together with factors which also suggest a developmental disorder.

Pronounced cholinergic but only moderate purinergic effects in isolated atrial and ventricular heart muscle from cats

1. The effects of cholinergic and purinergic stimulation on action potential, force of contraction and 86Rb efflux were investigated in cat atrial and/or ventricular heart muscle. 2. Acetylcholine and carbachol exerted a concentration-dependent negative inotropic effect in cat atrial heart muscle. Carbachol 10 mumol l-1 completely abolished the force of contraction and increased the rate constant of 86Rb efflux 2-3 fold, whereas the action potential duration was shortened to about 1/10 of its length under control conditions. 3. The effects of acetylcholine and carbachol in cat atrial heart muscle were mimicked, qualitatively, by adenosine and its analogues 5'-(N-ethyl)-carboxamido-adenosine (NECA) and (-)-N6-(R-phenyl-isopropyl)-adenosine (R-PIA). Maximal purinergic effects, however, amounted to about 15-50% in comparison to those of cholinergic stimulation. 4. In cat ventricular heart muscle, cholinergic or purinergic stimulation had no significant effects on the force of contraction in the absence of a cyclic AMP-dependent positive inotropic effect. Carbachol antagonized the positive inotropic effect elicited by either 3-isobutyl-1-methylxanthine, isoprenaline or cyclic 8-(4-chlorphenylthio)adenosine-3':5'-monophosphate; NECA and R-PIA were less effective. The inhibition by carbachol of the effects of isoprenaline was not related to a change in the rate constant of 86Rb efflux. 5. It is concluded that the effects of cholinoceptor and purinoceptor agonists in the cat heart involve a change in the potassium conductance in the atrium, whereas the effects in the ventricle may be related to changes of intracellular cyclic AMP levels. It seems reasonable to assume that, in comparison to cholinergic stimulation, a low density of purinoceptors in the cat heart is responsible for the relatively weak effects of adenosine agonists in this species.

Functional role of cholinoceptors and purinoceptors in human isolated atrial and ventricular heart muscle

1. The effects of cholinergic and purinergic stimulation on action potential, force of contraction and 86Rb efflux were investigated in human atrial and ventricular heart muscle. 2. In atrial heart muscle, carbachol and (-)-N6-(R-phenyl-isopropyl)-adenosine (R-PIA) and 5'-(N-ethyl)-carboxamido-adenosine (NECA) evoked transient decreases of action potential duration and force of contraction; the steady-state effects on force of contraction were virtually identical to control values. In the presence of propranolol, steady-state values after carbachol, R-PIA or NECA amounted to about 50% of control values. 3. In ventricular heart muscle, carbachol, NECA and R-PIA did not significantly affect the action potential configuration or force of contraction. 4. Carbachol, NECA and R-PIA induced a maintained depression of the positive inotropic response to isoprenaline in both atrial and ventricular heart muscle. 5. The rate constant of 86Rb efflux was slightly increased by carbachol, NECA and R-PIA in atrial (10-20%) but not in ventricular heart muscle. 6. In the presence of isoprenaline, carbachol, NECA and R-PIA did not significantly affect the rate constant of 86Rb efflux in both atrial and ventricular heart muscle. Isoprenaline alone increased the rate constant of 86Rb by about 25% in both tissues.

Anatomically corrected malposition of the great arteries, inflow ventricular septal defect, and subaortic stenosis: diagnostic and operative implications

Intracardiac correction of the combination of rare congenital heart lesion of anatomically corrected malposition of the great arteries, severe muscular as well as fibrous subaortic stenosis, and ventricular septal defects in the inflow and the trabecular septum in a 2 1/2 years old boy is reported. There was an additional large secundum atrial septal defect. The operation consisted of resection of the subaortic stenosis by a combined transatrial and transaortic approach, thereby regaining a wide outflow tract of the systemic ventricle. Both the ventricular and atrial septal defects were closed with Dacron patches. Reinvestigation 10 days after the operation revealed a residual pressure gradient across the outflow of the systemic ventricle of less than 10 mmHg. A secondary ventricular septal defect was detected in the anterior muscular septum at the same time and closed with a patch in a reintervention. At discharge from the hospital two weeks later the child was in excellent condition and had a stable sinus rhythm. The preoperative differential diagnosis of a double outlet right ventricle with L-malposition of the aorta as well as possible surgical approaches are discussed.

