The Impact of a Virtual Tobacco Prevention and Advocacy Training Among Youth in Appalachian Kentucky Communities

BACKGROUND

Engaging youth is an important component of comprehensive tobacco control programs.

PURPOSE

This paper describes the impact of a virtual tobacco prevention training program to encourage and prepare youth in Appalachia to support tobacco prevention policies, to strengthen interpersonal confidence to address tobacco use within their communities and enhance advocacy self-efficacy for tobacco control.

METHODS

A two-part evidence-informed peer-led tobacco prevention and advocacy training was implemented among 16 high school students from Appalachian counties in Kentucky. The initial training (January 2021) included an overview of the e-cigarette landscape, advocacy skills related to policy change, developing messages to decision makers, and media advocacy. A follow-up session (March 2021) included a breakdown of advocacy skills and overcoming barriers.

RESULTS

Overall, participants held strong beliefs that tobacco use is an issue that needs to be addressed in their community. There was a statistically significant average difference in student interpersonal confidence between baseline and post-surveys (t = 2.016, P = .062 < .1). Students who participated in at least 1 of the provided advocacy events indicated higher self-reported advocacy.

CONCLUSION

Youth in Appalachia expressed an interest to advocate for stronger tobacco policy in their communities. Youth who participated in the tobacco advocacy policy trainings reported improvements in attitudes, interpersonal confidence, advocacy self-efficacy, and self-reported advocacy. Youth engagement in tobacco policy advocacy is promising and needs to be further supported.

Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment

The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.

Aqueous-phase mechanism for secondary organic aerosol formation from isoprene: application to the Southeast United States and co-benefit of SO2 emission controls

Isoprene emitted by vegetation is an important precursor of secondary organic aerosol (SOA), but the mechanism and yields are uncertain. Aerosol is prevailingly aqueous under the humid conditions typical of isoprene-emitting regions. Here we develop an aqueous-phase mechanism for isoprene SOA formation coupled to a detailed gas-phase isoprene oxidation scheme. The mechanism is based on aerosol reactive uptake coefficients (γ) for water-soluble isoprene oxidation products, including sensitivity to aerosol acidity and nucleophile concentrations. We apply this mechanism to simulation of aircraft (SEAC⁴RS) and ground-based (SOAS) observations over the Southeast US in summer 2013 using the GEOS-Chem chemical transport model. Emissions of nitrogen oxides (NO_x ≡ NO + NO₂) over the Southeast US are such that the peroxy radicals produced from isoprene oxidation (ISOPO₂) react significantly with both NO (high-NO_x pathway) and HO₂ (low-NO_x pathway), leading to different suites of isoprene SOA precursors. We find a mean SOA mass yield of 3.3 % from isoprene oxidation, consistent with the observed relationship of total fine organic aerosol (OA) and formaldehyde (a product of isoprene oxidation). Isoprene SOA production is mainly contributed by two immediate gas-phase precursors, isoprene epoxydiols (IEPOX, 58% of isoprene SOA) from the low-NO_x pathway and glyoxal (28%) from both low- and high-NO_x pathways. This speciation is consistent with observations of IEPOX SOA from SOAS and SEAC⁴RS. Observations show a strong relationship between IEPOX SOA and sulfate aerosol that we explain as due to the effect of sulfate on aerosol acidity and volume. Isoprene SOA concentrations increase as NO_x emissions decrease (favoring the low-NO_x pathway for isoprene oxidation), but decrease more strongly as SO₂ emissions decrease (due to the effect of sulfate on aerosol acidity and volume). The US EPA projects 2013-2025 decreases in anthropogenic emissions of 34% for NO_x (leading to 7% increase in isoprene SOA) and 48% for SO₂ (35% decrease in isoprene SOA). Reducing SO₂ emissions decreases sulfate and isoprene SOA by a similar magnitude, representing a factor of 2 co-benefit for PM_2.5 from SO₂ emission controls.

Aqueous-phase mechanism for secondary organic aerosol formation from isoprene: application to the Southeast United States and co-benefit of SO2 emission controls

Isoprene emitted by vegetation is an important precursor of secondary organic aerosol (SOA), but the mechanism and yields are uncertain. Aerosol is prevailingly aqueous under the humid conditions typical of isoprene-emitting regions. Here we develop an aqueous-phase mechanism for isoprene SOA formation coupled to a detailed gas-phase isoprene oxidation scheme. The mechanism is based on aerosol reactive uptake coefficients (γ) for water-soluble isoprene oxidation products, including sensitivity to aerosol acidity and nucleophile concentrations. We apply this mechanism to simulation of aircraft (SEAC⁴RS) and ground-based (SOAS) observations over the Southeast US in summer 2013 using the GEOS-Chem chemical transport model. Emissions of nitrogen oxides (NO_x ≡ NO + NO₂) over the Southeast US are such that the peroxy radicals produced from isoprene oxidation (ISOPO₂) react significantly with both NO (high-NO_x pathway) and HO₂ (low-NO_x pathway), leading to different suites of isoprene SOA precursors. We find a mean SOA mass yield of 3.3 % from isoprene oxidation, consistent with the observed relationship of total fine organic aerosol (OA) and formaldehyde (a product of isoprene oxidation). Isoprene SOA production is mainly contributed by two immediate gas-phase precursors, isoprene epoxydiols (IEPOX, 58% of isoprene SOA) from the low-NO_x pathway and glyoxal (28%) from both low- and high-NO_x pathways. This speciation is consistent with observations of IEPOX SOA from SOAS and SEAC⁴RS. Observations show a strong relationship between IEPOX SOA and sulfate aerosol that we explain as due to the effect of sulfate on aerosol acidity and volume. Isoprene SOA concentrations increase as NO_x emissions decrease (favoring the low-NO_x pathway for isoprene oxidation), but decrease more strongly as SO₂ emissions decrease (due to the effect of sulfate on aerosol acidity and volume). The US EPA projects 2013-2025 decreases in anthropogenic emissions of 34% for NO_x (leading to 7% increase in isoprene SOA) and 48% for SO₂ (35% decrease in isoprene SOA). Reducing SO₂ emissions decreases sulfate and isoprene SOA by a similar magnitude, representing a factor of 2 co-benefit for PM_2.5 from SO₂ emission controls.

Broadband Radiometric LED Measurements

At present, broadband radiometric measurements of LEDs with uniform and low-uncertainty results are not available. Currently, either complicated and expensive spectral radiometric measurements or broadband photometric LED measurements are used. The broadband photometric measurements are based on the CIE standardized V(λ) function, which cannot be used in the UV range and leads to large errors when blue or red LEDs are measured in its wings, where the realization is always poor. Reference irradiance meters with spectrally constant response and high-intensity LED irradiance sources were developed here to implement the previously suggested broadband radiometric LED measurement procedure [1, 2]. Using a detector with spectrally constant response, the broadband radiometric quantities of any LEDs or LED groups can be simply measured with low uncertainty without using any source standard. The spectral flatness of filtered-Si detectors and low-noise pyroelectric radiometers are compared. Examples are given for integrated irradiance measurement of UV and blue LED sources using the here introduced reference (standard) pyroelectric irradiance meters. For validation, the broadband measured integrated irradiance of several LED-365 sources were compared with the spectrally determined integrated irradiance derived from an FEL spectral irradiance lamp-standard. Integrated responsivity transfer from the reference irradiance meter to transfer standard and field UV irradiance meters is discussed.

A nitric oxide-releasing solution as a potential treatment for fungi associated with tinea pedis

AIMS

To test a nitric oxide-releasing solution (NORS) as a potential antifungal footbath therapy against Trichophyton mentagrophytes and Trichophyton rubrum during the mycelial and conidial phases.

METHODS AND RESULTS

NORS (sodium nitrite citric acid) produces nitric oxide verified by gas chromatography and mass spectrometry (GC-MS). Antifungal activity of this solution was tested against mycelia and conidia of T. mentagrophytes and T. rubrum, using 1-20 mmol l(-1) nitrites and 10-30 min exposure times. The direct effect of the gas released from the solution on the viability of those fungi was tested. NORS demonstrated strong antifungal activity and was found to be dose and time dependent. NO and nitrogen dioxide (NO(2) ) were the only gases detected from this reaction and are likely responsible for the antifungal effect.

