Ineffectiveness of hemoadsorption in large animals with abdominal sepsis: a randomized controlled porcine study

OBJECTIVES

The use of hemoadsorption (HA) has become popular in the treatment of vasoplegic states associated with massive cytokine release, including septic shock. However, this approach does not seem to be based on robust evidence, and it does not follow international guidelines. To understand the pathophysiological rationale and timing of HA, we conducted a large animal septic shock experiment.

DESIGN

Prospective randomized large-animal peritoneal septic shock experiment.

SETTING

Laboratory investigation.

SUBJECTS

Twenty-six anesthetized, mechanically ventilated, and instrumented pigs randomly assigned into (1) sham-operated group with HA (SHAM, n = 5); (2) sepsis animals without HA (SEPSIS, n = 5); (3) sepsis group with HA at norepinephrine initiation (EARLY, n = 8); and (4) sepsis group with HA initiated at norepinephrine rate reaching 0.5 μg/kg/min (LATE, n = 8).

INTERVENTIONS

Peritoneal sepsis was induced by cultivated autologous feces inoculation. A CytoSorb cartridge (200 g) with a blood flow rate of 200 mL/min and heparin anticoagulation was used to perform HA. The animals received sedation and intensive organ support up to 48 h or until they experienced cardiovascular collapse.

MEASUREMENTS AND MAIN RESULTS

Systemic hemodynamics, multiple-organ functions, and immune-inflammatory response were measured at predefined periods. The HA treatment was not associated with any measurable benefit in terms of systemic hemodynamics and organ support. The systemic inflammatory markers were unaffected by any of the treatment timings. In contrast, the HA resulted in higher vasopressor load and decreased 36-h survival (5 animals in SHAM (100%), 4 (80%) in SEPSIS, 4 (57%) in EARLY, and 2 (25%) in LATE; p = 0.041). The HA exposure in healthy animals was associated with hemodynamic deterioration, systemic inflammatory response, and cytopenia.

CONCLUSIONS

In this large-animal-controlled fulminant sepsis study, the HA was unable to counteract the disease progression in the early or advanced septic shock phase. However, findings from the HA-exposed sham animals suggest potential safety concerns.

Long-term outcomes and reverse remodelling in recently diagnosed unexplained left ventricular systolic dysfunction

AIMS

In patients with recently diagnosed non-ischaemic LV systolic dysfunction, left ventricular reverse remodelling (LVRR) and favourable prognosis has been documented in studies with short-term follow-up. The aim of our study was to assess the long-term clinical course and stability of LVRR in these patients.

METHODS AND RESULTS

We prospectively studied 133 patients (37 women; 55 [interquartile range 46, 61] years) with recently diagnosed unexplained LV systolic dysfunction, with heart failure symptoms lasting <6 months and LV ejection fraction <40% persisting after at least 1 week of therapy. All patients underwent endomyocardial biopsy (EMB) at the time of diagnosis and serial echocardiographic and clinical follow-up over 5 years. LVRR was defined as the combined presence of (1) LVEF ≥ 50% or increase in LVEF ≥ 10% points and (2) decrease in LV end-diastolic diameter index (LVEDDi) ≥ 10% or (3) LVEDDi ≤ 33 mm/m2. LVRR was observed in 46% patients at 1 year, in 60% at 2 years and 50% at 5 years. Additionally, 2% of patients underwent heart transplantation and 12% experienced heart failure hospitalization. During 5-year follow-up, 23 (17%) of the study cohort died. In multivariate analysis, independent predictors of mortality were baseline right atrial size (OR 1.097, CI 1.007-1.196), logBNP level (OR 2.02, CI 1.14-3.56), and PR interval (OR 1.02, CI 1.006-1.035) (P < 0.05 for all). The number of macrophages on EMB was associated with overall survival in univariate analysis only. LVRR at 1 year of follow-up was associated with a lower rate of mortality and heart failure hospitalization (P = 0.025). In multivariate analysis, independent predictors of LVRR were left ventricular end-diastolic volume index (OR 0.97, CI 0.946-0.988), LVEF (OR 0.89, CI 0.83-0.96), and diastolic blood pressure (OR 1.04, CI 1.01-1.08) (P < 0.05 for all).

CONCLUSIONS

LVRR occurs in over half of patients with recent onset unexplained LV systolic dysfunction during first 2 years of optimally guided heart failure therapy and then remains relatively stable during 5-year follow-up. Normalization of adverse LV remodelling corresponds to a low rate of mortality and heart failure hospitalizations during long-term follow-up.

Lactate: The Fallacy of Oversimplification

Almost a quarter of a millennium after the discovery of an acidic substance in sour milk by Swedish chemist Carl Wilhelm Scheele and more than 100 years after the demonstration of a tight connection between this lactic acid and tissue hypoxia in shock, we are still surrounded by false beliefs and misunderstandings regarding this fascinating molecule. Common perceptions of lactate, the conjugate base of lactic acid, as a plain waste product of anaerobic metabolism and a marker of cellular distress could not be further from the truth. Lactate is formed and utilized continuously by our cells, even under fully aerobic conditions, in large quantities, and although marked hyperlactatemia is always a red flag in our patients, not all these conditions are life-threatening and vice versa-not all critically ill patients have hyperlactatemia. Lactate also does not promote acidosis by itself; it is not toxic, nor is it a metabolic renegade. On the contrary, it has many beneficial properties, and an interpretation of hyperlactatemia might be trickier than we tend to think. The aim of this article is to debunk some of the deeply rooted myths regarding this fascinating molecule.