Failure of opioids to affect excitation and contraction in isolated ventricular heart muscle

The opioid agonists morphine (selective for mu-receptors) and ethylketocyclazocine (selective for kappa-receptors), at concentrations evoking strong effects in neuronal structures, did not significantly affect the configuration of the intracellularly recorded action potential and the force of contraction in ventricular heart muscle isolated from guinea pigs, rabbits and man. These results suggest that any changes of heart functions in vivo in response to opioid-like drugs are probably not mediated postsynaptically at the myocardial cell membrane but rather presynaptically, influencing the release of noradrenaline and/or acetylcholine from the nerve terminals.

Treatment of major venous obstruction with an expandable endoluminal spiral prosthesis

Six patients with extensive iliofemoral and/or caval thrombosis were treated by thrombectomy and subsequent implantation of an expandable endoluminal spiral prosthesis in case of congenital caval stenoses (1) or extravascular compression or traction (5). Five of these patients had undergone previous surgery and thrombosis had developed despite low dose heparin given postoperatively. Three patients had had an unsuccessful thrombectomy prior to spiral implantation. No complications related to the endoluminal prosthesis occurred. There was one retroperitoneal hematoma from guide wire perforation of the inferior vena cava (IVC) necessitating laparotomy and reversal of the previously constructed femoral av-fistula with subsequent iliofemoral rethrombosis. All other endoluminally reconstructed veins remained open at early and late (up to 12 months) review confirmed by phlebography. We conclude that with increasing clinical experience endoluminal relining of obstructed major veins will probably become a valuable method of venous reconstruction with minimal surgical trauma.

Initial clinical experience with an endoluminal spiral prosthesis for treating complicated venous thrombosis and preventing pulmonary embolism

Fourteen patients with complicated venous thrombosis or recurrent pulmonary embolism were treated by implantation of an endoluminal spiral prosthesis subsequent to balloon angioplasty, surgical thrombectomy or embolectomy, a combination of these, or, in 2 cases, no other treatment. The patients were divided into 2 groups, based on their primary diagnosis and the purpose of the prosthesis. Group I included 8 patients with extensive iliofemoral or caval thrombosis, caused by congenital caval stenosis (1 case) or extravascular compression or retraction (7 cases); 7 of these patients had had previous operations, and the remaining patient had undergone thrombolysis, which failed. The current treatment consisted of balloon angioplasty and surgical thrombectomy or embolectomy, and implantation of an endoluminal spiral stent to prevent elastic recoil of the vessel. In 4 cases, an arteriovenous fistula was constructed and was taken down 3 months later; in 1 additional patient, a bilateral arteriovenous fistula was created. Group II comprised 6 patients with recurrent pulmonary embolism (4 cases), massive pulmonary embolism (1 case), or paradoxical bilateral carotid artery embolism (1 case). Four of these patients underwent surgical thrombectomy or embolectomy, while 2 had no treatment other than filter implantation. All 6 underwent transluminal implantation of a helix caval filter (a modification of the endoluminal spiral stent). All but 1 implantation was accomplished by means of either a transfemoral or a transjugular cutdown; the remaining implantation was performed transatrially after a pulmonary embolectomy. The only device-related complication was a retroperitoneal hematoma in Group I, resulting from perforation of the inferior vena cava by the guidewire during device implantation. This complication necessitated an emergency laparotomy and takedown of the arteriovenous fistula, which resulted in rethrombosis of the left iliofemoral vein. The other 7 stented veins were patent at early phlebographic follow-up, as were all 5 of those studied later. One Group-I patient died 4 months after surgery, due to tumor progression and without signs of caval restenosis. Twelve months postoperatively, 1 Group-II patient died of urosepsis without a recurrence of pulmonary embolism. Four of the 6 Group-II patients were studied late postoperatively, and all of their stented vessels were patent. There was no operative mortality or postoperative embolism. On the basis of these results, we conclude that endoluminal stenting with an expandable spiral prosthesis is a promising method for remote venous reconstruction. Moreover, it appears that the modified stent, or helix caval filter, compares favorably with commercially available filters.