CONCLUSIONS

This in vitro research suggests that a single 20-min exposure to NORS could potentially be used as an effective single-dose treatment against fungi that are associated with tinea pedis in both mycelia and spore phase.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides the background for developing a user-friendly footbath treatment for Athlete's Foot that will kill both vegetative fungi and its spores.

Performance of the NIST goniocolorimeter with a broad-band source and multichannel charged coupled device based spectrometer

The authors describe the NIST high-efficiency instrument for measurements of bidirectional reflectance distribution function of colored materials, including gonioapparent materials such as metallic and pearlescent coatings. The five-axis goniospectrometer measures the spectral reflectance of samples over a wide range of illumination and viewing angles. The implementation of a broad-band source and a multichannel CCD spectrometer corrected for stray light significantly increased the efficiency of the goniometer. In the extended range of 380 nm to 1050 nm, a reduction of measurement time from a few hours to a few minutes was obtained. Shorter measurement time reduces the load on the precise mechanical assembly ensuring high angular accuracy over time. We describe the application of matrix-based correction of stray light and the extension of effective dynamic range of measured fluxes to the values of 10(6) to 10(7) needed for the absolute characterization of samples. The measurement uncertainty was determined to be 0.7% (k = 2), which is comparable with similar instruments operating in a single channel configuration. Several examples of reflectance data obtained with the improved instrument indicate a 0.3% agreement compared to data collected with the single channel configuration.

Thoracic aortic aneurysms

Remarkable progress has been made in the surgical treatment of thoracoabdominal aortic aneurysms. The decline in mortality and complication rates can be attributed to improvements in perioperative care and in surgical technique, particularly the adoption of adjunct distal aortic perfusion and cerebrospinal fluid drainage. Neurologic deficit is no longer a major threat to patients, as the use of adjuncts has brought the incidence down to 2.4% for all thoracoabdominal aortic aneurysms. However, we continue to pursue research to improve organ preservation, particularly for the most troublesome extent II thoracoabdominal aortic aneurysm.

Potential application of gaseous nitric oxide as a topical antimicrobial agent

The presence of bacterial colonization in non-healing wounds and burn injuries interferes significantly with the normal process of healing. Recent evidence suggests that nitric oxide (NO) plays an important role in host defense against infection and regulates wound healing and angiogenesis. We investigated the potential application of a medical-grade gaseous form of NO (gNO) as a novel antibacterial agent in wound infection. Using a continuous horizontal-flow delivery system, the antibacterial activity of gNO was tested in vitro against a range of pathogens, including clinical isolates of Staphylococcus aureus, methicillin-resistant S. aureus, Escherichia coli, Group B Streptococcus, Pseudomonas aeruginosa, and Candida albicans. To probe the effect of topical application of gNO on the human skin, the proliferation and extracellular matrix gene expression of human dermal fibroblasts in culture were also analyzed by (3)H-thymidine incorporation assay and Northern blot techniques, respectively. Potent bacteriocidal activity was observed at 200 ppm gNO with an average of 4.1 +/- 1.1 h to completely stop bacterial growth. Interestingly, this dose of gNO did not show any cytotoxic effect in human dermal fibroblasts in culture exposed for up to 48 h. Analysis of gene transcription in fibroblasts revealed a significant increase in MMP-1 mRNA expression as early as 2 h post-exposure to gNO. Although to a lesser degree, a significant reduction in type I procollagen was also observed in the same fibroblasts. The results of this study suggest that exogenous gaseous NO has potent significant antibacterial properties that can be beneficial in reducing bacterial burden in infected wound in burn injuries or non-healing ulcers.

A direct nitric oxide gas delivery system for bacterial and mammalian cell cultures

Nitric oxide (NO) is the smallest known gaseous signaling molecule released by mammalian and plant cells. To investigate the pathophysiologic role of exogenous NO gas (gNO) in bacterial and mammalian cell cultures, a validated in vitro delivery method is required. The system should be able to deliver gNO directly to bacterial and/or cell cultures in a continuous, predictable, and reproducible manner over a long period of time (days). To accomplish this, a gas delivery system was designed to provide optimal growth conditions for bacteria and/or mammalian cells. Parameters for cell exposure, such as concentration of gNO, nitrogen dioxide (NO(2)), oxygen (O(2)), temperature, and relative humidity (RH) were continuously monitored and evaluated. Uptake of gNO into various media was monitored by measuring the nitrite concentration using the Griess reagent technique. A selection of standard growth media [saline, tryptic soy broth (TSB), Middlebrook 7H9 (MB 7H9), and Dulbecco's modified Eagle's medium (DMEM)] exposed to various concentrations of gNO revealed a steady and consistent transfer of gNO into the aqueous phase over a 48-h period. Validation of optimal growth conditions within the device, as compared to a conventional incubator, were accomplished by growing and observing viability of Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and human fibroblast cultures in the absence of gNO. These results indicate that an optimal growth environment for the above tested cells was accomplished inside the proposed delivery system. Dose-dependent toxicological data revealed a significant bacteriostatic effect on P. aeruginosa and S. aureus with continuous exposure to 80 ppm gNO. No toxic effects were observed on dermal fibroblast proliferation at concentrations up to 400 ppm gNO for 48 h. In conclusion, the designed gNO exposure system is capable of supporting cellular viability for a representative range of prokaryote and eukaryotic cells. The exposure system is also capable of obtaining toxicological data. Therefore, the proposed device can be utilized to continuously expose cells to various levels of gNO for up to 72 h to study the in vitro effects of gNO therapy.

Number needed to treat: analyzing of the effectiveness of thoracoabdominal aortic repair

BACKGROUND

Number needed to treat (NNT) is a method used to calculate the number of patients who need to be treated to prevent one adverse outcome. To analyze the effectiveness of thoracoabdominal and descending thoracic aortic aneurysm repair, we computed the NNT required to prevent one death.

METHODS

Between Jan 1991 and Feb 2003, we repaired 1004 aneurysms of the descending thoracic and thoracoabdominal aorta. We followed the patients from surgery until death. Five-year actuarial survival in our population was computed by the Kaplan-Meier method. Natural history data for comparison were taken from the population-based work of Bickerstaff et al., 1982. NNT was calculated as the reciprocal of the risk difference at 5 years. 95% confidence intervals were computed by the method of Daly.

RESULTS

Five-year mortality in the population-based cohort was 87 vs. 39% in our treated population, for a risk difference of 48%. 1/0.48=2, indicating that two patients need to be treated to prevent one death at 5 years (95% CI 1.8-2.5, p<0.0001).

CONCLUSION

An NNT of two demonstrates the effectiveness of surgical repair of descending thoracic and thoracoabdominal aortic aneurysms when compared to the natural history. By comparison, carotid endarterectomy for symptomatic lesions >70% has an NNT of 15 to prevent a single stroke or death. NNT can also be applied to aneurysm size criteria to estimate the effort required to prevent death or rupture for a given aneurysm size.

Validation of a morphometric method for evaluating fibroblast numbers in normal and pathologic tissues

The aim of this work was to validate an image analysis method, based on cell nuclei form factor determination, for counting fibroblasts within human dermis. We first used reconstructed dermal equivalents in which fibroblasts can also be counted directly after lysis of the collagen matrix. We found a good correlation between the results of direct counting and those of image analysis from day 10 to day 28 of culture. When applied to young normal donors' skin biopsies fixed in Bouin's solution and embedded in paraffin, the image analysis method yielded mid-dermis fibroblast counts of between 2100 and 4100 per mm3 of fresh tissue. A nuclear form factor (FF) comprised between 0.35 and 0.84 was found to be a biologic marker of fibroblasts. This was confirmed after fibroblast discrimination from other cell types, which had rounder nuclei (FF >/= 0.85) and were identified either by their location (e.g. endothelial cells) or by labeling with specific antibodies (e.g. lymphocytes and monocytes/macrophages). Similar results were obtained with seven healthy donors' skin biopsies that had been frozen in nitrogen liquid and cryostat-sectioned, showing that this counting method is independent of the histologic procedure. Finally, analysis of samples of hypertrophic scars from two patients revealed that fibroblast density in some parts of the dermis was more than twice the value found in other parts presenting a fibroblast density almost normal, showing that this cell counting method can also be used to assess fibroblast heterogeneity within a given tissue.