The rapid detection of procalcitonin in septic serum using immunoaffinity MALDI chips

BACKGROUND

Sepsis is a common worldwide health condition with high mortality. It is caused by a dysregulated immune response to the pathogen. Severe infections resulting in sepsis can be also determined by monitoring several bloodstream biomarkers, one of them being pro-hormone procalcitonin (PCT). PCT concentration in the bloodstream correlates well with sepsis and in severe cases increases up to a thousand times from the healthy physiological values in a short time. In this study, we developed a rapid technique for PCT detection by MALDI-TOF mass spectrometry, that uses in-situ enrichment directly on the specialized immuno MALDI chips that are utilized as MALDI plates. The method's ability to detect PCT was confirmed by comparing the results with LC-MS bottom-up workflow. The new method detects intact PCT by its m/z and uncovers its alternations in septic serum.

METHODS

The MALDI chips used for the detection of PCT were prepared by ambient ion soft landing of anti-PCT antibody on an ITO glass slide. The chips were used for the development of the rapid MALDI-TOF MS method. A parallel method based on affinity enrichment on magnetic beads followed by LC-MS/MS data-dependent peptide microsequencing was used to prove PCT presence in the sample. All samples were also tested by ELISA to determine PCT concentration prior to analyzing them by mass spectrometry methods.

RESULTS

The MALDI chip method was optimized using recombinant PCT spiked into the human serum. The PCT detection limit was 10 ng/mL. The optimized method was used to analyze 13 sera from patients suffering sepsis. The PCT results were confirmed by LC-MS/MS. The measurement of the intact PCT by the MALDI chip method revealed that sera of patients with severe sepsis have other forms of PCT present, which show post-processing of the primary sequence by cleavage of PCT, resulting in the formation of N and C termini fragments.

CONCLUSIONS

Procalcitonin from human serum was successfully enriched and detected using immunoaffinity MALDI chips. The intact PCT was characterized in 13 septic patients. The method is more specific compared to non-MS-based immunoaffinity techniques and allows observation of different variants of PCT in septic patients.

Evaluation of Mesenchymal Stem Cell Therapy for Sepsis: A Randomized Controlled Porcine Study

Background: Treatment with mesenchymal stem cells (MSCs) has elicited considerable interest as an adjunctive therapy in sepsis. However, the encouraging effects of experiments with MSC in rodents have not been adequately studied in large-animal models with better relevance to human sepsis.

Objectives: Here, we aimed to assess safety and efficacy of bone marrow-derived MSCs in a clinically relevant porcine model of progressive peritonitis-induced sepsis.

Methods: Thirty-two anesthetized, mechanically ventilated, and instrumented pigs were randomly assigned into four groups (n = 8 per group): (1) sham-operated group (CONTROL); (2) sham-operated group treated with MSCs (MSC-CONTROL); (3) sepsis group with standard supportive care (SEPSIS); and (4) sepsis group treated with MSCs (MSC-SEPSIS). Peritoneal sepsis was induced by inoculating cultivated autologous feces. MSCs (1 × 10⁶/kg) were administered intravenously at 6 h after sepsis induction.

Results: Before, 12, 18, and 24 h after the induction of peritonitis, we measured systemic, regional, and microvascular hemodynamics, multiple-organ functions, mitochondrial energy metabolism, systemic immune-inflammatory response, and oxidative stress. Administration of MSCs in the MSC-CONTROL group did not elicit any measurable acute effects. Treatment of septic animals with MSCs failed to mitigate sepsis-induced hemodynamic alterations or the gradual rise in Sepsis-related organ failure assessment scores. MSCs did not confer any protection against sepsis-mediated cellular myocardial depression and mitochondrial dysfunction. MSCs also failed to modulate the deregulated immune-inflammatory response.

Conclusion: Intravenous administration of bone marrow-derived MSCs to healthy animals was well-tolerated. However, in this large-animal, clinically relevant peritonitis-induced sepsis model, MSCs were not capable of reversing any of the sepsis-induced disturbances in multiple biological, organ, and cellular systems.

Occlusion of Epicardial Coronary Arteries by Localized Pericardial Calcification

Localized pericardial calcification is a relatively rare finding of often unknown etiology. We present the case of a 68-year-old man who was found to have bulky pericardial calcification, resulting in external compression of epicardial coronary arteries. (Level of Difficulty: Beginner.)

Back to Basics: Recognition of Sepsis with New Definition

Patients with serious infections at risk of deterioration represent highly challenging clinical situations, and in particular for junior doctors. A comprehensive clinical examination that integrates the assessment of vital signs, hemodynamics, and peripheral perfusion into clinical decision making is key to responding promptly and effectively to evolving acute medical illnesses, such as sepsis or septic shock. Against this background, the new concept of sepsis definition may provide a useful link between junior doctors and consultant decision making. The purpose of this article is to introduce the updated definition of sepsis and suggest its practical implications, with particular emphasis on integrative clinical assessment, allowing for the rapid identification of patients who are at risk of further deterioration.

Cellular Mechanisms of Myocardial Depression in Porcine Septic Shock

The complex pathogenesis of sepsis and septic shock involves myocardial depression, the pathophysiology of which, however, remains unclear. In this study, cellular mechanisms of myocardial depression were addressed in a clinically relevant, large animal (porcine) model of sepsis and septic shock. Sepsis was induced by fecal peritonitis in eight anesthetized, mechanically ventilated, and instrumented pigs of both sexes and continued for 24 h. In eight control pigs, an identical experiment but without sepsis induction was performed. In vitro analysis of cardiac function included measurements of action potentials and contractions in the right ventricle trabeculae, measurements of sarcomeric contractions, calcium transients and calcium current in isolated cardiac myocytes, and analysis of mitochondrial respiration by ultrasensitive oxygraphy. Increased values of modified sequential organ failure assessment score and serum lactate levels documented the development of sepsis/septic shock, accompanied by hyperdynamic circulation with high heart rate, increased cardiac output, peripheral vasodilation, and decreased stroke volume. In septic trabeculae, action potential duration was shortened and contraction force reduced. In septic cardiac myocytes, sarcomeric contractions, calcium transients, and L-type calcium current were all suppressed. Similar relaxation trajectory of the intracellular calcium-cell length phase-plane diagram indicated unchanged calcium responsiveness of myofilaments. Mitochondrial respiration was diminished through inhibition of Complex II and Complex IV. Defective calcium handling with reduced calcium current and transients, together with inhibition of mitochondrial respiration, appears to represent the dominant cellular mechanisms of myocardial depression in porcine septic shock.

