Cholesterol is required for secretion of very-low-density lipoprotein by rat liver

To study potential effects of hepatic cholesterol concentration on secretion of very-low-density lipoprotein (VLDL) by the liver, male rats were fed on unsupplemented chow, chow with lovastatin (0.1%), or chow with lovastatin (0.1%) and cholesterol (0.1%) for 1 week. Livers were isolated from these animals and perfused in vitro, with a medium containing [2-14C]acetate, bovine serum albumin and glucose in Krebs-Henseleit buffer, and with an oleate-albumin complex. With lovastatin feeding, the hepatic concentrations of cholesteryl esters and triacylglycerols before perfusion were decreased, although free cholesterol was unchanged. However, hepatic secretion of all the VLDL lipids was decreased dramatically by treatment with lovastatin. Although total secretion of VLDL triacylglycerol, phospholipid, cholesterol and cholesteryl esters was decreased, the decrease in triacylglycerol was greater than that in free cholesterol or cholesteryl esters, resulting in secretion of a VLDL particle enriched in sterols relative to triacylglycerol. In separate studies, the uptake of VLDL by livers from control animals or animals treated with lovastatin was measured. Uptake of VLDL was estimated by disappearance of VLDL labelled with [1-14C]oleate in the triacylglycerol moiety, and was observed to be similar in both groups. During perfusion, triacylglycerol accumulated to a greater extent in livers from lovastatin-fed rats than in control animals. The depressed output of VLDL triacylglycerols and the increase in triacylglycerol in the livers from lovastatin-treated animals was indicative of a limitation in the rate of VLDL secretion. Addition of cholesterol (either free cholesterol or human low-density lipoprotein) to the medium perfusing livers from lovastatin-fed rats, or addition of cholesterol to the diet of lovastatin-fed rats, increased the hepatic concentration of cholesteryl esters and the output of VLDL lipids. The concentration of cholesteryl esters in the liver was correlated with the secretion of VLDL by the liver. These data suggest that cholesterol is an obligate component of the VLDL required for its secretion. It is additionally suggested that cholesteryl esters are in rapid equilibrium with a small pool of free cholesterol which comprises a putative metabolic pool available and necessary for the formation and secretion of the VLDL. Furthermore, the specific radioactivity (d.p.m./mumol) of the secreted VLDL free cholesterol was much greater than that of hepatic free cholesterol, suggesting that the putative hepatic metabolic pool is only a minor fraction of total hepatic free cholesterol.

Keratoprosthesis: an update

Porous polytetrafluoroethylene and polyurethane skirt materials, as well as copolymers of poly (2-hydroxyethyl methacrylate), have shown promise in approaching the goal of a "biointegratable" keratoprosthesis. A novel fixation method that uses scleral haptics also has been introduced to increase stability. An all silicone device that can be sewn into position has been used successfully, temporarily, during vitreoretinal procedures. The prognosis of keratoprosthesis (KPro) procedures depends on the preoperative diagnosis: graft failure-noncicatrizing disease>ocular cicatricial pemphigoid>chemical burns>Stevens-Johnson syndrome. The likelihood of endophthalmitis after KPro surgery follows this scheme. Causative organisms tend to be gram-positive. Modified vitreoretinal techniques also have been developed, allowing successful treatment of posterior segment complications. The science of keratoprosthesis is advancing more rapidly than in previous years. However, use of KPro to address complicated corneal blindness worldwide remains limited. The authors conducted an English language literature review from January 1, 2000 to April 1, 2001 and describe advances of note in the field of keratoprosthesis design, materials, and medical and surgical management.