Incidence and survival trends of esophageal carcinoma in the United States: racial and gender differences by histological type

BACKGROUND

The incidence of esophageal adenocarcinoma in White males has been reported to be increasing. The aims of this study were to determine: 1) the incidence trends of esophageal carcinoma in the United States with an emphasis on histologic type, sex, and ethnicity, 2) whether the reported increase in stage IV tumors can be confirmed, and 3) survival trends and factors affecting survival.

METHODS

Data from the SEER program of the National Cancer Institute with submission dates 1973-98 were used. Data on Hispanics were available for analysis only for the years 1992-98. Statistical analysis was performed utilizing SEER*Stat and SAS statistical software packages.

RESULTS

The incidence of adenocarcinoma in White males is still rising (7.8%/year, P < 0.0001); however, the same trend was observed for White females (6.48%/year; P < 0.0001). Hispanic males (3.91 %/year; P < 0.02), and Hispanic females (9.4%/ year; P < 0.04). The incidence of squamous cell carcinoma has been steadily declining in White males and females and in Black females since 1973, with the incidence showing a dramatic and significant decline in Black males beginning in 1992 (8.53%/year; P = 0.0009). Stage 4 carcinoma is declining in incidence. Survival of patients with esophageal carcinomas has been improving. In a Cox multivariate model, independent prognostic factors in esophageal carcinoma included tumor stage, tumor type, gender, race, age at diagnosis, and year of diagnosis.

CONCLUSIONS

1) The incidence of adenocarcinoma continues to rise in White males and females, but also in Hispanics, while squamous cell carcinoma is declining; 2) the incidence of stage 4 carcinomas has been declining, and 3) survival has been steadily improving, independently of all other risk factors.

Determinants of hospital length of stay after thoracoabdominal aortic aneurysm repair

PURPOSE

Extended hospital length of stay (LOS) and consequent high costs are associated with thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery. In this study, we examined factors that may influence LOS after TAAA repair.

METHODS

Five hundred forty thoracic and TAAA repairs were performed by one surgeon between 1990 and 1999. The data were analyzed with multiple linear regression with appropriate logarithmic transformation. The predictor variables included patient demographics, disease extent, severity indicators, intraoperative factors, and postoperative complications.

RESULTS

The median LOS was 15 days. Postoperative creatinine level of greater than 2.9 was the most important predictor of LOS, followed by spinal cord deficit, age, and pulmonary complication (all statistically significant with P <.05). A second model constrained to preoperative risk factors showed both age and complete diaphragmatic division to be associated with increased LOS. Preservation of the diaphragm led to reduced LOS by an average of 4 days. The adjunct cerebrospinal fluid drainage and distal aortic perfusion was associated with a decrease in LOS, although it did not reach statistical significance.

CONCLUSION

Renal failure, spinal cord deficit, and pulmonary complication were the major determinants of LOS in patients for TAAA repair. This study shows that the preservation of diaphragmatic function and the use of the adjunct distal aortic perfusion and cerebrospinal fluid drainage may reduce hospital LOS.

Chronic aortic dissection not a risk factor for neurologic deficit in thoracoabdominal aortic aneurysm repair

OBJECTIVE

chronic aortic dissection has long been considered a risk factor for neurologic deficit following thoracoabdominal aortic aneurysm (TAA) surgery. We reviewed our experience with regard to aneurysm extent and the use of adjunct, (distal aortic perfusion/cerebrospinal fluid drainage), and examined the impact of these factors on neurologic deficit among chronic dissection and non-dissection cases.

METHODS

between February 1991 and March 2001, we repaired 800 aneurysms of the descending thoracic and thoracoabdominal aorta. Seven hundred and twenty-nine cases were elective; 196 chronic dissection, 533 non-dissection. 182/729 (24.9%) were TAA extent II. Among these, 61/182 (33%) involved chronic dissection. Adjunct was used in 507/729 (69.6%). We conducted detailed multivariate analyses to isolate the impact of chronic aortic dissection on neurologic morbidity, with other important risk factors taken into account.

RESULTS

overall, 32/729 (4.4%) patients had neurologic deficit upon awakening; 7/196 (3.6%) in chronic dissections, and 25/533 (4.7%) in non-dissections. Adjunct had a major effect, reducing neurologic deficit in TAA extent II from 10/36 (27.8%) to 10/146 (6.9%) (p=0.001). However, in univariate and multivariate analysis, chronic dissection did not increase the risk of neurologic deficit, regardless of extent or mode of treatment.

CONCLUSION

in contrast to previous reports, we determined that chronic aortic dissection is not a risk factor in TAA patients.

Staged repair of extensive aortic aneurysms: morbidity and mortality in the elephant trunk technique

BACKGROUND

Extensive aortic aneurysms (ascending aorta, aortic arch, and descending or thoracoabdominal aorta) require innovative surgical techniques. Some surgeons advocate a single procedure with long periods of profound hypothermia, whereas others use a staged approach. We adopted a two-staged procedure (elephant trunk technique) in 1991 for elective repair of extensive aortic aneurysms.

METHODS AND RESULTS

Between February 1991 and May 2000, we performed a total of 1146 aortic aneurysm operations. Of these, 182 (15.9%) operations were first- or second-stage elephant trunk procedures, performed in a total of 117 patients. Stage 1 was completed in all 117 patients. Stage 2 was completed in 65 (55.6%) of 117 patients. Thirty-day mortality rate for the first stage was 5.1% (6 of 117). Mortality rate during the interval between operations was 3.6% (4 of 111), of which 75% (3 of 4) were the result of aneurysm rupture. Thirty-day mortality rate for the second stage was 6.2% (4 of 65). A total of 43 patients did not return for second-stage repair. Among these patients, within an average period of 3.4 years (range, 1.5 months to 4.9 years), 13 of 43 (30.2%) died, 4 of 13 (30.8%) as the result of rupture. Two of 117 (1.7%) first-stage patients had postoperative stroke. No spinal cord dysfunction occurred in second-stage patients.

CONCLUSIONS

Extensive aortic aneurysms can be repaired with acceptable morbidity and mortality rates through the use of the elephant trunk technique. Death was most commonly the result of rupture, both in interval patients awaiting scheduled second-stage repair and in patients who did not return. After the first stage, prompt treatment of the remaining segment is crucial to the success of staged repair.

Effect of avocado and soybean unsaponifiables on gelatinase A (MMP-2), stromelysin 1 (MMP-3), and tissue inhibitors of matrix metalloproteinase (TIMP- 1 and TIMP-2) secretion by human fibroblasts in culture

BACKGROUND

In inflamed periodontal tissues, gingival fibroblasts are able to express matrix metalloproteinases (MMPs) and their natural inhibitors, tissue inhibitors of matrix metalloproteinases (TIMPs). They can also respond to growth factors and cytokines. In this study, the in vitro effects of avocado and soybean unsaponifiable residues (ASU), their fractions (avocado unsaponifiable [ASF] or soy unsaponifiable [SSF]) on MMP-2 and MMP-3, and the activity and secretion of their inhibitors TIMP-1 and TIMP-2 were investigated using cultured human gingival fibroblasts.

METHODS

Gingival fibroblasts were cultured for 72 hours with ASU, ASF, and SSF at concentrations of 0. 1, 0.5, 2.5, 5, and 10 microgram/ml of culture medium, after pretreatment or no pretreatment for 1 hour with interleukin-1beta (IL-1beta). MMP-2 and MMP-3 were detected and quantified in the culture media after zymography and image analysis. TIMP-1, TIMP-2, MMP-2, and MMP-3 were also evidenced by dot blotting and quantified by image analysis.