Pathologic Intimal Thickening Plaque Phenotype: Not as Innocent as Previously Thought. A Serial 3D Intravascular Ultrasound Virtual Histology Study

INTRODUCTION AND OBJECTIVES

Pathologic intimal thickening (PIT) has been considered a benign plaque phenotype. We report plaque phenotypic changes in a baseline/follow-up intravascular ultrasound-based virtual histology study.

METHODS

A total of 61 patients with stable coronary artery disease were analyzed from the HEAVEN trial (89 patients randomized between routine statin therapy vs atorvastatin 80mg and ezetimibe 10mg) with serial intravascular ultrasound imaging of nonculprit vessels. We compared changes in 693 baseline and follow-up 5-mm long segments in a novel risk score, Liverpool Active Plaque Score (LAPS), plaque parameters, and plaque composition.

RESULTS

The PIT showed the highest increase of risk score and, with fibrous plaque, also the LAPS. Necrotic core (NC) abutting to the lumen increased in PIT (22 ± 51.7; P = .0001) and in fibrous plaque (17.9 ± 42.6; P = .004) but decreased in thin cap fibroatheroma (TCFA) (⿿15.14 ± 52.2; P = .001). The PIT was the most likely of all nonthin cap fibroatheroma plaque types to transform into TCFA at follow-up (11% of all TCFA found during follow-up and 35.9% of newly-developed TCFA), but showed (together with fibrous plaque) the lowest stability during lipid-lowering therapy (24.7% of PIT remained PIT and 24.5% of fibrous plaque remained fibrous plaque).

CONCLUSIONS

Over the 1-year follow-up, PIT was the most dynamic of the plaque phenotypes and was associated with an increase of risk score and LAPS (together with fibrous plaque), NC percentage (together with fibrous plaque) and NC abutting to the lumen, despite a small reduction of plaque volume during lipid-lowering therapy. The PIT was the main source for new TCFA segments.

Non-invasive endothelial function assessment using digital reactive hyperaemia correlates with three-dimensional intravascular ultrasound and virtual histology-derived plaque volume and plaque phenotype

BACKGROUND AND AIM

To study relationships between endothelial dysfunction (ED) and coronary atherosclerosis derived from intravascular ultrasound (IVUS) and virtual histology (VH).

METHODS

Endothelial dysfunction was examined by EndoPAT system (Itamar Medical) in 56 patients who underwent IVUS and VH (Volcano corp.). Reactive hyperaemia index (RHI) < 2 was used for definition of ED. IVUS sequences were divided into 5 mm-long non-overlapping and adjacent vessel segments. Plaque phenotype was determined for each frame and 5 mm vessel segment was labeled according to highest frame score (from 0 for "no lesion" to 5 for "thin cap fibroatheroma; TCFA").

RESULTS

IVUS-VH data were collected from 41 patients suitable for three-dimensional analysis. Patients with ED exhibited larger plaque burden than those without ED (0.46 ± 0.08 vs. 0.39 ± 0.07, p = 0.014), smaller lumen area (8.59 ± 2.19 vs. 11.90 ± 3.50, p = 0.016), higher plaque risk score (2.82 ± 1.18 vs. 1.84 ± 0.90, p = 0.012), and higher number of TCFA frames (0.36 ± 0.22 vs. 0.22 ± 0.16, p = 0.038). Relative amounts of fibrous tissue correlated positively with RHI (p = 0.034, r = 0.33). The numbers of fibroatheromas and calcified plaques correlated with RHI inversely (r = -0.34, p = 0.031 and r = -0.32, p = 0.044, respectively).

CONCLUSIONS

Endothelial dysfunction correlates with severity and phenotype of coronary lesions and can contribute to non-invasive detection of individuals with higher risk of cardiovascular events.

Self-assembled magnetic bead chains for sensitivity enhancement of microfluidic electrochemical biosensor platforms

In this paper, we present a novel approach to enhance the sensitivity of microfluidic biosensor platforms with self-assembled magnetic bead chains. An adjustable, more than 5-fold sensitivity enhancement is achieved by introducing a magnetic field gradient along a microfluidic channel by means of a soft-magnetic lattice with a 350 μm spacing. The alternating magnetic field induces the self-assembly of the magnetic beads in chains or clusters and thus improves the perfusion and active contact between the analyte and the beads. The soft-magnetic lattices can be applied independent of the channel geometry or chip material to any microfluidic biosensing platform. At the same time, the bead-based approach achieves chip reusability and shortened measurement times. The bead chain properties and the maximum flow velocity for bead retention were validated by optical microscopy in a glass capillary. The magnetic actuation system was successfully validated with a biotin-streptavidin model assay on a low-cost electrochemical microfluidic chip, fabricated by dry-film photoresist technology (DFR). Labelling with glucose oxidase (GOx) permits rapid electrochemical detection of enzymatically produced H2O2.