Adrenoceptor-mediated changes of action potential and force of contraction in human isolated ventricular heart muscle

1. The effects of alpha-adrenoceptor stimulation on the action potential and force of contraction were investigated in human isolated ventricular heart muscle and compared with those of beta-adrenoceptor stimulation. 2. The maximal stimulation by isoprenaline of beta-adrenoceptors produced large changes in the force of contraction, which were accompanied by moderate increases in the height of the action potential. The maximal inotropic effect produced by stimulation of alpha-adrenoceptors with phenylephrine, in the presence of propranolol (1 mumol 1(-1)) was much smaller (about 10% of that seen in response to beta-adrenoceptor stimulation), and no significant changes of the action potential configuration were observed. 3. The effects of noradrenaline and adrenaline on the force of contraction were not affected by prazosin. 4. It is concluded that the adrenoceptor-mediated changes of the force of contraction (in the presence of either noradrenaline or adrenaline) in the human ventricle are due virtually exclusively to the stimulation of beta-adrenoceptors.

Tetrodotoxin slightly shortens action potential duration in ventricular but not in atrial heart muscle

Tetrodotoxin (TTX), at concentrations significantly decreasing maximal upstroke velocity (dV/dtmax) of the action potential, exerted variable effects on action potential duration (APD) in different myocardial preparations. APD was virtually unchanged by tetrodotoxin in the guinea pig atrium, but slightly shortened in the guinea pig ventricle at maximally effective concentrations. In the human ventricle, both dV/dtmax and APD were reduced in the same concentration range of TTX. These results suggest that a TTX-sensitive sodium current significantly contributes to the repolarization phase of the action potential in ventricular but not in atrial heart muscle.

[Successful post-bypass extracorporeal circulatory assistance with the centrifugal pump]

Patients with reduced left ventricular function do have an increased risk of inability to be weaned off bypass after open heart surgery despite maximal pharmacologic support and intraaortic balloon counter-pulsation. Centrifugal pumps used for extracorporeal circulatory assist can maintain a patient in low cardiac output up to days without anticoagulation. We used a centrifugal pump in 3 patients: as a left ventricular assist device (LVAD) in 2 patients and right ventricular assist device (RVAD) in 1 patient. One LVAD-patient became a long-term survivor after 20 h of assist, another was bridged successfully to an open heart procedure for 2 h after papillary muscle rupture. One RVAD patient died on the operating table due to massive tracheal bleeding probably caused by pulmonary hypertension.

Double inlet left ventricular main chamber, subaortic small left sided right ventricle and interrupted aortic arch type A. What operation is indicated when?

A case of a 23 year old female patient who suffered from the complex congenital heart lesion of a double inlet left ventricular main chamber, subaortic small left sided right ventricle and interrupted aortic arch type A is reported. With equally high blood pressures, the perfusion in the upper half of the body was maintained through the ascending aorta while the lower half and the lungs were supplied through the pulmonary artery and a patent ductus arteriosus (PDA). Angiographically, the bulbo-ventricular foramen appeared to be nonrestrictive. However, distinct signs of muscular subaortic stenosis were detected. The hemodynamic status principally allowed surgical correction when this became necessary because of increasing left heart failure. Treatment for this complex lesion undoubtedly required reduction of pulmonary perfusion, even when associated with the danger of increasing cyanosis. Various forms of surgical treatment (functional correction, palliative procedures) were discussed. The most elegant was performed without cardiopulmonary bypass: this consisted in connection of the pulmonary artery with the descending aorta using a 16 mm Dacron tube, reconstruction of the aortic arch by a prostheso-subclavian synthetic graft, suture ligation of the PDA, and banding of the pulmonary artery trunk distal to the origin of the prosthesis. One year after the operation, the patient's physical performance has improved. Moreover, despite the disappearance of cardiac failure she has not become more cyanotic during exertion.