RESULTS

In the absence of IL-1beta, a slight decrease in the secretion of MMP-2 was observed with lower doses of ASU, ASF, and SSF. The decrease of MMP-3 secretion was clearly marked with all fractions especially at low concentrations (0.1 and 2.5 microgram/ml). A slight decrease in TIMP-2 secretion was seen for low doses of ASU, ASF, and SSF, while a small increase was seen at higher concentrations. Concerning TIMP-1, no significant variation was observed in culture medium for low concentrations, and a decrease was noted for 5 and 10 microgram/ml of ASU, ASF, and SSF. As anticipated, IL-1beta induced a marked release of MMP-2, MMP-3, and TIMP-1, but no variation for TIMP-2 was seen. ASU, ASF, and SSF reversed the IL-1beta effect on gingival fibroblasts for MMP-2 and MMP-3, particularly with doses varying from 0.1 to 2.5 microgram/ml and for TIMP-1, particularly with doses varying from 2.5 to 10 microgram/ml.

CONCLUSIONS

These findings suggest a potential role for avocado and soy unsaponifiable extracts to prevent the deleterious effects of IL-1beta that occur during periodontal diseases.

Neurologic outcome after thoracic and thoracoabdominal aortic aneurysm repair

BACKGROUND

Neurologic deficit (paraparesis and paraplegia) after repair of the thoracic and thoracoabdominal aorta remains a devastating complication. The purpose of this study was to determine the effect of cerebrospinal fluid drainage and distal aortic perfusion upon neurologic outcome during repair of thoracic and thoracoabdominal aortic aneurysm (TAAA) repair.

METHODS

Between February 1991 and March 2000, we performed 654 repairs of the thoracic and thoracoabdominal aorta. The median age was 67 years and 420 (64%) patients were male. Forty-five cases (6.9%) were performed emergently. Distribution of TAAA was the following: extent I, 164 (25%); extent II, 165 (25%); extent III, 61 (9%); extent IV, 95 (15%); extent V, 23 (3.5%); and descending thoracic, 147 (22%). The adjuncts cerebrospinal fluid drainage and distal aortic perfusion were used in 428 cases (65%).

RESULTS

Thirty-day mortality was 14% (94 of 654). The in-hospital mortality was 16% (106 of 654). Early neurologic deficits occurred in 33 patients (5.0%). Overall, 14 of 428 (3.3%) neurologic deficits were observed in the adjunct group, and 19 of 226 (8.4%) in the nonadjunct group (p = 0.004). When the adjuncts were used during extent II repair, the incidence was 10 of 129 (7.8%) compared with 11 of 36 (30.6%) in the nonadjunct group (p < 0.001). Multivariate analysis demonstrated that risk factors for neurologic deficit were cerebrovascular disease and extent of TAAA (II and III) (p < 0.05).

CONCLUSIONS

The combined adjuncts of distal aortic perfusion and cerebrospinal fluid drainage demonstrated improved neurologic outcome with repair of thoracic and TAAAs. In extent II aneurysms, adjuncts continue to make a considerable difference in the outcome and to provide significant protection against spinal cord morbidity. Future research should focus on spinal cord protection in patients with high-risk extent II aneurysms.

Physiologic characteristics of canine skeletal muscle: implications for timing skeletal muscle cardiac assist devices

BACKGROUND

Optimal clinical stimulation for skeletal muscle cardiac assist systems (such as dynamic cardiomyoplasty) is not clearly defined. The pressure-generating capacity of canine skeletal muscle ventricles (SMVs) at a variety of preloads and stimulation frequencies was examined as was time for SMVs to develop peak pressure.

METHODS

SMVs were analyzed just after construction and after 3 months of electrical conditioning. Pressure generation and time to develop peak pressure were determined using a distensible mandrel.

RESULTS

Higher preloads resulted in increased pressure generation; conditioned SMVs generated significantly less pressure than unconditioned SMVs. Increasing stimulation frequency from 20 to 50 Hz increased pressure-generating capacity; increases beyond 50 Hz did not result in further increases. Time to 90% peak pressure was least at 10 HZ and 65 Hz.

CONCLUSIONS

Higher stimulation frequencies and preloads result in a more quickly contracting muscle, which generates more pressure. Midrange stimulation frequencies of 30 Hz provide optimal muscle strength and minimize time to develop peak pressure. Initiation of contraction should begin before the time maximal pressure is desired.

Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion

BACKGROUND

Neurologic deficit (paraplegia or paraparesis) remains a significant morbidity in the repair of descending thoracic aortic aneurysm.

METHODS

Between February 1991 and February 2000, we operated on 182 patients for descending thoracic aortic aneurysm. For the purpose of this study-to identify the impact of the combined adjuncts distal aortic perfusion and cerebrospinal fluid (CSF) drainage on neurologic outcome-we selected the 148 of 182 nonemergent patients who had received conventional treatment (simple cross-clamping with or without adjuncts). The mean patient age was 61 years, and 49 of the 148 (33%) patients were women. Nine of the 148 patients (6%) had acute type B dissections. We compared the results of 105 of the 148 patients (71%) who received the combined adjuncts of CSF drainage and distal aortic perfusion with the remaining 43 (29%) patients who underwent repair using the simple cross-clamp with or without the addition of a single adjunct.

RESULTS

Overall 30-day mortality was 13 of 148 patients (8.8%). Overall early neurologic deficit was 4 of 148 (2.7%): 1 of 105 (0.9%) patients who had received distal aortic perfusion and CSF drainage, versus 3 of 43 (7%) in all other patients (p < 0.04).

CONCLUSIONS

In our practice the use of the combined adjuncts of CSF drainage and distal aortic perfusion has all but eliminated the incidence of immediate postoperative neurologic deficit in nonemergent patients with aneurysms of the descending thoracic aorta.

Androgen induced cell death in SHSY5Y neuroblastoma cells expressing wild-type and spinal bulbar muscular atrophy mutant androgen receptors

Spinal bulbar muscular atrophy (SBMA) is one of a family of inherited neurodegenerative diseases caused by expansion of CAG encoding polyglutamine repeats; in SBMA the affected gene is the androgen receptor. To understand further the mechanisms that lead to neuronal cell death in SBMA, we generated SHSY5Y neuroblastoma cell lines that stably express identical levels of wild-type (19 polyglutamine repeat) or SBMA (52 polyglutamine repeat) androgen receptor. Parental SHSY5Y cells do not express detectable levels of the androgen receptor. In the absence of androgen, the transfected cell lines have similar phenotypes and growth characteristics to parental SHSY5Y cells. However, upon treatment with androgen, both cell lines undergo a marked dose-dependent loss of viability; this loss was significantly greater in cells expressing the SBMA receptor. Morphological analyses of the androgen treated cells revealed that cell death bore hallmarks of apoptosis involving altered nuclear morphology and cleavage of poly(ADP-ribose) polymerase and of caspase 3 in both wild-type and SBMA cell lines. The caspase inhibitor VAD-fmk was able to decrease loss of viability of both cell lines on exposure to androgen.

A new predictive model for adverse outcomes after elective thoracoabdominal aortic aneurysm repair

BACKGROUND

Recent recommendations have emphasized individualized treatment based on balancing a patient's risk of thoracoabdominal aortic aneurysm rupture with the risk of an adverse outcome after surgical repair. The purpose of this study was to determine which preoperative risk factors currently predict an adverse outcome after elective thoracoabdominal aortic aneurysm repair.

METHODS

A single, composite end point termed adverse outcome was defined as the occurrence of any of the following: death within 30 days, death before discharge from the hospital, paraplegia, paraparesis, stroke, or acute renal failure requiring dialysis. A risk factor analysis was performed using data from 1,108 consecutive elective thoracoabdominal aortic aneurysm repairs.

RESULTS

The incidence of an adverse outcome was 13.0% (144 of 1,108 patients); predictors included preoperative renal insufficiency (p = 0.0001), increasing age (p = 0.0035), symptomatic aneurysms (p = 0.020), and extent II aneurysms (p = 0.0001). These risk factors were used to construct an equation that estimates the probability of an adverse outcome for an individual patient.

CONCLUSIONS

This new predictive model may assist in decisions regarding elective thoracoabdominal aortic aneurysm operations. For patients who are acceptable candidates, contemporary surgical management provides favorable results.

Treatment of metastatic breast cancer with somatostatin analogues--a meta-analysis

BACKGROUND

Somatostatin analogues appear to have antiproliferative effects in breast cancer by inhibiting various hormones. Several small phase 1 and 2 clinical trails have evaluated the efficacy of somatostatin analogues, but the results are varied. The purpose of this study was to use the technique of meta-analysis to determine the effect of somatostatin analogues on tumor response, toxicity, and serum hormone levels in women with metastatic breast cancer.