Antiplasmodial activity of four Kenyan medicinal plants

A preliminary antiplasmodial and phytochemical screening of four Kenyan medicinal plants was carried out. The medicinal plants were extracted and tested for in vitro antiplasmodial activity against chloroquine-sensitive (K67) and chloroquine-resistant (ENT36) strains of Plasmodium falciparum. Out of 16 extracts, 12 were active against ENT36 strain while seven were active against K67 strain, that is, IC50 < or = 50 micrograms/ml. The most active extracts on both strains were those of leaves of Phyllanthus reticulatus Poir, and Suregada zanzibariensis Baill. (Euphorbiaceae) with IC50 < or = 10 micrograms/ml. The stembark of Terminalia spinosa Engl. (Combretaceae) and the stems of Dissotis brazzae Cogn. (Melastomataceae) had IC50 < or = 10 micrograms/ml for strains K67 and ENT36, respectively. A preliminary phytochemical analysis of these plants revealed the presence of different classes of primary and secondary metabolites.

One- to ten-year follow-up results of balloon angioplasty of native coarctation of the aorta in adolescents and adults

OBJECTIVES

We attempted to evaluate the role of balloon angioplasty in the treatment of discrete coarctation of the aorta in adolescents and adults, with special emphasis on long-term results.

BACKGROUND

Controversy persists over the use of balloon dilation for the treatment of native coarctation of the aorta.

METHODS

Between July 1986 and January 1997, 43 consecutive adolescent and adult patients with discrete coarctation of the aorta underwent balloon angioplasty. One- to 10-year follow-up data of 37 patients, including results of cardiac catheterization and magnetic resonance imaging (MRI), form the basis of this study.

RESULTS

No early or late deaths occurred. Balloon angioplasty produced a reduction in the peak to peak coarctation gradient from a mean +/- SD of 69 +/- 24 mm Hg (95% confidence interval [CI] 61 to 76) to 12 +/- 8 mm Hg (95% CI 10 to 14.8) (p < 0.001). Follow-up catheterization 12 months later (37 patients) revealed a residual gradient of 6.7 +/- 6 mm Hg (95% CI 4.6 to 8.9); 3 (7%) of 43 patients had suboptimal results with development of recoarctation, defined as peak gradient >20 mm Hg, with successful repeat angioplasty. A small aneurysm developed at the site of dilation in 3 (7%) of the 43 patients. MRI follow-up data 1 to 10.8 years (mean 5.2 +/- 2.7) after angioplasty (37 patients) revealed no new aneurysm or appreciable change in the size of the preexisting aneurysm in the three patients. The blood pressure had normalized without medication in 27 (73%) of 37 patients at follow-up examination.

CONCLUSIONS

Balloon angioplasty is safe and effective and should be considered a viable alternative to operation for treatment of discrete coarctation of the aorta in adolescents and adults.

A multi-center study in order to further define the molecular basis of beta-thalassemia in Thailand, Pakistan, Sri Lanka, Mauritius, Syria, and India, and to develop a simple molecular diagnostic strategy by amplification refractory mutation system-polymerase chain reaction

The spectrum of the beta-thalassemia mutations of Thailand, Pakistan, India, Sri Lanka, Mauritius and Syria has been further characterized by a multi-center study of 1,235 transfusion-dependent patients, and the mutations discovered used to assess the fidelity of a simple diagnostic strategy. A total of 44 beta-thalassemia mutations were identified either by allele-specific oligonucleotide hybridization, amplification with allele-specific primers, or DNA sequencing of amplified product. The results confirm and extend earlier findings for Thailand, Pakistan, India, Mauritius and Syria. This is the first detailed report of the spectrum of mutations for Sri Lanka. Two novel mutations were identified, codon 55 (-A) and IVS-I-129 (A-->C), both found in Sri Lankan patients. Two beta-thalassemia mutations were found to coexist in one beta-globin gene: Sri Lankan patients homozygous for the beta0 codon 16 (-C) frameshift were also homozygous for the beta+ codon 10 (C-->A) mutation. Studies of Sri Lankan, Pakistani, and Indian carriers suggest the codon 10 (C-->A) mutation is just a rare polymorphism on an ancestral allele, on which the beta0 codon 16 (-C) mutation has arisen. Each country was found to have only a few common mutations accounting for 70% or more of the beta-thalassemia alleles. A panel of primers to diagnose the majority of the mutations by the amplification refractory mutation system was developed, enabling a simple molecular diagnostic strategy to be introduced for each country participating in the multi-center study.