Fauna Europaea: Coleoptera 2 (excl. series Elateriformia, Scarabaeiformia, Staphyliniformia and superfamily Curculionoidea)

Fauna Europaea provides a public web-service with an index of scientific names (including synonyms) of all living European land and freshwater animals, their geographical distribution at country level (up to the Urals, excluding the Caucasus region), and some additional information. The Fauna Europaea project covers about 230,000 taxonomic names, including 130,000 accepted species and 14,000 accepted subspecies, which is much more than the originally projected number of 100,000 species. This represents a huge effort by more than 400 contributing specialists throughout Europe and is a unique (standard) reference suitable for many users in science, government, industry, nature conservation and education. Coleoptera represent a huge assemblage of holometabolous insects, including as a whole more than 200 recognized families and some 400,000 described species worldwide. Basic information is summarized on their biology, ecology, economic relevance, and estimated number of undescribed species worldwide. Little less than 30,000 species are listed from Europe. The Coleoptera 2 section of the Fauna Europaea database (Archostemata, Myxophaga, Adephaga and Polyphaga excl. the series Elateriformia, Scarabaeiformia, Staphyliniformia and the superfamily Curculionoidea) encompasses 80 families (according to the previously accepted family-level systematic framework) and approximately 13,000 species. Tabulations included a complete list of the families dealt with, the number of species in each, the names of all involved specialists, and, when possible, an estimate of the gaps in terms of total number of species at an European level. A list of some recent useful references is appended. Most families included in the Coleoptera 2 Section have been updated in the most recent release of the Fauna Europaea index, or are ready to be updated as soon as the FaEu data management environment completes its migration from Zoological Museum Amsterdam to Berlin Museum für Naturkunde.

Can rove beetles (Staphylinidae) be excluded in studies focusing on saproxylic beetles in central European beech forests?

Monitoring saproxylic beetle diversity, though challenging, can help identifying relevant conservation sites or key drivers of forest biodiversity, and assessing the impact of forestry practices on biodiversity. Unfortunately, monitoring species assemblages is costly, mainly due to the time spent on identification. Excluding families which are rich in specimens and species but are difficult to identify is a frequent procedure used in ecological entomology to reduce the identification cost. The Staphylinidae (rove beetle) family is both one of the most frequently excluded and one of the most species-rich saproxylic beetle families. Using a large-scale beetle and environmental dataset from 238 beech stands across Europe, we evaluated the effects of staphylinid exclusion on results in ecological forest studies. Simplified staphylinid-excluded assemblages were found to be relevant surrogates for whole assemblages. The species richness and composition of saproxylic beetle assemblages both with and without staphylinids responded congruently to landscape, climatic and stand gradients, even when the assemblages included a high proportion of staphylinid species. At both local and regional scales, the species richness as well as the species composition of staphylinid-included and staphylinid-excluded assemblages were highly positively correlated. Ranking of sites according to their biodiversity level, which either included or excluded Staphylinidae in species richness, also gave congruent results. From our results, species assemblages omitting staphylinids can be taken as efficient surrogates for complete assemblages in large scale biodiversity monitoring studies.

Prediction of coronary vessel involvement on the basis of atherosclerosis risk factor analysis

The prediction of coronary vessel involvement by means of noninvasive tests is one of the fundamental objectives of preventive cardiology. This review describes the current possibilities of coronary vessel involvement prediction by means of ultrasonographic examination of carotid arteries, analysis of polymorphisms in the genes encoding enzymes responsible for production of nitric oxide and carbon monoxide and assessment of levels of certain proinflammatory cytokines. In the presented work these noninvasive markers are correlated with the extent of coronary vessel involvement as assessed by coronary angiography, intravascular ultrasound and virtual histology (Fig. 5, Ref. 40).

The prediction of coronary artery disease based on non-invasive examinations and heme oxygenase 1 polymorphism versus virtual histology

OBJECTIVE

Prediction of coronary atherosclerosis in patients with stable angina based on non-invasive examinations.

METHODS

Pro-inflammatory markers, heme oxygenase-1 (HO-1) polymorphism, lipid levels, Framingham risk score (FRS), and carotid ultrasound were analyzed and compared to grayscale and virtual histology intravascular ultrasound (VH-IVUS).

RESULTS

A total of 101 patients were included, and genetic analysis was performed on 81 patients (80.2%). The HO-1 risk polymorphism was more frequent in patients post-myocardial infarction (61.3% vs 32%; P=.0097), or with diabetes (68.4% vs 35.5%; P=.011) or a higher FRS (21.5 vs 15.7; P=.014). Plaques in patients with the HO-1 risk polymorphism contained less fibro-fatty tissue (17.1% vs 23.2%; P=.005) and more necrotic core (NC; 17.1% vs 12.7%; P=.02) and calcification (10.2% vs 5.7%; P=.035) compared to patients without the HO-1 risk polymorphism. Carotid intima media thickness (P=.05) and carotid bulb plaque (P=.008) predicted plaque burden. The level of Apo A inversely correlated with NC (P=.047; r = -0.27) and was lower in patients with VH-thin-cap fibroatheroma (VH-TCFA; 1.19 mmol/L vs 1.3 mmol/L; P=.04). FRS correlated with NC (P=.007; r = 0.2), with angiographic disease severity (P=.032; r = 0.21) and was higher in patients with VH-TCFA (9.1 vs 7.8; P=.03).

CONCLUSION

Carotid ultrasound and HO-1 polymorphism improve coronary atherosclerosis prediction.

Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. "Prague OHCA study"

Background

Out of hospital cardiac arrest (OHCA) has a poor outcome. Recent non-randomized studies of ECLS (extracorporeal life support) in OHCA suggested further prospective multicenter studies to define population that would benefit from ECLS. We aim to perform a prospective randomized study comparing prehospital intraarrest hypothermia combined with mechanical chest compression device, intrahospital ECLS and early invasive investigation and treatment in all patients with OHCA of presumed cardiac origin compared to a standard of care.

Methods

This paper describes methodology and design of the proposed trial. Patients with witnessed OHCA without ROSC (return of spontaneous circulation) after a minimum of 5 minutes of ACLS (advanced cardiac life support) by emergency medical service (EMS) team and after performance of all initial procedures (defibrillation, airway management, intravenous access establishment) will be randomized to standard vs. hyperinvasive arm. In hyperinvasive arm, mechanical compression device together with intranasal evaporative cooling will be instituted and patients will be transferred directly to cardiac center under ongoing CPR (cardiopulmonary resuscitation). After admission, ECLS inclusion/exclusion criteria will be evaluated and if achieved, veno-arterial ECLS will be started. Invasive investigation and standard post resuscitation care will follow. Patients in standard arm will be managed on scene. When ROSC achieved, they will be transferred to cardiac center and further treated as per recent guidelines.