METHODS

All published and unpublished trials were reviewed. Meta-analysis was preformed by best linear unbiased estimate regression with observations weighted inversely to their variance. Significance was considered at P < .05.

RESULTS

Fourteen studies (N = 210) were included. Positive tumor response was reported in 87 patients (41.4%). Mean duration of response was 3.9 months. Response was best when somatostatin analogues were given as first-line therapy (69.5% versus 28.5%, P < .006) and in patients with < or =2 metastases (45.0% versus 5.6%, P = .3). Mild side effects occurred in 47 of 185 patients (25.4%). Therapy was associated with a decrease in serum insulin-like growth factor (IGF-1) and an increase in growth hormone.

CONCLUSIONS

In patients with metastatic breast cancer, treatment with somatostatin analogues was associated with a tumor response of over 40% with few side effects. Best results were achieved when somatostatin analogues were given as first-line therapy.

The neuronal adaptor protein X11alpha interacts with the copper chaperone for SOD1 and regulates SOD1 activity

The neuronal adaptor protein X11alpha participates in the formation of multiprotein complexes and intracellular trafficking. It contains a series of discrete protein-protein interaction domains including two contiguous C-terminal PDZ domains. We used the yeast two-hybrid system to screen for proteins that interact with the PDZ domains of human X11alpha, and we isolated a clone encoding domains II and III of the copper chaperone for Cu,Zn-superoxide dismutase-1 (CCS). The X11alpha/CCS interaction was confirmed in coimmunoprecipitation studies plus glutathione S-transferase fusion protein pull-down assays and was shown to be mediated via PDZ2 of X11alpha and a sequence within the carboxyl terminus of domain III of CCS. CCS delivers the copper cofactor to the antioxidant superoxide dismutase-1 (SOD1) enzyme and is required for its activity. Overexpression of X11alpha inhibited SOD1 activity in transfected Chinese hamster ovary cells which suggests that X11alpha binding to CCS is inhibitory to SOD1 activation. X11alpha also interacts with another copper-binding protein found in neurons, the Alzheimer's disease amyloid precursor protein. Thus, X11alpha may participate in copper homeostasis within neurons.

Three different human tau isoforms and rat neurofilament light, middle and heavy chain proteins are cellular substrates for transglutaminase

Abnormal aggregates of tau and neurofilaments are pathologies of Alzheimer's disease. Some of these aggregates are insoluble in chaotropic salts and ionic detergents but the mechanisms that lead to this are not clear. One suggestion is that it is due to crosslinking by tissue transglutaminase. Both tau and neurofilaments can be crosslinked by transglutaminase in vitro and one isoform of tau is now known to be a cellular transglutaminase substrate. However there is no evidence to demonstrate that neurofilaments are cellular substrates for transglutaminase and it is not clear whether other isoforms of tau are equally susceptible to transglutaminase crosslinking. Here, we demonstrate that three different tau isoforms and neurofilament light, middle and heavy chain proteins are all cellular substrates for transglutaminase.

Phosphorylation of thr(668) in the cytoplasmic domain of the Alzheimer's disease amyloid precursor protein by stress-activated protein kinase 1b (Jun N-terminal kinase-3)

Threonine(668) (thr(668)) within the carboxy-terminus of the Alzheimer's disease amyloid precursor protein (APP) is a known in vivo phosphorylation site. Phosphorylation of APPthr(668) is believed to regulate APP function and metabolism. Thr(668) precedes a proline, which suggests that it is targeted for phosphorylation by proline-directed kinase(s). We have investigated the ability of four major neuronally active proline-directed kinases, cyclin dependent protein kinase-5, glycogen synthase kinase-3 beta, p42 mitogen-activated protein kinase and stress-activated protein kinase-1b, to phosphorylate APPthr(668) and report here that SAPK1b induces robust phosphorylation of this site both in vitro and in vivo. This finding provides a molecular framework to link cellular stresses with APP metabolism in both normal and disease states.

p35/cdk5 binds and phosphorylates beta-catenin and regulates beta-catenin/presenilin-1 interaction

The neuronal cyclin-dependent kinase p35/cdk5 comprises a catalytic subunit (cdk5) and an activator subunit (p35). To identify novel p35/cdk5 substrates, we utilized the yeast two-hybrid system to screen for human p35 binding partners. From one such screen, we identified beta-catenin as an interacting protein. Confirmation that p35 binds to beta-catenin was obtained by using glutathione S-transferase (GST)-beta-catenin fusion proteins that interacted with both endogenous and transfected p35, and by showing that beta-catenin was present in p35 immunoprecipitates. p35 and beta-catenin also displayed overlapping subcellular distribution patterns in cells including neurons. Finally, we demonstrated that p35/cdk5 phosphorylates beta-catenin. beta-catenin also binds to presenilin-1 and altered beta-catenin/presenilin-1 interactions may be mechanistic in Alzheimer's disease (AD). Abnormal p35/cdk5 activity has also been suggested to contribute to AD. We therefore investigated how modulation of p35/cdk5 activity influenced beta-catenin/presenilin-1 interactions. Inhibition of p35/cdk5 with roscovitine did not alter the steady state levels of either beta-catenin or presenilin-1 but reduced the amount of presenilin-1 bound to beta-catenin. Thus, p35/cdk5 binds and phosphorylates beta-catenin and regulates its binding to presenilin-1. The findings reported here therefore provide a novel molecular framework to connect p35/cdk5 with beta-catenin and presenilin-1 in AD.

Molecular cloning and expression analysis of human glycogen synthase kinase-3 alpha promoter

Human glycogen synthase kinase-3 alpha (GSK-3 alpha) is a serine/threonine kinase that phosphorylates a variety of cytoplasmic and nuclear proteins. It also phosphorylates components of the neuronal cytoskeleton including tau and neurofilament heavy chain. Hyperphosphorylated tau is found in neurofibrillary tangles, a hallmark of Alzheimer's disease and aberrant phosphorylation of neurofilament heavy chain is observed in motor neuron disease. Alterations in GSK-3 alpha activity may therefore contribute to the disease process in these disorders. As a first step to understand the transcriptional regulation of GSK-3 alpha, a 2-kb (p-1751/+243) DNA fragment upstream of the GSK-3 alpha initiation codon was obtained from a YAC clone and characterised. Using primer extension assays, a putative transcriptional start site was located to a G nucleotide 244 bp upstream of the ATG codon. Several transcription factor-binding sites were identified on the promoter region, but no TATA-like element was located close to the start site. Deletion mutants of the 2-kb DNA fragment were generated and fused to a promoterless chloramphenicol acetyltransferase (CAT) gene. Transfection study in a neuroblastoma cell line revealed the 1-kb (p-719/+243) fragment carried strong promoter activity, while the 2-kb construct that contains an Alu-like sequence was only 50% active.

Delayed onset of neurologic deficit: significance and management

As contemporary adjuncts have substantially reduced the overall incidence of paraplegia and paraparesis after the surgical repair of thoracoabdominal aortic aneurysm, delayed-onset neurologic deficit has emerged as a significant clinical entity. It is generally agreed that neurologic deficits are attributable to the duration of spinal cord ischemia sustained during aortic cross-clamping. Factors known to increase the risk of spinal cord injury include the aneurysm extent, aortic cross-clamp time, aneurysm rupture, and associated acute aortic dissection. Clinically and experimentally, studies have shown different adjuncts to improve spinal cord protection, providing further insights into the pathophysiology of spinal cord ischemia. However, the pathophysiology of delayed-onset spinal cord deficit after thoracoabdominal aortic aneurysm repair remains largely controversial. This review discusses the significance and management of delayed-onset neurologic deficit.

Fe65 and X11beta co-localize with and compete for binding to the amyloid precursor protein

The Fe65s and X11s are two families of adaptor proteins that bind to the Alzheimer's disease amyloid precursor protein (APP). Although both the X11s and Fe65s bind to similar regions of APP, they have opposing effects on Abeta production and hence may represent novel therapeutic targets. However, there is no evidence that the Fe65s and X11s are present within the same cell type or cell compartment and are thus capable of competing for binding to APP. Here we show that in neurones and transfected cells, APP, Fe65 and X11beta show overlapping subcellular distributions. Furthermore, we demonstrate that Fe65 and X11beta compete for binding to APP.