Evidence for two single copy units in Theileria parva ribosomal RNA genes

Bacteriophage clones containing ribosomal RNA genes of Theileria parva were isolated from genomic DNA libraries. Physical mapping studies revealed 2 ribosomal DNA units, which were distinguishable by restriction enzyme site polymorphisms in flanking sequences. The cloned ribosomal DNA units were mapped to 2 separate T. parva chromosomes. Analysis of sequences contained in lambda EMBL3 recombinants, together with Southern blot analysis of genomic DNA and data on the copy number of the rRNA genes, suggested that the rDNA units were not tandemly repeated. This organisation of ribosomal transcription units is similar to that described for other genera of apicomplexan protozoa, but 2 rDNA units, each containing single copies of the rRNA coding genes, would be the lowest copy number described for any eukaryote in which amplification of rRNA genes is not known to occur. EcoRI restriction fragment length polymorphisms, which were revealed using rRNA gene probes, separated T. parva stocks into 2 categories. Nucleotide sequence analysis of polymerase chain reaction-amplified internal transcribed spacer DNA revealed 2 different ITS sequences derived from rDNA transcription units within the genome of a cloned T. parva parasite. Polymorphism was also observed between ITS sequences amplified from the DNA of different T. parva stocks. A synthetic oligonucleotide derived from T. parva Uganda ribosomal ITS DNA sequences hybridised to DNA from the T. parva Uganda stock, but not to the DNA of the T. parva Muguga stock. This oligonucleotide is potentially useful as a marker for the T. parva Uganda stock.

Immediate and long-term effect of mitral balloon valvotomy on severe pulmonary hypertension in patients with mitral stenosis

The pulmonary vascular hemodynamics were studied in 21 patients with severe mitral stenosis and severe pulmonary hypertension. Hemodynamic data were obtained before and immediately after mitral balloon valvotomy (MBV) and at follow-up 7 to 14 months (mean 12 months) later by repeat catheterization. The mean pulmonary capillary wedge pressure (PCW) decreased from 27 +/- 5 to 15 +/- 4 mm Hg (p < 0.001). The mean mitral valve gradient (MVG) decreased from 18 +/- 4 to 6 +/- 2 mm Hg (p < 0.001). Mitral valve area (MVA) increased from 0.6 +/- 0.1 to 1.5 +/- 0.3 cm2 (p < 0.02). Cardiac index increased from 2.2 +/- 0.3 to 2.6 to 0.5 L/min/m2 (p < 0.02). The pulmonary artery systolic pressure decreased from 65 +/- 13 to 50 +/- 13 mm Hg (p < 0.001), and no significant change was seen in pulmonary vascular resistance (PVR) immediately after MBV from 461 +/- 149 to 401 +/- 227 dynes/sec/cm(-5) (p = 0.02). At follow-up the MVA increased from 1.5 +/- 0.3 to 1.7 +/- 0.3 cm2 (p < 0.02). Cardiac index increased further to 3 +/- 0.4 L/min/m2 (p < 0.02). MVG and PCW pressure remained the same. The pulmonary artery systolic pressure decreased further to 38 +/- 9 mm Hg (p < 0.02). PVR decreased significantly to 212 +/- 99 dynes/sec/cm(-5) (p < 0.02). We concluded that the pulmonary artery pressure decreased without normalizing immediately after MBV and normalized in patients with optimal results from mitral balloon valvotomy 7 to 14 months later. Insignificant change in PVR was seen immediately after MBV and markedly decreased or normalized at late follow-up in patients with optimal result from MBV.