Primary outcome

6 months survival with good neurological outcome (Cerebral Performance Category 1–2). Secondary outcomes will include 30 day neurological and cardiac recovery.

Discussion

Authors introduce and offer a protocol of a proposed randomized study comparing a combined “hyperinvasive approach” to a standard of care in refractory OHCA. The protocol is opened for sharing by other cardiac centers with available ECLS and cathlab teams trained to admit patients with refractory cardiac arrest under ongoing CPR. A prove of concept study will be started soon. The aim of the authors is to establish a net of centers for a multicenter trial initiation in future.

Ethics and registration

The protocol has been approved by an Institutional Review Board, will be supported by a research grant from Internal Grant Agency of the Ministry of Health, Czech Republic NT 13225-4/2012 and has been registered under ClinicalTrials.gov identifier: NCT01511666.

Intracoronary injection of autologous bone marrow-derived mononuclear cells in patients with large anterior acute myocardial infarction and left ventricular dysfunction: a 24- month follow up study

OBJECTIVE AND BACKGROUND

Despite the use of reperfusion therapies, outcomes in patients with large myocardial infarction (MI), late reperfusion and left ventricular (LV) dysfunction are poor. We investigated long-term safety and efficacy of intracoronary injections of autologous bone marrow-derived mononuclear cells (BMNCs).

METHODS

27 patients with anterior MI (age 59±12 years, mean baseline LV ejection fraction (LVEF) 39±5 %), who underwent percutaneous coronary intervention 4-24 hours after the onset of symptoms, were randomly assigned either to intracoronary BMNCs injection (n=17, BMNCs group, out of which 14 underwent long-term follow-up), or to standard therapy (n=10, Control group). The LVEF, the LV end-diastolic and end-systolic volumes (LVEDV, LVESV) were assessed by echocardiography at discharge, Month 4 and 24. Myocardial perfusion was assessed using SPECT at baseline and Month 4.

RESULTS

At 24-month, there was no difference in rates of serious clinical events (36 % vs 50 %, p=0.54). At Month 4 LVEF improved to similar extent in both groups (absolute change +5.8 % vs +7.6 %, p=0.75), with similar infarct size reductions (-10.9 % vs -12.2 %, p=0.47). However, at Month 24, LVEF further improved in BMNCs patients (+12 % vs +8.5 %, p=0.03). This effect resulted from a more pronounced reduction in LVESV (-2.6 ml vs -1.8 ml, p=0.26) and a smaller increase in LVEDV (+16.7 ml vs +17.9 ml, p=0.27) suggesting beneficial long-term effects on LV remodeling.

CONCLUSIONS

BMNCs injections in patients with MI and LV dysfunction were associated with a significant improvement of global LVEF during long term follow-up compared to standard therapy (Tab. 3, Fig. 1, Ref. 50). Full Text in PDF www.elis.sk.

Veno-arterial ECMO in severe acute right ventricular failure with pulmonary obstructive hemodynamic pattern

Extracorporeal membrane oxygenation (ECMO) is an effective rescue method for severe respiratory and cardiac failure. Right ventricular (RV) failure with cardiogenic shock is a critical condition with generally poor prognosis unless aggressive therapeutical measures are undertaken. Authors report on their initial experience with ECMO support in severe RV failure with cardiogenic shock caused by an obstructive hemodynamic pattern. Four patients with cardiogenic shock due to severe RV failure related to pulmonary arterial hypertension (2 patients), congenital heart disease with Eisenmenger physiology (1 subject) and massive pulmonary embolism (1 patient) were supported with emergency veno-arterial ECMO. ECMO circuit was instituted using peripheral cannulation in all subjects. Immediate hemodynamic and ventilatory improvement was observed in all patients. The mean support duration was 11 days (range 5-16 days), 2 (50%) patients were successfully weaned off ECMO and survived to hospital discharge. The other 2 patients were considered by mutual consensus to have irreversible organ damage, the ECMO support was withdrawn and the patients died. Bleeding complications were the main complications observed. As per initial experience, veno-arterial ECMO allows bypassing of the pulmonary bed, therefore, relieves the RV pressure overload and does not cause further elevation of the pulmonary pressures in contrary to RV assist devices. This aggressive management approach requires further clinical evaluation in order to establish its definite role in critical RV failure.

Presence of Borrelia burgdorferi in endomyocardial biopsies in patients with new-onset unexplained dilated cardiomyopathy

Dilated cardiomyopathy (DCM) represents the third most common cause of heart failure and the most frequent cause of heart transplantation. Infectious, mostly viral, and autoimmune mechanisms, together with genetic abnormalities, have been reported as three major causes of DCM. We hypothesized that Lyme disease (LD), caused by spirochete Borrelia burgdorferi (Bb), might be an important cause of new-onset unexplained DCM in patients living in a highly endemic area for LD such as the Czech Republic. We performed endomyocardial biopsy (EMB) in 39 consecutive patients presenting with symptomatic unexplained left ventricular (LV) systolic dysfunction lasting no more than 12 months. In eight subjects (21%), Bb was detected in the EMB sample by polymerase chain reaction or by electron microscopy. None of these patients exhibited any form of atrioventricular block or other extracardiac manifestation of Bb infection. Serological testing identified IgG antibodies against Bb in only two cases and IgM antibodies in none. All affected patients were treated with intravenous ceftriaxone for 3 weeks. At 6 months follow-up, LV morphology and function as well as functional status of these patients significantly improved. In conclusion, Bb infection may represent an important cause of new-onset unexplained DCM in patients living in endemic regions such as the Czech Republic. Because the antibiotic treatment appears to be markedly effective and serological examination does not provide a tool for diagnosing the disease, EMB focused on the detection of Bb should be performed in all patients from endemic areas with new-onset unexplained DCM not responding to conventional therapy.