X11 alpha and x11 beta interact with presenilin-1 via their PDZ domains

X11 alpha and X11 beta are two neuronal adaptor proteins that interact with the Alzheimer's disease amyloid precursor protein (APP). X11 alpha and X11 beta stabilise APP and inhibit production of proteolytic APP fragments including the A beta peptide that is deposited in the brains of Alzheimer's disease patients. The mechanisms by which X11 alpha and X11 beta modulate APP processing are not clear but one possibility is that they influence the activity of the secretases that cleave APP to give rise to A beta. Presenilin-1 is required for gamma-secretase activity and here we demonstrate that both X11 alpha and X11 beta interact with presenilin-1. X11/presenilin-1 binding is via two X11 PDZ domains and sequences within the carboxy-terminus of presenilin-1. We also demonstrate that both X11 alpha and X11 beta mediate the formation of complexes between APP and presenilin-1. These results suggest that the X11 regulation of APP processing is controlled, at least in part, via their interactions with APP and presenilin-1.

Significance of lipoxygenase-derived monohydroxy fatty acids in cutaneous biology

The skin displays a highly active metabolism of polyunsaturated fatty acids (PUFA). Dietary deficiency of linoleic acid (LA), an 18-carbon (n-6) PUFA, results in characteristic scaly skin disorder and excessive epidermal water loss. Although arachidonic acid (AA), a 20-carbon (n-6) PUFA, is metabolized via cyclooxygenase pathway into predominantly prostaglandin E2 (PGE2) and PGF2alpha. The 15-lipoygenase is very active in this tissue and catalyzes the transformation of 20-carbon AA into predominantly 15-hydroxyeicosatetraenoic acid (15-HETE). Similarly, the epidermal 15-lipoxygenase also catalyzes the transformation of 18-carbon LA and 20-carbon dihomo-gamma-linolenic acid (DGLA) to 13-hydroxyoctadecadienoic acid (13-HODE) and 15-hydroxyeicosatrienoic acid (15-HETrE), respectively. The monohydroxy fatty acids are incorporated in phospholipids which undergo catalysis to yield substituted-diacylglycerols (13-HODE-DAG) and 15-HETrE-DAG) which exert anti-inflammatory/antiproliferative effects on the skin.

Chest radiograph heterogeneity predicts functional improvement with volume reduction surgery

BACKGROUND

Using a historical cohort study model, we tested the hypothesis that heterogeneity of emphysematous changes on the preoperative chest radiograph correlated with favorable outcome of lung volume reduction surgery.

METHODS

The test population consisted of 21 patients with severe emphysema who were being treated at a 1,000-bed university-affiliated tertiary teaching hospital. A simple but quantitative index of heterogeneity has been devised, whereby the preoperative posteroanterior chest radiographic lung fields are divided into four geometric quadrants. Each quadrant is scored (0 to 4) for emphysematous changes by two radiologists blinded as to subsequent patient management and outcome. Criteria for determining presence of emphysema were hyperlucency, decreased vascular markings, and parenchymal crowding indicating compressed lung. Heterogeneity index is the sum of the two highest scores minus the two lowest, with a maximum index of 8 and a minimum of 0. Preoperative chest radiographs and postoperative changes in forced expiratory volume in 1 second were examined.

RESULTS

The heterogeneity index was positively correlated with change in forced expiratory volume in 1 second after operation with an r2 of 0.31 and an average increase of 117 mL per unit increase in heterogeneity index (p < 0.009).

CONCLUSIONS

This simple index of heterogeneity may be useful as a predictor of improved pulmonary function after lung volume reduction surgery.

Glutamate slows axonal transport of neurofilaments in transfected neurons

Neurofilaments are transported through axons by slow axonal transport. Abnormal accumulations of neurofilaments are seen in several neurodegenerative diseases, and this suggests that neurofilament transport is defective. Excitotoxic mechanisms involving glutamate are believed to be part of the pathogenic process in some neurodegenerative diseases, but there is currently little evidence to link glutamate with neurofilament transport. We have used a novel technique involving transfection of the green fluorescent protein-tagged neurofilament middle chain to measure neurofilament transport in cultured neurons. Treatment of the cells with glutamate induces a slowing of neurofilament transport. Phosphorylation of the side-arm domains of neurofilaments has been associated with a slowing of neurofilament transport, and we show that glutamate causes increased phosphorylation of these domains in cell bodies. We also show that glutamate activates members of the mitogen-activated protein kinase family, and that these kinases will phosphorylate neurofilament side-arm domains. These results provide a molecular framework to link glutamate excitotoxicity with neurofilament accumulation seen in some neurodegenerative diseases.

The efficacy of thyroidectomy for Graves' disease: A meta-analysis

BACKGROUND

Surgery for Graves' disease was largely replaced in the mid-1900s by radioiodine and antithyroid drugs, due to the belief that they were more safe and effective. Since then, thyroid surgery has improved with preoperative drug therapy and modern operative techniques. Recent clinical studies of thyroidectomy for Graves' disease may not reflect outcomes accurately because of small sample size, especially when estimating ideal thyroid remnant size. The purpose of this study was to combine modern clinical trials and use meta-analysis to determine the overall efficacy of both total (TT) and subtotal thyroidectomy (ST) for Graves' disease, compare thyroid function and complications rates of TT and ST, and determine ideal thyroid remnant size.

METHODS

Meta-analysis was performed on published studies in which patients underwent either TT or ST for Graves' disease. Meta-analysis was performed by weighted least-squares linear regression. P < 0.05 was considered significant.

RESULTS

There were 35 studies comprising 7241 patients. Mean follow-up was 5.6 years. Overall, persistent or recurrent hyperthyroidism occurred in 7.2% of patients. TT was performed on 538 patients and hypothyroidism occurred in all cases. ST was performed in 6703 patients, 59.7% of whom achieved euthyroidism, 25. 6% became hypothyroid, and 7.9% had either persistent or recurrent hyperthyroidism. Permanent recurrent laryngeal nerve injury occurred in 0.9% of TT patients and 0.7% of ST patients (P = NS). Permanent hypoparathyroidism occurred in 1.6% of TT patients and 1.0% of ST patients (P = NS). There was an 8.9% decrease in hypothyroidism and 6.9% increase in euthyroidism for each gram of thyroid remnant (P < 0.0001 each).

CONCLUSIONS

Overall, thyroidectomy successfully treated hyperthyroidism in 92% of patients with Graves' disease. There were no cases of hyperthyroidism following TT. ST achieved a euthyroid state in almost 60% of patients with an 8% rate of persistent or recurrent hyperthyroidism. There was no significant difference in complication rates between TT and ST.

Bilateral internal thoracic artery operations in the elderly

BACKGROUND

Elderly surgical patients have higher operative morbidity and mortality than younger cohorts, particularly when the procedure is lengthy and complex. While use of bilateral internal thoracic arteries (BITA) is often associated with increased surgical risk, we nevertheless hypothesized that the use of BITA in elderly coronary artery bypass patients would not significantly increase their operative risk beyond that encountered using single internal thoracic arterial (SITA) or saphenous vein grafts (SVG). We maintained that arterial grafts remain essentially unaffected by arteriosclerosis, and that extension of a high-quality life is a desirable outcome regardless of age at operation.

METHODS

EXPERIMENTAL DESIGN

We studied myocardial revascularization in 673 patients over 65 years of age at the time of operation. All operations were conducted or supervised by a single surgeon during a ten-year period from January 1986 to January 1996. Preoperative and operative dates were recorded prospectively.

SETTING

All patients underwent coronary artery bypass grafting.

INTERVENTIONS

The study compared outcomes in patients having all veins, SITA or BITA operations. For the first analysis, 673 patients were divided into three groups: 163 patients (Group 1) had saphenous vein used for all bypasses; 338 patients had a SITA with supplemental vein grafts (Group 2); and 172 patients (Group 3) had BITAs with additional vein grafts as needed. In the second analysis, Group 3 was subdivided and grouped by the coronary arteries which received the ITA grafts, and the analysis was repeated. One hundred and sixteen patients (Group 3A) underwent traditional placement of ITA bypasses (left ITA to the LAD, right ITA to the RCA); in Group 3B, 56 patients received revascularization of branches of the left coronary artery (left ITA to the circumflex system, right ITA to the LAD).