Distinct phosphoisoforms of the Xenopus Mcm4 protein regulate the function of the Mcm complex

Initiation of DNA replication in eukaryotes requires the assembly of prereplication complexes (pre-Rcs) at the origins of replication. The assembly and function of the pre-Rcs appear to be controlled by phosphorylation events. In this study we report the detailed characterization of the cell cycle phosphorylation of one component of the Xenopus pre-Rcs, the Mcm protein complex. We show that individual Mcm subunits are differentially phosphorylated during the cell cycle. During mitosis, the Mcm4 subunit is hyperphosphorylated, while the other subunits are not actively phosphorylated. The mitotic phosphorylation of Mcm4 requires Cdc2-cyclin B and other unknown kinases. Following exit from mitosis, the Mcm4 subunit of the cytosolic interphase complex undergoes dephosphorylation, and the Mcm2, Mcm3, or Mcm6 subunits are then actively phosphorylated by kinase(s) other than cyclin-dependent kinases (Cdks) or Cdc7. The association of the Mcm complex with the pre-Rcs correlates with the formation of a transient interphase complex. This complex contains an intermediately phosphorylated Mcm4 subunit and is produced by partial dephosphorylation of the mitotic hyperphosphorylated Mcm4 protein. Complete dephosphorylation of the Mcm4 subunit inactivates the Mcm complex and prevents its binding to the chromatin. Once the Mcm complex is assembled on the chromatin the Mcm4 and the Mcm2 proteins are the only subunits phosphorylated during the activation of the pre-Rcs. These chromatin-associated phosphorylations require nuclear transport and are independent of Cdk2-cyclin E. These results suggest that the changes in Mcm4 phosphorylation regulate pre-Rc assembly and the function of the pre-Rcs on the chromatin.

Cultivation of Plasmodium falciparum parasites in a serum-free medium

The elimination of serum from Plasmodium falciparum culture media could decrease costs, enhance procurement, and improve the feasibility of large-scale production of parasite material. We provide a semi-defined, serum-free formulation, of commercially available constituents that supports P. falciparum parasite growth at rates comparable with those obtained with serum-supplemented media. The medium is composed of RPMI 1640 to which HEPES, extra glucose, bicarbonate, and hypoxanthine have been added. Bovine albumin and serum-derived, lipids-cholesterol-rich mixture are then used in place of serum.

Successful Lung Transplantation From Hepatitis C Positive Donor to Seronegative Recipient

Lung transplantation using RNA+ hepatitis C (HCV+) donors to seronegative recipients is not currently performed due to the very high risk of transmission. Previous reports have shown poor survival when this practice was applied. The emergence of new direct-acting antiviral drugs (DAA) suggests a high chance of sustained virologic response in immunocompetent patients. We report here successful transplantation of lungs from HCV+ donor to HCV- recipient. The recipient was an HCV- patient with chronic lung allograft dysfunction. Viral transmission occurred early posttransplant but excellent clinical outcomes were observed including elimination of HCV after 12 weeks of treatment using DAAs.

A comparison of amodiaquine and sulfadoxine-pyrimethamine as first-line treatment of falciparum malaria in Kenya

A randomized 14-day study in vivo compared the response of Plasmodium falciparum malaria to amodiaquine (35 mg/kg) and sulfadoxine-pyrimethamine (sulfadoxine, 25 mg/kg) in symptomatic outpatients at 2 sites in northern and western Kenya during 1993. Of the 239 patients recruited, 181 (76%) completed the study [84 (46%) on amodiaquine and 97 (54%) on sulfadoxine-pyrimethamine]. There were no significant differences in the parasitological, clinical or haematological responses between the 2 drug groups in both areas, with 18.5% resistance to amodiaquine versus 9.5% for sulfadoxine-pyrimethamine in the north and 35.1% against amodiaquine versus 34.5% for sulfadoxine-pyrimethamine in the west. In both sites defervescence was significantly more rapid with amodiaquine (P < 0.05) and true clinical failure (symptomatic illness with recurrent parasitaemia) was unusual (9%). As high-level resistance to chloroquine is widespread, both drugs are valuable alternatives. However, the significantly higher levels of resistance in the west may be a sign of the increased drug pressure in this holoendemic area and send an important warning concerning resistance to sulfadoxine-pyrimethamine.