Successful post-bypass ventricular assist with a centrifugal pump

A 56 year old male with massive anterior wall infarction and development of a large aneurysm underwent aneurysmectomy and aorto-coronary bypass grafting to the RCA. Preoperative ejection fraction was 20%, LVedP was 30 mm Hg. During induction of anesthesia the patient sustained ventricular fibrillation and was successfully resuscitated. With the patient in progressive cardiogenic shock the operation was performed under emergency conditions. Despite adequate myocardial protection and cross-clamp time as well as prolonged reperfusion and balloon counterpulsation the patient could not be weaned off cardiopulmonary bypass. In this situation a centrifugal pump system was connected between the left atrium and the ascending aorta. With a pump flow of 5 l/min the patient was taken off cardiopulmonary bypass. After 20 hours of extracorporeal support without anticoagulation the device could be removed: explantation of the IABP followed 48 hours later. The patient gradually recovered and finally was discharged home in fair condition.

Prenatal developmental disturbances in the limbic allocortex in schizophrenics

Sixty-four autopsied brains of schizophrenic patients were neuropathologically examined and compared with 10 brains of non-schizophrenic controls. Clinical diagnoses were established retrospectively according to the Research Diagnostic Criteria and the International Classification of Diseases. We found: brains without deviations of the sulcogyral pattern of the temporal lobe or abnormal gross configuration (n = 22); brains with abnormal sulcogyral pattern of the temporal lobe or abnormal gross configuration (n = 42): with definite cytoarchitectonic abnormalities of the rostral entorhinal region in the parahippocampal gyrus and, in 16 cases only, in the ventral insular cortex (n = 20); with equivocal changes of the cytoarchitecture in these two regions (n = 22). Generally, these anatomical abnormalities were asymmetric. The histological findings in the two limbic regions consisted mainly of poorly developed structure in the upper layers, with a heterotopic displacement of single groups of nerve cells in the entorhinal region. Particularly, the disturbed structure of the second layer Pre-alpha in medial and central fields of the entorhinal region, situated in the parahippocampal gyrus (group 2a), suggests a disturbance of neuronal migration in a later phase of cortical development.

Stem cells and embryo-derived cell lines: tools for study of gene expression

Embryonal carcinoma (EC) cells obtained either from teratocarcinomas or directly from in vitro cultures of mouse embryos (EK) can be used as models for the early stages of normal mammalian development. A few known examples of experimental designs with such cells are reviewed: aggregates with normal embryos, promotion of parthenogenetic development by injection of EK cells into blastocysts, EK cells homozygous for a lethal gene, timing of expression in differentiating EC cells of a tissue-specific gene product, and X chromosome inactivation.

Evaluation of fibrin sealing for cardiovascular surgery

Hemorrhage remains a problem in patients undergoing cardiovascular surgery. To evaluate fibrin sealant, a completely biodegradable hemostatic agent, three series of experiments were performed in mongrel dogs. In series I, 18 dogs had a 7 cm interposition of knitted Dacron (water porosity 1500 ml/min/cm2) in the descending aorta. In group A, all prostheses were treated with fibrin sealant and in group B by blood preclotting. Measurements of blood loss demonstrated 1.29 +/- 0.26 ml/min in group A as compared with 30.16 +/- 2.85 ml/min in group B (p less than .001). In series II, six dogs of each group were compared for thrombogenicity and platelet survival by using indium-111-labeled autologous platelets. According to Goldman et al., the thrombogenicity index was calculated. The mean thrombogenicity index for group A was 0.23 +/- 0.02 in contrast to 0.33 +/- 0.05 for group B (p greater than .05). Mean platelet survival was 5.59 +/- 0.23 days in group A in contrast to 5.34 +/- 0.05 days in group B (p greater than .05). In series III, the gluing potential was investigated by creating four types of injuries: four dogs had an aortic stab wound 3 to 5 mm, six dogs received a 10 to 15 mm stab wound to the left ventricle, seven dogs had a 3 cm laceration of the left atrial appendage, and four dogs had bilateral division of their carotid arteries. Wounds of the aorta and left atrial appendage were treated by partial clamping and the sole use of fibrin sealant, the carotid arteries were repaired by four simple sutures and fibrin sealant, and the left ventricular stab wounds were treated by the combined use of heterologous collagen and fibrin sealant without suture.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined application of heterologous collagen and fibrin sealant for liver injuries