Increase in plasma free haemoglobin during cardiopulmonary bypass in heart valve surgery: assessment of renal dysfunction by RIFLE classification

Heart valve surgery carries a high risk of renal insufficiency as an independent risk factor due to prolonged cardiopulmonary bypass. Multiple causes of cardiopulmonary bypass-associated renal damage have been described, and haemoglobin-induced renal injury is presently being investigated. Forty-three patients scheduled for heart valve surgery (mostly combined) were enrolled in the prospective study. Plasma free haemoglobin (PFH) levels were evaluated by photocolorimetric measurement at the start of procedures (t(0)) and before the end of extracorporeal circulation (t(1)). A statistically significant increase in PFH levels during cardiopulmonary bypass was detected [median values (interquartile range) - t(0): 62.0 (53.4) mg/L, t(1): 320.4 (352.2) mg/L], P < 0.001. A significant regression relationship between the duration of cardiopulmonary bypass and the increased PFH was found (Spearman's correlation coefficient 0.628, P < 0.001). In some elderly patients, the tendency towards a high release of PFH during cardiopulmonary bypass was more pronounced, but the overall association between age and PFH levels was of borderline significance (P = 0.077). The correlation between PFH and post-operative serum creatinine was low and non-significant, but the latter correlated highly with the pre-operative serum creatinine values (Spearman's correlation coefficient reached values of 0.6-0.7, P < 0.001). Patients were classified according to the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-stage renal failure (RIFLE) classification for acute renal dysfunction during post-operative days 1 - 4; the influence of PFH levels at t(1) on the consequent RIFLE classification was not proven (P=0.648), but 4 patients in the Injury category had shown a higher median value of PFH (433.6 mg/L) in comparison with the others (29 patients with no acute renal dysfunction - 313.7 mg/L, 10 patients at Risk - 330.1 mg/L).

Intravascular ultrasound assessment of coronary artery involvement in Fabry disease

AIM

We used intravascular ultrasound (IVUS) to characterize coronary artery involvement in patients with Fabry disease (FD).

METHODS

Nine FD patients (5 women) were matched to 10 control patients (5 women) chosen from our IVUS database. Standard volumetric IVUS analyses were performed along with assessment of plaque echodensity.

RESULTS

Plaques in FD patients were diffuse and hypoechogenic compared with more focal and more echogenic lesions in control patients. Echogenicity of plaques was significantly lower in FD patients (median 30.7 +/- 12.9 vs 55.9 +/- 15.7, p = 0.0052, mean 37.2 +/- 15.6 vs 66.2 +/- 13.3, p = 0.0014). Diffusiveness was assessed as differences between mean and median plaque burden versus the plaque burden in each of the analysed cross-sections. These differences were lower in FD vs controls (5.8 +/- 4.8 vs 8.7 +/- 6.6, p < 0.001 for mean, and 5.8 +/- 4.9 vs 8.8 +/- 7.3, p < 0.001 for median) indicating a more diffuse involvement. The occurrence of lipid cores was significantly higher in FD patients than in controls (2.4 +/- 1.5 vs 1.0 +/- 0.94, p = 0.02).

CONCLUSION

IVUS showed diffuse hypoechogenic plaques in patients with FD. The explanation may be higher lipid content in plaques and accumulation of glycosphingolipid in smooth-muscle and endothelial cells.

Lack of association of iron metabolism and Dupuytren's disease

BACKGROUND

Iron accumulation as seen in genetic haemochromatosis is a major cause of hepatic fibrogenesis. A link between chronic liver disease and Dupuytren's disease (DD) is well established, especially in alcoholics.

AIM

The aim of the present study was to test the hypothesis that iron accumulation might cause fibrosis of the palmar aponeurosis leading to DD.

PATIENTS AND METHODS

We examined iron metabolism, mutations of the HFE gene, serum cholesterol, alcohol consumption, presence of chronic liver disease, diabetes and history of severe manual work in a group of 90 patients who had undergone surgery for a severe form of DD. The tissue removed during surgery was histologically examined to confirm the diagnosis of DD. For a control group, we used 33 healthy subjects with similar profiles.

RESULTS

The DD group consisted of 82 men and 8 women. Chronic liver disease was found in 27% of DD patients, compared with 6.1% of control subjects (P = 0.013). A history of hand traumatization was present in 33% of DD patients vs. 15% of control subjects (P = 0.048). Excessive alcohol consumption was present in 35.5% of DD patients compared with 15.1% of controls (P = 0.029). None of the other tested parameters, including the prevalence of HFE gene mutations, showed a significant difference between the two groups.

CONCLUSIONS

Iron accumulation does not play a major role in the pathogenesis of DD. However, sex, age, manual labour and alcohol consumption are risk factors for progression of DD. We observed a high incidence of chronic liver disease in patients with DD.

The ubiquitin ligase SCF(Grr1) is required for Gal2p degradation in the yeast Saccharomyces cerevisiae

F-box proteins represent the substrate-specificity determinants of the SCF ubiquitin ligase complex. We previously reported that the F-box protein Grr1p is one of the proteins involved in the transmission of glucose-generated signal for proteolysis of the galactose transporter Gal2p and fructose-1,6-bisphosphatase. In this study, we show that the other components of SCF(Grr1), including Skp1, Rbx1p, and the ubiquitin-conjugating enzyme Cdc34, are also necessary for glucose-induced Gal2p degradation. This suggests that transmission of the glucose signal involves an SCF(Grr1)-mediated ubiquitination step. However, almost superimposable ubiquitination patterns of Gal2p observed in wild-type and grr1Delta mutant cells imply that Gal2p is not the primary target of SCF(Grr1) ubiquitin ligase. In addition, we demonstrate here that glucose-induced Gal2p proteolysis is a cell-cycle-independent event.