Chest physiotherapy and post-extubation atelectasis in infants

We investigated the role of chest physiotherapy (CPT) in preventing post-extubation atelectasis (PEA) in infants. Sixty-three infants who were admitted to the neonatal intensive care unit and intubated for more than 24 hours and who showed no evidence of atelectasis by chest x-ray prior to extubation were enrolled in the study. Infants were randomly assigned to 2-hourly CPT, 4-hourly CPT, or a no CPT group. Chest physiotherapy began immediately after extubation and consisted of postural drainage, bilateral chest vibration, and suctioning. A second chest x-ray was obtained on all infants 24 hours following extubation. The three groups were comparable in birth weight, gestational age, and duration of intubation. In the 24-hour period following extubation, the incidence of PEA was not statistically significant in the three groups (P = 0.33). Two infants in the 2-hourly CPT group were placed on nasal continuous positive airway pressure; two in each of the 2-hourly and the no CPT groups required re-intubation and intermittent positive pressure ventilation to treat symptomatic atelectasis. We conclude that post extubation chest physiotherapy as used in this study did not prevent atelectasis in extubated infants.

Advantage of Inoue balloon catheter in mitral balloon valvotomy: experience with 220 consecutive patients

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon catheter was attempted in 220 consecutive patients with severe symptomatic mitral stenosis. Their age range was 10-63 mean 30 +/- 10 years; 161 patients were females and 59 were males; 29 patients were in atrial fibrillation. Eleven patients were pregnant; 14 patients underwent previous surgical commissurotomy. The procedure was technically successfully performed in 215 (97.7%) patients. The mean fluoroscopy time was 15.5 +/- 6.4 min and mean procedure time was 109 +/- 79 min. Optimal results (group I) was achieved in 207 patients who have mitral score of 7 +/- 1. PMV resulted in decrease in left atrial pressure from 23 +/- 5 to 14 +/- 4 mm Hg (P < 0.001), the mean mitral valve gradient (MVG) decreased from 15 +/- 4 to 6 +/- 3 mm Hg (P < 0.001). The mitral valve area (MVA) by catheter increased from 0.7 +/- 0.2 to 1.7 +/- 0.5 cm2 (P < 0.001) and MVA as determined by echocardiography (2DE) increased from 0.8 +/- 0.1 to 1.9 +/- 0.3 cm2 (P < 0.001). The results were suboptimal in eight patients who have a mitral score of 10 +/- 1 (group II) MVA by catheter increased from 0.7 +/- 0.2 to 1 +/- 0.1 cm2 and Doppler MVA increased from 0.8 +/- 0.1 to 1.3 +/- 0.1 cm2. There were no deaths or thromboembolism. Two patients developed cardiac tamponade; mild mitral regurgitation (MR) developed in 24 patients (11%) and increased by one grade in another 22 patients (10%). Severe MR was encountered in three patients (1.4%). A small ASD (QP/QS < or = 1.3) was detected by oximetry in 5% of patients and by color-flow mapping in 26% of patients. One hundred fifty-eight patients from group I were followed up, for a mean of 32 +/- 12 months; MVA remained at 1.7 +/- 0.4 cm2. Seven patients developed mitral restenosis in group I, and 5 out of 8 patients developed restenosis in group II. We conclude that the hemodynamic results are good and comparable with those reported with double balloon technique. However, the Inoue balloon has several advantages over the double balloon technique: (1) low incidence of mitral regurgitation and ASDs; (2) shorter procedure and fluoroscopy time; and (3) low complication rates and the valve anatomy affects the immediate and late outcome of mitral balloon valvotomy.

Gallbladder ascariasis: presentation and management

BACKGROUND

As many as 1.5 billion people around the world harbour Ascaris lumbricoides in the digestive tract. Gallbladder ascariasis, although less common than bile duct ascariasis, is quite often seen in endemic areas.

METHODS

Some 1300 patients with hepatobiliary ascariasis, admitted between October 1992 and June 1998, were analysed prospectively. The clinical features and outcome of 56 cases of gallbladder ascariasis are presented.