MEASURES

We communicated directly with 90.5% of the patients, their families, or their physicians. The survival status of the remainder was determined through the National Social Security Death Index Network. This allowed us to obtain follow-up longevity data for 100% of the study sample at a mean observation period of 5.03+/-3.1 years with variation between 10.8 years to 2.4 years.

RESULTS

A multivariate analysis showed that placement of both ITA grafts to left-sided arteries in older patients independently improved long-term survival (p=0.031).

CONCLUSIONS

The BITA procedure does not have greater operative morbidity or mortality in the elderly despite the length or complexity of the surgery. To realize improved long-term survival rates, however, both ITAs must be grafted to the left coronary artery branches.

Reversal of twice-delayed neurologic deficits with cerebrospinal fluid drainage after thoracoabdominal aneurysm repair: a case report and plea for a national database collection

Delayed neurologic deficits are an uncommon yet devastating complication of thoracoabdominal aortic aneurysm repair. The mechanisms involved in the development of delayed spinal cord ischemia remain ill defined. We report a case of complete reversal of delayed neurologic deficits with postoperative cerebrospinal fluid (CSF) drainage. After a thoracoabdominal aneurysm extent I repair, the patient experienced delayed paraplegia at 6 hours and again at 34 hours after the operation, with elevated CSF pressure (>10 mm Hg) on both occasions. Prompt CSF decompression completely reversed the neurologic deficits within hours after onset. The findings in this case further support the role of CSF drainage in spinal cord protection for patients who undergo thoracoabdominal aneurysm repair and make a plea for a national database collection.

Phosphorylation of neurofilament heavy chain side-arms by stress activated protein kinase-1b/Jun N-terminal kinase-3

Neurofilaments comprise three subunit proteins; neurofilament light, middle and heavy chains (NF-L, NF-M and NF-H). The carboxy-terminal domains of NF-M and NF-H form side-arms that project from the filament and that of NF-H contains multiple repeats of the motif lys-ser-pro, the serines of which are targets for phosphorylation. The level of phosphorylation on the lys-ser-pro repeats varies topographically within the cell; in cell bodies and proximal axons, the side-arms are largely non-phosphorylated whereas in more distal regions of axons, the side-arms are heavily phosphorylated. Here we show that stress activated protein kinase 1b (SAPK1b), a major SAPK in neurones will phosphorylate NF-H side-arms both in vitro and in transfected cells. These studies suggest that SAPK1b targets multiple phosphorylation sites within NF-H side-arms. Additionally, we show that glutamate treatment induces activation of SAPK1b in primary cortical neurones and increased phosphorylation of NF-H in cell bodies. This suggests that glutamate causes increased NF-H phosphorylation at least in part by activation of stress activated protein kinases.

Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis

BACKGROUND

Recent recommendations regarding thoracoabdominal aortic aneurysm (TAAA) management have emphasized individualized treatment based on balancing a patient's calculated risk of rupture with their anticipated risk of postoperative death or paraplegia. The purpose of this study was to enhance this risk-benefit decision by providing contemporary results and determining which preoperative risk factors currently predict mortality and paraplegia after TAAA surgery.

METHODS

Risk factor analyses based on data regarding 1,220 consecutive patients undergoing TAAA repair from 1986 through 1998 were performed using multiple logistic regression with step-wise model selection.

RESULTS

The 30-day mortality rate was 4.8% (58 of 1,220) and the incidence of paraplegia was 4.6% (56 of 1,206). For elective cases, predictors of operative mortality included renal insufficiency (p = 0.0001), increasing age (p = 0.0005), symptomatic aneurysms (p = 0.0059), and extent II aneurysms (p = 0.0054). Extent II aneurysms (p = 0.0023) and diabetes (p = 0.0402) were predictors of paraplegia.

CONCLUSIONS

These risk models may assist in decisions regarding elective TAAA operations. For patients who are acceptable candidates, contemporary surgical management provides favorable results.

Metabolism of polyunsaturated fatty acids by skin epidermal enzymes: generation of antiinflammatory and antiproliferative metabolites

In the skin epidermis, the metabolism of polyunsaturated fatty acids (PUFAs) is highly active. Dietary deficiency of linoleic acid (LA), the major 18-carbon n-6 PUFA in normal epidermis, results in a characteristic scaly skin disorder and excessive epidermal water loss. Because of the inability of normal skin epidermis to desaturate LA to gamma-linolenic acid, it is transformed by epidermal 15-lipoxygenase to mainly 13-hydroxyoctadecadienoic acid, which functionally exerts antiproliferative properties in the tissue. In contrast, compared with LA, arachidonic acid (AA) is a relatively minor 20-carbon n-6 PUFA in the skin and is metabolized via the cyclooxygenase pathway, predominantly to the prostaglandins E(2), F(2)(alpha), and D(2). AA is also metabolized via the 15-lipoxygenase pathway, predominantly to 15-hydroxyeicosatetraenoic acid. At low concentrations, the prostaglandins function to modulate normal skin physiologic processes, whereas at high concentrations they induce inflammatory processes. PUFAs derived from other dietary oils are also transformed mainly into monohydroxy fatty acids. For instance, epidermal 15-lipoxygenase transforms dihomo-gamma-linolenic acid (20:3n-6) to 15-hydroxyeicosatrienoic acid, eicosapentaenoic acid (20:5n-3) to 15-hydroxyeicosapentaenoic acid, and docosahexaenoic acid (22:6n-3) to 17-hydroxydocosahexaenoic acid, respectively. These monohydroxy acids exhibit antiinflammatory properties in vitro. Thus, supplementation of diets with appropriate purified vegetable oils, fish oil, or both may generate local cutaneous antiinflammatory and antiproliferative metabolites which could serve as less toxic in vivo monotherapies or as adjuncts to standard therapeutic regimens for the management of inflammatory skin disorders.

Polyglutamine repeat length influences human androgen receptor/c-Jun mediated transcription

The androgen receptor and c-Jun are known to interact to modulate each others transcriptional activities. The androgen receptor contains a polymorphic polyglutamine repeat and expansion of this repeat to beyond approximately 40 causes spinobulbar muscular atrophy (SBMA; also known as Kennedy's disease), a genetic form of motor neurone disease. Here we show that the size of this polyglutamine tract influences both c-Jun regulation of androgen receptor-mediated transcription and androgen receptor regulation of c-Jun activity. c-Jun is a key mediator of neuronal survival and death by apoptosis. Inappropriate interactions between c-Jun and androgen receptors containing pathological length glutamine repeats may therefore be part of the pathogenic process in SBMA.

Low use of breast conservation surgery in medically indigent populations

BACKGROUND

Breast conservation surgery (BCS) with radiation is an acceptable treatment for early-stage breast cancer.

METHODS

Data were obtained from hospital cancer registries on women surgically treated for Stage 0 to II breast cancer from 1993 to 1997. Data on 1,747 patients were analyzed for surgical treatment, hospital type (private versus public), disease stage, and ethnic origin.

RESULTS

In this study, 34% of women received BCS. Women treated in private hospitals received BCS more often than women treated in public hospitals. Women with stage II disease received BCS less often than women with earlier stage disease. Hospital type (public versus private) and disease stage were strong, independent predictors for use of BCS. When hospital type and disease stage were statistically controlled, no treatment differences across ethnic groups were identified.

CONCLUSIONS

Use of BCS in this study was low compared with National Cancer Database statistics. Women treated in publicly funded hospitals and those with stage II disease were significantly less likely to receive BCS.