[Primary biliary cirrhosis--specific anti-mitochondrial antibodies]

Primary biliary cirrhosis is a chronic liver disease, characterized by the destruction of the epithelial cells of the sublobular, interlobular and septal bile ducts and with the development of cirrhosis. The presence of anti-mitochondrial antibodies against the subunits of mitochondrial 2-oxoacids dehydrogenases is characteristic for patients with primary biliary cirrhosis. The aim of this work was to study the effect of anti-mitochondrial antibodies upon activity of the isolated mitochondrial pyruvate dehydrogenase complex after the incubation with serum from patients with primary biliary cirrhosis.

GROUP OF PATIENTS AND METHODS

The activity of the purified bovine pyruvate dehydrogenase complex was studied spectrophotometrically in presence of the serum (1: 1000) from five patients with primary biliary cirrhosis and from ten disease free controls.

RESULTS

The activity of the pyruvate dehydrogenase was decreased after incubation with the serum from patients with primary biliary cirrhosis. No similar inhibitory effect was found after incubation with serum from controls.

DISCUSSION

The inhibitory effect of the anti-mitochondrial antibodies upon activity of pyruvate dehydrogenase may broaden the spectrum of diagnostic methods in patients with primary biliary cirrhosis. Further investigations are necessary to assess the possible application of this method for monitoring of changes during the course of the disease and for assignation of the disease prognosis.

Glucose-induced monoubiquitination of the Saccharomyces cerevisiae galactose transporter is sufficient to signal its internalization

In Saccharomyces cerevisiae, the addition of glucose to cells growing on galactose induces internalization of the galactose transporter Gal2p and its subsequent proteolysis in the vacuole. Here we report that the essential step in Gal2p down-regulation is its ubiquitination through the Ubc1p-Ubc4p-Ubc5p triad of ubiquitin-conjugating enzymes and Npi1/Rsp5p ubiquitin-protein ligase. Moreover, Gal2p appears to be stabilized in mutant cells defective in the ubiquitin-hydrolase Npi2p/Doa4p, and the mutant phenotype can be reversed by overexpression of ubiquitin. An analysis of the fate of Gal2p in cells overexpressing wild-type ubiquitin as well as its variants incompetent to form polyubiquitin chains showed that monoubiquitination of Gal2p is sufficient to signal internalization of the protein into the endocytic pathway.

Virtual PCR

We present an algorithm that uses public sequence data to predict PCR products. The algorithm is implemented as a CGI script. Output is compared to real-world PCR.

AVAILABILITY

Perl code and instructions for installation are freely available over the internet at http://www.sci.muni.cz/LMFR/vpcr.html.

Optimisation of the quantitative determination of chlormequat by matrix-assisted laser desorption/ionisation mass spectrometry

The plant growth regulator chlormequat, an involatile quaternary ammonium salt, has been quantified by matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOFMS). Restrictions for quantitative MALDI-TOFMS analysis, such as irreproducible crystallisation and unsatisfactory laser stability, have been overcome by the application of two synthesised isotopically labelled standards and the optimisation of the measurement protocol. Data acquisition at constant laser power was compared to data acquisition at approximately constant ion abundance of the relevant ions (analyte and internal standards). Data acquisition at constant ion abundance performed better and enabled a high number of consecutive firings to the same sample deposition area. Furthermore an increased sample-to-sample repeatability and a high reproducibility over several weeks without re-calibration have been attained by this method. Linearity over three orders of magnitude (0.05 to 30 ng/microL chlormequat), with a correlation coefficient of 0.9997, was achieved using [13C3]-chlormequat as internal standard. Limit of detection and limit of determination were determined to be in the low pg/microL range for pure standard solutions. Thin-layer chromatography was applied for the removal of high amounts of choline, which is often present in plant tissue extracts and can adversely affect the ionisation and detection of chlormequat by MALDI-TOFMS. The use of two internal standards ([13C3]- and [2H9]-chlormequat) enabled direct quantification and simultaneous control of the recovery.

Emergent management of the airway. New pharmacology and the control of comorbidities in cardiac disease, ischemia, and valvular heart disease

Once it is decided that the patient in distress requires tracheal intubation, the primary goal is to secure the airway as quickly and safely as possible to assure adequate oxygenation and ventilation. The clinician should quickly review the patient's history, physical examination findings, and laboratory data to determine the presence of cardiovascular disease, assess intravascular volume status, and formulate a plan for induction of anesthesia. The stresses of hypoxia, hypercarbia, acidosis, and extreme fatigue result in near-maximal sympathetic outflow that is manifest as tachycardia, labile blood pressure, and increased myocardial contractility. The astute clinician should anticipate that the tachycardia and hypertension associated with laryngoscopy and tracheal intubation is followed by a period of hypotension. This postintubation hypotension results from the acute marked attenuation of the sympathetic tone associated with resolution of hypoxia and hypercarbia, direct drug-induced negative inotropic effect, and vasodilation. The decrease in sympathetic vascular tone may result in hypotension by exacerbating the decrease in cardiac preload and afterload from hypovolemia. In addition, the use of positive pressure ventilation and positive end-expiratory pressure (PEEP) in these hypovolemic patients will further decrease ventricular preload by impeding venous return, leading to profound hypotension. Several pharmacologic agents are required to treat effectively the hemodynamic perturbations associated with induction, laryngoscopy, and tracheal intubation. Most sedative hypnotic agents that are administered for induction provide minimal to no analgesia. Patients are most often given a combination of drugs to provide adequate sedation, analgesia to blunt the noxious stimuli, and muscle relaxation to facilitate the laryngoscopy. The major challenge is to choose a combination of drugs that at the appropriate doses, effectively blunt the responses to intubation without contributing to postlaryngoscopy hypotension. One can use several strategies to accomplish these goals; administration of a narcotic analgesic before induction decreases the dose of induction agent and can attenuate the sympathetic response to intubation. Because of the prevalence of cardiovascular disease and hypovolemia in this population of patients, all chosen drugs should have minimal negative effect on cardiac function and patients with hypovolemia should be hydrated. Most clinical studies have been performed in hemodynamically stable patients, so the routine dosages of sedative hypnotics should be reduced substantially and titrated to effect. An additional strategy is to treat significant hemodynamic perturbations with vasopressors, vasodilators, short-acting selective beta-1 blockers, and inotropic agents. The choice of vasoactive agent depends on the magnitude of the hemodynamic response and the presence of specific underlying cardiovascular pathology.