RESULTS

Forty-seven patients were diagnosed by ultrasonography and nine were diagnosed at laparotomy. Only ten patients diagnosed by ultrasonography expelled the worms spontaneously, with resolution of symptoms and signs. The remaining 37 patients underwent cholecystectomy.

CONCLUSION

Gallbladder ascariasis is a significant entity in endemic areas which usually requires cholecystectomy.

Antifolate drug resistance and point mutations in Plasmodium falciparum in Kenya

Due to increased chloroquine resistance, the antifolate/sulpha drug combinations are becoming increasingly important in the chemotherapy of falciparum malaria. However, point mutations in the dihydrofolate reductase gene lead to resistance to the antifolate drugs. We therefore investigated the prevalence of the 6 reported point mutations in this gene among field isolates of Plasmodium falciparum from Kenya, to determine if the mutations correlated with resistance to pyrimethamine and the biguanides cycloguanil and chlorcycloguanil. We used a mutation-specific polymerase chain reaction technique to test for these reported mutations in 21 Kenyan isolates and 4 reference lines. We also amplified and directly sequenced the dihydrofolate reductase coding sequence from these parasites to confirm the results and test for other possible mutations. Of the reported mutations, we found S108N, which is the central mutation of pyrimethamine resistance, and mutations N51I and C59R, which modulate the levels of resistance and may confer decreases in response to cycloguanil that are folate and p-aminobenzoic acid dependent. No isolate possessed the paired point mutations S108T and A16V, or I164L and S108N, which have been associated with cycloguanil resistance in previous studies. These results provided supportive evidence for the combined use of a cycloguanil-class drug (e.g., chlorproguanil) and a sulpha drug (e.g., dapsone) against P.falciparum malaria in Kenya.

Management of Brucella endocarditis with aortic root abscess

Three cases of Brucella endocarditis with aortic root abscess are reported. Two patients were successfully managed by a combination of medical therapy and surgery. The third patient died suddenly 36 hours after admission to hospital.

Long-term effects of balloon angioplasty on systemic hypertension in adolescent and adult patients with coarctation of the aorta

AIMS

To define the long-term effect of balloon angioplasty of aortic coarctation on hypertension, in adolescent and adult patients.

METHODS

Balloon angioplasty of discrete, native aortic coarctation was performed on 50 patients (34 male) aged 23+/-8 (mean+/-standard deviation) years. In 42 of these patients cardiac catheterization and angiography were repeated 1 year later, and on the basis of sphygmomanometric blood pressure determination at that time, they were divided into 31 patients (group A) with normalized blood pressure and 11 patients (group B) who still needed antihypertensive medication. Both groups were followed annually thereafter for 12-123 (66+/-37) months.

RESULTS

Coarctation gradient values before, immediately after and 1 year after angioplasty were 69+/-24 mmHg, 12+/-8 mmHg (P<0.001) and 7+/-6 mmHg. The corresponding systolic blood pressure values were 165+/-17 mmHg, 128+/-12 mmHg (P<0.001) and 115+/-10 mmHg (P<0.001) in group A; 182+/-21 mmHg, 141+/-24 mmHg (P<0.001) and 134+/-18 mmHg (P<0.001) in group B. Echocardiographic left ventricular mass index before angioplasty and at follow-up was 130+/-31 g x m-2 and 105+/-23 g x m-2 in group A; 157+/-38 g x m-2 and 132+/-35 g x m-2 in group B (P<0.001 for both comparisons).

CONCLUSION

Normalization of blood pressure without medication occurred in 74% of patients after angioplasty for aortic coarctation, with subsequent long-term regression of left ventricular hypertrophy. In comparison to reported surgical results, balloon angioplasty should be considered as first line treatment for native, discrete aortic coarctation in adolescent and adult patients.