Progress in the management of type I thoracoabdominal and descending thoracic aortic aneurysms

We reviewed our categorization of patients at high risk for neurologic complications in the repair of descending thoracic and thoracoabdominal aortic aneurysm in which we used cerebrospinal fluid drainage and distal aortic perfusion (adjuncts). A total of 409 patients were operated on by one surgeon for descending thoracic or thoracoabdominal aortic aneurysm between 1992 and 1997. Of these patients, 232 had total descending thoracic or type I thoracoabdominal aortic aneurysm, 131 (56%) of whom were operated on with adjuncts. These patients were compared to 101 nonadjunct patients for demographic variables, intraoperative variables, blood product consumption, and neurologic status. In 131 consecutive patients with adjuncts, all but one awoke from anesthesia without neurologic deficit. In nonadjunct patients, however, neurologic deficit occurred in 6 of 101 (6%) (p < 0.003). The adjunct group had more preoperative renal insufficiency (p < 0.05), an established risk factor for neurologic deficit (odds ratio = 2.2 in published studies). All other risk factors for neurologic deficit occurred with comparable frequency in both groups. We conclude that the introduction of adjuncts has dramatically reduced the neurologic risk associated with type I thoracoabdominal or total descending thoracic aortic repair. Previously considered high risk for neurologic complications, these aneurysms can now be reclassified as low risk in surgery accompanied by adjuncts. Future investigations will focus on type II thoracoabdominal aortic aneurysm as the major source of neurologic morbidity.

Molecular cloning and characterization of the human glycogen synthase kinase-3beta promoter

Glycogen synthase kinase 3beta (GSK-3beta) is a proline-directed kinase that forms part of the wingless signaling pathway. Recent studies have shown that GSK-3beta phosphorylates the microtubule-associated protein tau in vitro and in cell culture. Tau is the principal component of the paired helical filaments (PHFs) found in the brains of patients with Alzheimer disease, and PHF-tau is hyperphosphorylated. GSK-3beta is therefore one of the candidate kinases for phosphorylating tau in Alzheimer disease. GSK-3beta activity is negatively regulated by phosphorylation on serine 9 and positively regulated by phosphorylation on tyrosine 216. However, since overexpression of GSK-3beta by transfection leads to increased activity in the absence of any stimuli, GSK-3beta activity may also be regulated at the transcriptional level. Indeed, increased GSK-3beta protein levels are found in Alzheimer disease brains, and GSK-3beta is found associated with PHFs in Alzheimer disease. To understand how GSK-3beta activity may be regulated at the transcriptional level, we have isolated the human GSK-3beta promoter. The GSK-3beta promoter does not contain a conventional TATA box although several other transcription factor binding sites were identified. A putative transcription start site was mapped by 5' RACE. Transfection of various GSK-3beta promoter CAT reporter genes into both COS-7 cells and SHSY5Y neuronal cells revealed that the GSK-3beta promoter is more active in neuronal cells. Such transfection studies involving promoter deletion mutants revealed that a negative transcriptional response element may be present at position -1421 to -1363 and an activator sequence at position -427 to -384. CP2 binding sites were also present within the promoter. CP2 has recently been shown to interact with the Alzheimer disease amyloid precursor protein binding protein Fe65. The significance of these results with respect to Alzheimer disease pathogenesis are discussed.

Hypoxia-inducible factor-1alpha mediates hypoxia-induced delayed neuronal death that involves p53

Hypoxia-induced delayed neuronal death is known to require de novo gene expression; however, the molecular mediators that are involved remain undefined. The transcription factor hypoxia-inducible factor-1alpha (HIF-1alpha), in addition to promoting the expression of adaptive genes under conditions of hypoxia, has been implicated as being a necessary component in p53-mediated cell death in tumors. Using herpes amplicon-mediated gene transfer in cortical neuronal cultures, we demonstrate that delivery of a dominant-negative form of HIF-1alpha (HIFdn), capable of disrupting hypoxia-dependent transcription, reduces delayed neuronal death that follows hypoxic stress. In contrast, hypoxia-resistant p53-null primary cultures are not protected by HIFdn expression. These data indicate that, in hypoxic neurons, HIF-1alpha and p53 conspire to promote a pathological sequence resulting in cell death.

Expression analysis of glycogen synthase kinase-3 in human tissues

Human glycogen synthase kinase-3 (GSK-3) is a multisubstrate, proline-directed kinase that phosphorylates tau, beta-amyloid and neurofilaments. In this study, the expression levels of the two GSK-3 isoforms, alpha and beta, RNA and proteins in different human tissues were examined. Northern analysis demonstrated that GSK-3alpha is encoded by a 2.6-kb mRNA and GSK-3beta by 8.3- and 2.8-kb mRNAs. The two GSK-3beta mRNA species were variably expressed in different tissues. Northern and quantitative polymerase chain reaction demonstrated that both GSK-3alpha and GSK-3beta mRNA were prominently expressed in testis, thymus, prostate and ovary but were low in adult lung and kidney. Western blot analysis showed that the 51-kDa GSK-3alpha protein was highly expressed in lung, ovary, kidney and testis, whereas the 46-kDa GSK-3beta protein was highly expressed in lung, kidney and brain. The differential expression of GSK-3alpha and GSK-3beta mRNA and proteins and the lack of relationship between transcription and translation in some tissues indicate that GSK-3alpha and GSK-3beta are subject to different means of regulation.

Cyclin dependent kinase-5 (CDK-5) phosphorylates neurofilament heavy (NF-H) chain to generate epitopes for antibodies that label neurofilament accumulations in amyotrophic lateral sclerosis (ALS) and is present in affected motor neurones in ALS

1. Accumulations of phosphorylated neurofilaments are seen in affected motor neurones in amyotrophic lateral sclerosis (ALS). 2. The authors demonstrate that cyclin dependent kinase-5 (cdk-5) will induce cellular phosphorylation of neurofilament heavy chain side-arms to generate epitopes for several antibodies that label these neurofilament accumulations. 3. By creating recombinant neurofilament fragments of NF-H side-arm domains, the authors also map the epitopes for several of these antibodies. 4. Finally, the authors demonstrate that cdk-5 is also present in affected motor neurones in ALS. These studies implicate cdk-5 in the pathogenesis of ALS.

Mint2/X11-like colocalizes with the Alzheimer's disease amyloid precursor protein and is associated with neuritic plaques in Alzheimer's disease

Aberrant metabolism of the amyloid precursor protein (APP) is believed to be at least part of the pathogenic process in Alzheimer's disease. The carboxy-terminus of APP has been shown to interact with the Mint/X11 family of phosphotyrosine binding (PTB) domain-bearing proteins. It is via their PTB domains that the Mints/X11s bind to APP. Here we report the cloning of full-length mouse Mint2 and demonstrate that in primary cortical neurons, Mint2 and APP share highly similar distributions. Mint2 also colocalizes with APP in transfected CHO cells. In Mint2/APP-cotransfected cells, Mint2 reorganizes the subcellular distribution of APP and also increases the steady-state levels of APP. Finally, we demonstrate that Mint2 is associated with the neuritic plaques found in Alzheimer's disease but not with neurofibrillary tangles. These results are consistent with a role for Mint2 in APP metabolism and trafficking, and suggest a possible role for the Mints/X11s in the pathogenesis of Alzheimer's disease.

Holmium:YAG laser transmyocardial revascularization relieves angina and improves functional status

BACKGROUND

Transmyocardial revascularization (TMR) surgery uses laser channeling of diseased myocardium to treat ischemia and angina. Rigorous prospective randomized studies have been previously unavailable.

METHODS

Forty-three patients were randomized to a medication group and 43 to a group scheduled for TMR surgery and medication. All had advanced cardiac ischemia with CCSA class 3 or 4 angina, took at least 2 cardiac medications at maximum doses, and were ineligible for angioplasty or bypass.

RESULTS

Forty-two of 43 TMR group patients received surgery and were discharged after hospitalizations averaging 3.2 days. Two suffered perioperative MIs, with one death. Four others died within 12 months of surgery, 3 from cardiac events and 1 from pneumonia. Five medical group patients died from cardiac events within 12 months. Three, 6, and 12 month exams showed angina class improvement in TMR patients compared to preoperative values (3.86 +/- 0.05 vs 1.71 +/- 0.2, P < 0.0001), and to controls at 12 months (3.77 +/- 0.07 vs 1.71 +/- 0.2, P < 0.0001). Exercise tolerance improved in TMR patients over preoperative values, and was better than medication group scores after 12 months (490 +/- 17 sec. vs 294 +/- 12 sec., p = 0.0002).

CONCLUSIONS

Holmium:YAG laser channeling of the myocardium improves function and reduces angina in advanced cardiac patients who lack alternative therapeutic options.