Coronary angiography in Qatar: the first ten years

Cardiac catheterization in Qatar was initiated in July 1982. In ten years, a total of 3900 procedures were performed at Hamad General Hospital. Computerized data registry has been maintained since 1982. Isolated coronary angiography was done in 2911 patients; of these, 2635 (90.5%) were men, and 276 (9.5%) were women, the average age of the patients was 47+/-9.2 years (range, twenty-five to eighty-eight). Patients' nationality was Qatari in 492 (17%), and other Arabs in 610 (21%), and 1512 (52%) were from the Asian subcontinent. Myocardial infarction was the most common indication (43%). Single-vessel disease was found in 638 (22%), two-vessel disease in 630 (22%), three-vessel disease in 950 (33%), and nonsignificant coronary artery disease in 693 (24%) patients. Morbidity related to the coronary angiography was reported in 147 (5%) patients, but there was no mortality related to the procedure. In 822 (28%) patients, the age was forty years or younger. The angiographic findings of these younger patients were compared with those of the older ones. Younger patients were usually men of Asian subcontinental origin with a recent myocardial infarction (MI). Often, they had normal coronary arteries or single-vessel disease. Patients of Asian subcontinent origin were usually young male patients with a recent MI, who receive streptokinase, and have single-vessel disease.

The pharmacokinetics of lamivudine in patients with impaired hepatic function

OBJECTIVE

This study was designed to evaluate the effect of hepatic impairment on the pharmacokinetics of lamivudine.

METHODS

Sixteen patients not infected with hepatitis B virus or human immunodeficiency virus who had hepatic impairment due to liver cirrhosis were assigned to moderately or severely impaired groups by clinical signs/symptoms, 14C-aminopyrine metabolic activity and caffeine clearance and compared with eight healthy controls. Following a 300-mg dose of lamivudine, blood and urine samples were taken for drug assay.

RESULTS

Lamivudine was well tolerated in patients with hepatic impairment. There were no statistical differences in overall lamivudine exposure (in terms of AUC or Cmax) or other major pharmacokinetic parameters i.e. CLR, tmax and t1/2, between healthy control subjects and patients with moderate or severe hepatic impairment.

CONCLUSIONS

Hepatic impairment does not warrant dose modification of lamivudine based on this single-dose pharmacokinetic study.

Percutaneous transluminal coronary angioplasty experience in qatar: an analysis of more than 600 consecutive procedures

The present study describes the indications and results of 636 Percutaneous Transluminal Coronary Angioplasty (PTCA) procedures that were carried out in 596 patients. Of these, 366 (61.4 %) patients had Single Vessel Disease (SVD), 183 (30.7%) had Two Vessel Disease (2VD) and 47 (7.8%) had all Three Vessels Diseased (3VD). Dilatation of a single lesion was carried out in 564 (93.5%) patients. In another 41 (6.5%) patients, more than one vessel was dilated. The patients were predominantly male (562/596,93%) with a mean age of 46 (7.9 years. The indication for angiography was angina in 65.8% and for recent Acute Myocardial Infarction (AMI) in 34.2%. The number of procedures increased from 106 in 86-89 to 320 in 92-96 (an increase of 280%).

PTCA was carried out in the same session as the angiography in 113/596 (19%). In the remaining 81%, PTCA was planned as an elective procedure with a similar success rate (85% and 87% respectively, p=N.S). Females and Qatari patients had the highest success rates (97.6% and 90.5%) respectively.

The Left Anterior Descending (LAD) was the most frequently tackled vessel (53% of cases), Left Circumflex (LCX) in 20% and Right Coronary Artery (RCA) in 27%. For coronary stenoses, the overall success rate was 89%, being highest in the LAD (89.5%), lowest for LCX (82%) and moderate for RCA (88%). When faced with a total occlusion the overall success rate was 71% and was highest in RCA (84% success) and lowest in LCX (43%) and moderate in LAD (74%). Major complications were rare with only one mortality (1/596, 0.16%) and four emergency CABG is (4/596, 0.7%). Intracoronary stents were used as a bailout device in five patients and to obtain an optimal result in one patient. Stents were technically successful in all but one case.

Catabolite inactivation of the galactose transporter in the yeast Saccharomyces cerevisiae: ubiquitination, endocytosis, and degradation in the vacuole

When Saccharomyces cerevisiae cells growing on galactose are transferred onto glucose medium containing cycloheximide, an inhibitor of protein synthesis, a rapid reduction of Gal2p-mediated galactose uptake is observed. We show that glucose-induced inactivation of Gal2p is due to its degradation. Stabilization of Gal2p in pra1 mutant cells devoid of vacuolar proteinase activity is observed. Subcellular fractionation and indirect immunofluorescence showed that the Gal2 transporter accumulates in the vacuole of the mutant cells, directly demonstrating that its degradation requires vacuolar proteolysis. In contrast, Gal2p degradation is proteasome independent since its half-life is unaffected in pre1-1 pre2-2, cim3-1, and cim5-1 mutants defective in several subunits of the protease complex. In addition, vacuolar delivery of Gal2p was shown to be blocked in conditional end3 and end4 mutants at the nonpermissive temperature, indicating that delivery of Gal2p to the vacuole occurs via the endocytic pathway. Taken together, the results presented here demonstrate that glucose-induced proteolysis of Gal2p is dependent on endocytosis and vacuolar proteolysis and is independent of the functional proteasome. Moreover, we show that Gal2p is ubiquitinated under conditions of glucose-induced inactivation.