Feeding of lovastatin to rats increases the activity of the hepatic mitochondrial outer carnitine palmitoyltransferase

Administration of lovastatin to male, Sprague-Dawley rats by addition of the drug to the normal chow diet caused a two-fold increase in the activity of the hepatic mitochondrial outer carnitine palmitoyltransferase, but lovastatin apparently did not affect the sensitivity of the outer carnitine palmitoyltransferase to inhibition by malonyl-CoA. There was also no effect of lovastatin on the activity of the hepatic mitochondrial inner carnitine palmitoyltransferase. Feeding of cholestyramine to rats did not affect either the mitochondrial outer carnitine palmitoyltransferase or the mitochondrial inner carnitine palmitoyltransferase.

Plasmodium falciparum: DNA probe diagnosis of malaria in Kenya

We previously reported isolation of DNA probe which specifically recognizes Plasmodium falciparum and developed a simple method for its use. The sensitivity and specificity of this DNA probe method have now been extensively field tested in comparison with those of conventional microscopic examination of blood films in two separate studies in Malindi, Kenya, involving a total of 1179 patients. In the second study, which used improved techniques, sensitivity of the DNA probe was 89% when compared to microscopy. We conclude that the DNA probe method compares favorably with conventional microscopy in detecting parasite densities as low as 25 parasites per microliter of blood. A significant advantage of the DNA probe method is that it utilizes a standardized procedure which can simultaneously and reproducibly analyze a large number of samples without opportunity for significant reader bias.

Hematopoietic colony-stimulating factors for neutropenic patients in the ICU

OBJECTIVE

To assess whether adjunct hematopoietic colony-stimulating factor (H-CSF) accelerates neutrophil recovery and improves survival.

DESIGN

A retrospective study.

SETTING

Medical/surgical intensive care unit (ICU).

PATIENTS

30 neutropenic patients admitted to the ICU and treated with H-CSF. Controls were the preceding 30 neutropenic patients not treated with H-CSF.

MEASUREMENTS AND RESULTS

Patient admission characteristics were reviewed. Endpoints were neutrophil recovery ( > 1.0 x 10(9)/l), length of ICU stay and survival. Depth and duration of neutropenia (0.267 +/- 0.04 x 10(9)/l for 12 +/- 1.7 days vs 0.293 +/- 0.05 x 10(9)/l for 15 +/- 1.9 days; p = 0.67 and 0.21), and the Acute Physiology and Chronic Health Evaluation II and organ system failure scores were similar. Systemic candidiasis was lower in the H-CSF group (20 vs 3 %; p > 0.05). In 11 (36.6 %) and 10 (33.3 %) patients neutrophil count recovered ( > 1.0 x 10(9)/l); H-CSF did not reduce the duration of neutropenia (7.8 +/- 1.4 vs 5.7 +/- 1.3 days; p = 0. 28), the length of ICU stay (7.8 +/- 1.1 vs 8.9 +/- 1.5 days; p = 0. 55) or improve survival (23 vs 10 %; p = 0.168).

CONCLUSION

H-CSF for treatment of neutropenia in patients admitted to the ICU did not accelerate neutrophil recovery or improve survival.

Immediate and long-term effect of mitral balloon valvotomy on left ventricular volume and systolic function in severe mitral stenosis

To determine the immediate and long-term effect of mitral balloon valvotomy (MBV) on left ventricular (LV) volume and function, we studied 17 patients (mean age 27 +/- 9 years) with severe mitral stenosis undergoing MBV by cardiac catheterization and angiography before and immediately after MBV and at mean 12 months later. At baseline, LV end-diastolic volume index (EDVI) was reduced. Ten patients had EDVI < or = 55 ml/m2, and four patients (23.5%) had LV ejection fraction < 50%. EDVI increased from 60 +/- 17 ml/m2 to 66 +/- 17 ml/m2 (p < 0.05) immediately after MBV and increased further to 72 +/- 16 ml/m2 (p < 0.05) later. Stroke volume index increased from 34 +/- 10 ml/m2 to 41 +/- 12 ml/m2 (p < 0.05) immediately after MBV and increased further to 50 +/- 11 ml/m2 (p < 0.001) later. LV end diastolic pressure increased from 12 +/- 5 mm HG to 16 +/- 4 mm HG (p < 0.05) immediately after MBV and fell to 13 +/- Hg at follow-up. LV ejection fraction increased from 57 +/- 7% to 62 +/- 6% (p < 0.05) immediately after MBV and 71 +/- 8% later (p < 0.001). Mean systolic ejection rate increased from 82 +/- 35 ml/sec to 101 +/- 48 ml/sec (p < 0.05) immediately after and 165 +/- 81 ml/sec later (p < 0.05). Systemic vascular resistance fell from 1887 +/- 525 dyne/sec/cm-5 to 1280 +/- 231 dyne/sec/cm-5 (p < 0.001) at follow-up. We conclude that the LV end-diastolic volume and systolic function are reduced in patients with mitral stenosis, and the LV end-diastolic volume is increased immediately after MBV and continues to increase at follow-up 12 months later; the LV ejection performance improves after successful MBV because of an increase in end-diastolic LV volume (preload) and reduction of SVR.