Hemostasis in complex liver injuries remains a problem despite improvements in operative techniques including debridement, suturing or packing. To evaluate fibrin sealant (FS), a new biodegradable hemostatic agent in combination with porcine collagen for sealing of liver injuries, three series of experiments were performed in 132 rats. In series I, 18 rats had a 10-mm in diameter and 2-mm in depth punch defect to the left lateral lobe. In the FS group (n = 9), bleeding was treated by insertion of an FS-soaked piece of collagen of equal size which was firmly attached to a plastic disk with wire anchor. In the control group (n = 9), collagen alone was inserted. Fifteen minutes after the insertion the lobe was excised and pull-off experiments were performed with simultaneous script chart recording. There was a highly significant difference in the adhesion to the liver surface (85.6 +/- 7.1 in the FS group versus 24.8 +/- 2.6 g/cm2 in the control group, P less than 0.001). In series II, 42 anticoagulated rats (Coumadin, PT 27.5% +/- 1.3) with lobectomy or liver rupture were placed in three groups (n = 14). Group I was treated with FS, group II with FS and collagen, and group III with catgut sutures which served as controls. Fourteen days later 12 rats of group I, 13 of group II, and 7 of group III were alive yielding 85.7, 92.8, and 50% overall survival rates, P less than 0.05 groups I and II versus group III. In series III, 72 non-anticoagulated rats were treated identically to series II and examined morphologically at 1, 7, 28, and 56 days.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of fibrin sealant for reinforcing arterial anastomoses

Despite improvements in needles, sutures, and technique, hemorrhage remains a problem in cardiovascular surgery. In this study conventional vascular suture lines and suture lines reinforced with fibrin sealant are compared for blood loss and burst strength. Bilateral femoral arteries in 20 dogs were divided at 50% of their circumference and repaired with six 6-0 polypropylene sutures. Ten animals were systemically heparinized (3 mg/kg), and 10 were not on anticoagulants. The right femoral artery anastomosis was treated with fibrin sealant in all animals, and the left suture line served as the control. Three minutes after initiation of the sealing procedure, blood flow was reinstituted in both femoral arteries. After 3 minutes a significant difference in blood loss between the conventional suture technique and fibrin-reinforced anastomoses was noted in both heparinized (12.1 +/- 2.79 vs. 0.13 +/- 0.06 ml/min; p less than 0.01) and nonheparinized dogs (8.45 +/- 1.37 vs. 0.20 +/- 0.08 ml/min; p less than 0.001). After 30 minutes volume inflow and pressure catheters were inserted into snared compartments encompassing the femoral artery anastomosis. Continuous pressure recordings during volume loading with normal saline solution demonstrated increased bursting pressures of the fibrin-sealed suture lines in both the heparinized (317.5 +/- 13.18 vs. 135 +/- 23.17 mm Hg; p less than 0.001) and nonheparinized animals (474.5 +/- 26.82 vs. 311 +/- 29.31 mm Hg; p less than 0.001). Histologic examination revealed no fibrosis or foreign body reaction and complete resorption of the fibrin sealant within 3 weeks. Fibrin sealant, a powerful hemostatic agent produced from human donors not suffering from hepatitis, decreases blood loss and strengthens suture lines.(ABSTRACT TRUNCATED AT 250 WORDS)

Two specific markers for neural differentiation of embryonal carcinoma cells

Two multipotential embryonal carcinoma (EC) cell lines, 1003 and 1009, can be induced to form preferentially neural derivatives in vitro. Synthesis of specific proteins during neural differentiation was followed by two-dimensional gel electrophoresis. The comparison of protein patterns obtained with neural and non-neural derivatives of these EC cell lines indicates that two changes are specific for the neural pathway: (i) the appearance of a new beta-tubulin isoform and (ii) the accumulation of the brain isozyme of creatine phosphokinase already present in small amounts in EC stem cells. These changes were found to take place early in the course of differentiation and to occur even when neurite outgrowth was prevented.