Identification of a high risk subgroup of patients with silent ischaemia after myocardial infarction: a group for early therapeutic revascularisation?

Asymptomatic ("silent") ischaemia has been shown to be of prognostic significance in patients with stable and unstable angina and more recently in patients recovering after myocardial infarction. No therapeutic regimen has yet been shown to improve the prognosis of patients with silent ischaemia after infarction, which can be found in as many as a third of these patients. Attempts to achieve therapeutic revascularisation in all these patients may be undesirable, but early revascularisation could be especially beneficial in some selected high risk patients. Two hundred and fifty consecutive clinically stable survivors of myocardial infarction who had predischarge submaximal exercise tests were followed up for a year. Silent ischaemia was found in 27% of these patients; 15% had symptomatic ischaemia. Patients with a positive exercise test were prescribed a beta blocker before discharge. Mortality in patients with silent (9.4%) and symptomatic (5.4%) ischaemia in the first year after infarction was not significantly different. Patients with symptomatic ischaemia were more likely to have undergone coronary artery bypass grafting in the first year. Patients with silent ischaemia were, however, significantly more likely to die than patients with a negative exercise test (relative odds 12:1). Patients with silent ischaemia and an abnormal blood pressure response or who could not complete a submaximal exercise protocol were at particularly high risk, being 32 times more likely to die than those with a negative test (95% confidence interval from 3.3 to 307 times more likely). First year mortality in this group was 22%. The benefits of therapeutic revascularisation in this high risk group need to be studied.

Mitral balloon valvotomy in children with Inoue balloon technique: immediate and intermediate-term result

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon technique was attempted in 170 patients. Of these, 30 patients were children aged 10 to 18 years (mean 15.9 +/- 2.7 years). There were 16 female and 14 male patients. All were in sinus rhythm. The procedure was successful in 28 patients (93%). PMV was performed using 20 to 28 mm (mean 25 mm) diameter balloon catheters with an echo-Doppler guided stepwise mitral dilation technique. After PMV, the mean left atrial pressure decreased from 25 +/- 5 to 14 +/- 4 mm Hg (p < 0.001). The mean mitral valve gradient (MVG) decreased from 16 +/- 4 to 6 +/- 3 mm Hg (p < 0.001). The mitral valve area (MVA) by catheter increased from 0.7 +/- 0.2 to 1.7 +/- 0.5 cm2 (p < 0.001), and MVA as determined by echocardiography (2DE) increased from 0.8 +/- 0.1 to 1.9 +/- 0.3 cm2 (p < 0.01). There were no deaths or thromboembolic complications; cardiac tamponade developed in one patient, mild mitral regurgitation (MR) developed in three patients (10%) and increased by one grade from (1+ to 2+) in another two patients (8%). A small atrial septal defect (ASD) assessed by color flow mapping developed in seven patients (25%); 90% were closed at 3 months. The Doppler and 2DE MVAs were maintained at 1.8 +/- 0.4 cm2 at 17 months' mean follow-up; one patient developed restenosis. We conclude the PMV using the Inoue balloon catheter is safe and effective in the treatment of severe mitral stenosis in children, with a low complication rate.